What happens to patients discharged against medical advice?

Abstract

Introduction:Discharge against medical advice (DAMA) when requested by family members of patients in Indian Critical Care Units (CCUs) leads to loss of follow-up and unknown patient outcomes. Exclusion of these patients from research analysis and quality audits confounds these results. We hence explored the proportion of patients leaving DAMA, reasons, and their outcomes at 30 and 90 days.Methods:This was a prospective study of CCU patients admitted from July 2013 to February 2014. All patients, who were DAMA during this period, were included in this study. Demographics, APACHE data, and outcomes were collected and compared to patients discharged regularly during the same period. Outcomes of DAMA patients at 30 and 90 days were gathered by telephone follow-up.Results:Among the 663 patients admitted to the CCU, 15.1% (100 patients) were DAMA. The baseline APACHE score of the DAMA group was higher than the regular discharge group (29.5 ± 8.6 vs. 26.1 ± 10.3; P = 0.002). During the 30-day follow-up, 23% were alive, 56% dead, and 21% could not be contacted. At 90 days, mortality was 62% and survivors decreased to 14%. Common reasons for DAMA were – wanting to take the patient to another hospital (21%), reluctance for further treatments (12%), financial constraints (9%), and overall poor prognosis (7%).Conclusion:A significant proportion of patients in the CCU get DAMA despite high severity of illness. Understanding the outcomes of these patients will help refine CCU quality audit reports and research study results.

Traumatic Brain Injury in Cameroon: A Prospective Observational Study in a Level I Trauma Centre

“…Two patients registered in this study received treatment and were later not permitted to leave the hospital premises until they settled their debts. This situation likely caused psychological distress and negatively impacted their recovery, as suggested in the literature [ 42 , 43 , 44 ]. Findings from this study revealed that survivors of DAMA cases were more likely to have disabilities and a poorer quality of life six months after injury than survivors discharged regularly ( p = 0.019 for QoLIBRI).…”

Intensive Care in India in 2018–2019: The Second Indian Intensive Care Case Mix and Practice Patterns Study

“…However, only 9% of their patients were discharged because of an overall poor prognosis. 9 Thus classifying all TDs does overestimate mortality, but excluding them would grossly underestimate mortality.…”

Prevalence of frailty and association with patient centered outcomes: A prospective registry-embedded cohort study from India

“…For the primary analysis, patients who left the ICU against medical advice (LAMA) were considered to have been discharged alive. Because these patients may be more likely to die [ 26 ], we conducted a best-worst and worst-best sensitivity analysis. The best-worst analysis considered non-frail patients with LAMA status to be alive, while frail patients were considered dead.…”