Factors Associated with Discharge Against Medical Advice from Emergency Department, Universiti Kebangsaan Malaysia Medical Centre
DAMA
Vol. 11 No. 1 : 2016 (29-37)
Abstract
Patients who self-discharge against medical advice (DAMA) are susceptible to life-threatening consequences. By understanding the factors associated with DAMA, healthcare centres can build strategies to assist patients to receive optimal medical care and prevent unfavourable outcome. The objective of this study was to determine the factors associated with DAMA from the Emergency Department (ED) of Universiti Kebangsaan Malaysia Medical Centre (UKMMC). This was a prospective unmatched case control study conducted over a 4-month period. For every DAMA episode, two patients who were admitted on the same day were randomly selected as control. Following patient consent, data was collected using a standardized questionnaire. Patients were contacted by the investigator for information regarding hospitalization within two weeks of DAMA. Ninety three patients were recruited; 31 DAMA patients and 62 admitted patients. Payment method was significantly associated with DAMA (OR 3.17 95% CI 1.29-7.98; p=0.01). The likelihood of self-paying patients to take DAMA was three times higher than those who had a guarantor letter from their employer or insurance provider. Other factors which influence DAMA were family obligations (OR 4.08 95% CI 1.09-15.26; p = 0.03) and work problems (OR 3.83 95% CI 1.13-12.94; p=0.03). A total of 19.4% of DAMA patients left following symptomatic pain relief. A total of 80.6% DAMA patients were admitted to hospital within two weeks of the DAMA episode. Payment method significantly influences DAMA. Payment planning, social welfare services, non-governmental organization funds and the introduction of a national health policy scheme may aid hospital payment, alleviate financial limitation of patients and reduce DAMA episodes.
Keywords :
DAMA,
discharge,
emergency,
hospital,
treatment,
Correspondance Address
Ahmad Khaldun Ismail, Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia. Tel: +603-91455493 Fax: +603-91456577 Email: khaldun_ismail@yahoo.com
References
Alfandre, D.J. 2009. “I’m going home”: discharges against medical advice. Mayo Clin Proc 84(3): 255-60.
Appelbaum, P.S. 2007. Clinical practice. Assessment of patients’ competence to treatment. N Engl J Med 357(18): 1834-40.
Baptist, A.P., Warrier, I., Arora, R., Ager, J., Massanari, R.M. 2007. Hospitalized patients with asthma who leave against medical advice: characteristics, reasons and outcomes. J Allergy Clin Immunol 119(4): 924-9.
Bell, J., Hays, I., Emerson, G., Morris, W.W., Dunn, T.C., Clark, A., Arnold, R.D. 1847. Obligations of patients to their physicians. Chicago: American Medical Association Original Code of Ethics Philadelphia; 96.
Berger, J.T. 2008. Discharge against medical advice: ethical considerations and professional obligations. J Hosp Med 3(5): 403-8.
Carrese, J.A. 2006. Refusal of care: patient’s well-being and physicians’ ethical obligations: “but doctor, I want to go home”. JAMA 296(6): 691-5.
Devitt, P.J., Devitt, A.C., Dewan, M. 2000a. An examination of whether discharging patients against medical advice protects physicians from malpractice charges. Psychiatr Serv 51(7): 899-902.
Devitt, P.J., Devitt, A.C., Dewan, M. 2000b. Does identifying a discharge as “against medical advice” confer legal protection? J Fam Pract 49(3): 224-7.
Fiscella, K., Meldrum, S., Barnett, S. 2007. Hospital discharge against advice after myocardial infarction: deaths and readmissions. Am J Med 120(12): 1047-53.
Green, P., Watts, D., Poole, S., Dhopesh, V. 2004. Why patients sign out against medical advice (AMA): factors motivating patients to sign out AMA. Am J Drug Alcohol Abuse 30(2): 489-93.
Grisso, T., Appelbaum, P.S. 1998. MacArthur Competence Assessment Tool for Treatment (MacCAT-T). Sarasota, FL: Profesional Resource Press.
Hwang, S.W., Li, J., Gupta, R., Chien, V., Martin, R.E. 2003. What happens to patients who leave hospital against medical advice? CMAJ 168(4): 417-20.
Ibrahim, S.A., Kwoh, C.K., Krishnan, E. 2007. Factors associated with patients who leave acute-care hospitals against medical advice. Am J Public Health 97(12): 2204-8.
Kim, S.Y., Caine, E.D. 2002. Utility and limits of the mini mental state examination in evaluating consent capacity in Alzheimer’s disease. Psychiatr Serv 53(10): 1322-4.
McKinstry, B., Ashcroft, R.E., Car, J., Freeman, G.K., Sheikh, A. 2006. Interventions for improving patients’ trust in doctors and group of doctors. Cochrane Database Syst Rev 3: CD004134.
Morris, N.S., Grant, S., Repp, A., Maclean, C., Littenberg, B. 2011. Prevalence of limited health literacy and compensatory strategies used by hospitalized patients. Nurs Res 60(5): 361-6.
Moy, E., Bartman, B.A. 1996. Race and hospital discharge against medical advice. J Natl Med Assoc 88(10): 658-60.
Naess, A.C., Foerde, R., Steen, P.A. 2001. Patient autonomy in emergency medicine. Med Health Care Philos 4(1): 71-7.
Nasir, A.A., Babalola, O.M. 2008. Clinical spectrum of discharges against medical advice in a developing country. Indian J Surg 70(2): 68-72.
Onukwugha, E., Saunders, E., Mullins, C.D., Pradel, F.G., Zuckerman, M., Weir, M.R. 2010. Reasons for discharges against medical advice: a qualitative study. Qual Saf Health Care 19(5): 420-4.
Osborn, C.Y., Paasche-Orlow, M.K., Bailey, S.C., Wolf, M.S. 2011. The mechanisms linking health literacy to behavior and health status. Am J Health Behav 35(1): 118-28.
Pennycook, A.G., McNaughton, G., Hogg, F. 1992. Irregular discharge against medical advice from the accident and emergency department – a cause for concern. Arch Emerg Med 9(2): 230-8.
Phillips, G., Mason, S., Baston, S. 2009. Mental health and the law: the Australasian and UK perspectives. In Textbook of Adult Emergency Medicine. 3rd edition. Edited by Cameron, P., Jelinek, G., Kelly, A., Murray, L., Brown, A. F. Churchill Livingstone Elsevier; 751-60.
Seaborn Moyse, H., Osmun, W.E. 2004. Discharges against medical advice: a community hospital’s experience. Can J Rural Med 9(3): 148-53.
Wong, T.W., Lee, K.M., Chan, R., Lau, C.C. 2000. A study of patients who leave an accident and emergency department against medical advice. Hong Kong J Emerg Med 7(1): 22–6.
