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 Table of Contents  
Year : 2017  |  Volume : 24  |  Issue : 3  |  Page : 174-177

Self-discharge against medical advice from tertiary health institution: A call for concern

1 Department of Surgery, Ekiti State University, Ado Ekiti, Nigeria
2 Department of Surgery, Ekiti State University Teaching Hospital, Ado Ekiti, Nigeria

Date of Web Publication30-Oct-2017

Correspondence Address:
Moruf Babatunde Yusuf
Department of Surgery, Ekiti State University, Ado Ekiti
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/npmj.npmj_88_17

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Background: Self-discharge by patients without completing their treatment is a problematic issue in healthcare and is strongly associated with readmission and poor treatment outcome. Patients and Methods: A descriptive study of the rate and reasons why patients with limb injuries took self-discharge against medical advice (DAMA) from our facility, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria, a tertiary health institution between May 2011 and April 2014. Results: One hundred and thirty-one (16.2%) patients took DAMA out of 810 patients seen with limb injuries. Age ranges from 3 to 95 years with a mean of 36.31 ± 19.34 years. Road traffic crash accounted for 110 (84%) of the injuries. One hundred and sixteen (88.5%) had fractures and 9 (6.9%) had soft tissue injuries. Fifty-eight (44.3%) of the patients were referred cases, 128 (97.7%) signed DAMA form while 3 (2.3%) absconded from the hospital. Reasons for DAMA were mainly; belief more in traditional bone setters (TBSs) (36.6%); pressure from relations (22.9%) and high cost of hospital care (19.8%). One hundred and one (77.1%) of the patients volunteered that they were going to TBS for continued care. Conclusion: High percentage of patients DAMA from our facility and majority of them were in favour of unorthodox form of treatment.

Keywords: Medical-advice, self-discharge, tertiary-institution

How to cite this article:
Yusuf MB, Ogunlusi JD, Popoola SO, Ogunlayi SO, Babalola WO, Oluwadiya KS. Self-discharge against medical advice from tertiary health institution: A call for concern. Niger Postgrad Med J 2017;24:174-7

How to cite this URL:
Yusuf MB, Ogunlusi JD, Popoola SO, Ogunlayi SO, Babalola WO, Oluwadiya KS. Self-discharge against medical advice from tertiary health institution: A call for concern. Niger Postgrad Med J [serial online] 2017 [cited 2022 Jan 27];24:174-7. Available from: https://www.npmj.org/text.asp?2017/24/3/174/217406

  Introduction Top

The concept of patient voluntarily leaving the care of a physician without completion of his/her treatment has been described using various terms; taking own leave (TOL), absconding, leaving hospital, leaving medical care against medical advice, discharge against medical advice (DAMA), absent without leave, self-discharge, walking off and TOL.[1]

Significant proportions of patients who present to the emergency department take DAMA.[2] This represents a problematic issue in healthcare for patients and health-care providers alike. It causes interruption of treatment therapies and is strongly associated with increased morbidity and mortality, readmission and increased health-care expenditure.[3] The act of DAMA cut across several clinical specialities with neither race nor socioeconomic bias.[1],[4],[5],[6] There is an increased rate of road traffic crash (RTC) with attendant limb injuries.[7] These patients with limb injury usually require acute care which entails resuscitation, stabilisation and subsequent definitive care. We observed that many patients in our centre took DAMA after resuscitation. There is no report from our centre on how many of these patients took discharge and reasons for the discharge. Hence, this study looked at the proportion of patients with limb injury that took DAMA and the reasons for taken such decision.

  Patients and Methods Top

This was a descriptive study that looked at rate and reasons patients with limb injuries took DAMA from our facility, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria, a tertiary health institution in South-Western Nigeria. The records of patients with long bone fractures that took DAMA were looked into from May 2011 to April 2014. Patients' biodata, educational status, aetiology and nature of injury, involved bone and side, associated injury, duration of stay before DAMA, treatment instituted before DAMA and reasons for DAMA were retrieved and entered into a statistical package for social sciences data editor for analysis.

Data were analysed using statistical package for social sciences (SPSS Inc., Chicago, IL, USA) software for windows. Frequency distribution of the variables and means of the values were presented in tables and charts.

  Results Top

A total of 810 patients with limb injury were seen during the study, and 131 (16.2%) of the patients took their DAMA. Age of the DAMA patients ranged from 3 to 95 years with a mean of 36.31 ± 19.34 years. Ninety-seven were males (M) and 34 were females (F) with M: F of 2.9:1. More than half of the patients, 90 (68.7%), had a minimum of secondary school education.

The interval between injury and presentation ranged between 0.5 h to 24 h with mean of 4.38 ± 5.02 h and 36.8% of the patients presented within 1 h of the injury. RTC accounted for 110 (84%) of the injury; fall, 15 (11.5%); assaults, gunshot and industrial accident accounted for 2 (1.5%) each.

