An informed refusal of care and treatment discussion and documentation should include, but not be limited to, consideration of the following elements:

• All information necessary to make an informed health care decision, presented in an understandable way, including medical conditions and plan of care
• Risks and benefits of continuing and refusing care and treatment
• Confirmed understanding of the information
• An opportunity to ask questions

Source – Frederick Levy, MD, JD; Darren P. Mareiniss, MD, JD; Corianne Iacovelli, JD. The Importance of a Proper Against Medical Advice (AMA) Discharge. J Emerg Med. 2012;43(3):516-520.