More than three-quarters of the patients had fractures, 116 (88.5%) and 9 (6.9%) involved only soft tissue [Table 1]. The pattern of the injury is shown in [Figure 1], with lower limb affected in most of the injuries. Seventy-three (55.6%) of the patients presented directly to our centre while 58 (44.3%) were referred. Forty-four (33.6%) of the patients were to be treated in the emergency room and discharge to the clinic for follow-up while 87 (66.4%) of the patients were to be admitted to the ward for further evaluation and treatment. Thirteen (9.9%) of the patients stayed for <8 h; 52 (39.7%) stayed between 8 and 24 h; 31 (23.7%) stayed between 24 and 72 h while 35 (26.7%) stayed longer than 72 h before they took their discharge. Sixty-three (48.1%) of the patient had resuscitation and fracture splintage only; 55 (42.0%) had resuscitations, fracture splintage and investigations commenced while definitive treatment had been commenced for 13 (9.9%) of the patients before they took their discharge. One hundred and twenty-eight (97.7%) patients formally took their DAMA while 3 (2.3%) patients absconded from the hospital. Reasons given by the patients/relatives for taken their discharge were mainly: belief more in traditional bone setters (TBSs), 48 (36.6%); pressure from relations, 30 (22.9%) and high cost of hospital care, 26 (19.8%) [Table 2].
Figure 1: Distribution of the injury pattern the patients had

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Table 1: Distribution of nature of injuries

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Table 2: Reason for discharge against medical advice

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Possible places for further care are shown in [Table 3], 101 (77.1%) of the patients/parents volunteered that they are going to TBS for their treatment while 21 (16%) are going to another hospital.
Table 3: Intended places for further care

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  Discussion Top

Patients that DAMA not only risk their own health but also challenge hospital administrators and health professionals' duty of care and ethical practice regimes.[1],[8] Most of the time, patients that took DAMA are readmitted to the hospital with severe limb and life-threatening complications. The treatment of these complications could be challenging and with very poor prognosis. ALthough the patients have the legal right to take self-discharge and are under no obligation to follow medical advice, it is crucial that they are made to understand the implications of this decision.[2] This is usually effected by making the patient or parent sign a disclaimer that the decision is taking freely and they are aware of the possible consequences.

From the study, the number of male triples that of female and more than half of the patients had at least secondary level education. RTC accounted for more than three-quarter of the limb injury, and more than four-fifth of the patients had bone/joint injury. These showed that males are more exposed to RTCs and high literacy level of the patients did not deter them from DAMA in our environment. Of important note, the mean interval between the injury and presentation for care was <5 h and more than one-third of the patients presented at our facility within 1 h of their injury. This implies that patients realised the need for urgent acute care and resuscitation which are better received at hospitals and once administered, they DAMA.

In most of the studies done outside Africa, the highest incidence of DAMA is seen among psychiatric patients, drug addicts and HIV/AIDS victims.[9] Pages et al.[10] reported DAMA rate for psychiatric inpatients of 6%–35% of cases, with a mean rate of 16 percent. The percentages of local DAMA rate is as follow, 0.002 by Eze et al.[5] in Enugu in general medical admissions and 2.6 in work done by Udosen et al.[9] in Calabar among Accident and Emergency patients. This study revealed very high DAMA rate of 16.2% which could be explained by the inability of the patients to pay for the cost of management of the injury and the pressures for family members to seek alternative treatment options.

Studies showed that patients who self-discharge were more likely to be readmitted within a short period, often within 14–30 days.[4],[11] None of the DAMA patients represented at our facility after taking their discharge. Although the patients are at liberty to seek care at the facility of their choice, readmission is not always to the same hospital if there are complications.[4] There is a reluctance to return to the same facility by patients who DAMA because of sense of guilty of DAMA in the first instance, embarrassment and the fear of a negative reaction by hospital staff.[12] Hwang et al.[4] were able to ascertain readmission of patients that DAMA through review of databases at their facility and 4 nearby hospitals that provide care to patients from their catchment area.

The reasons often cited by the patient for DAMA are legions. In addition to financial constraints, perceived improvement in clinical state and preference for alternative therapists such as traditional bone-setters were prominent in some local studies; low levels of trust, partnership and communications between patients and their doctors were responsible in others.[8] From our study, the three most important reasons patient took their discharge are belief more in TBSs (36.6%), relations pressure (22.9%) and high cost of hospital care (19.8%). This is similar to the finding of Orimolade et al.[13] in their study, cost of treatment and believe in TBSs were the 2 main reasons why most patients with fracture DAMA. Whereas in Eze et al.[5] study on general medical admissions; financial constraints (37.2%), poor response to treatment (17.7%) and dissatisfaction with the hospital environment (15%) accounted for the majority of their DAMA patients.

In terms of outcome, the medical literature supports the commonly held view that patients discharged against medical advice have worse outcomes than patients without such discharges.[10],[12] Premature discharge and subsequent readmission to hospital significantly disrupt patient continuity of care, which is crucial for effective treatment and improved health outcomes.[3] Patients who DAMA have higher resource utilisation because they often returned, and when they do, they are sicker and require more and higher levels of resources for their care.[12] Clark et al.[12] proposed assess, investigate, mitigate, explain and document framework in situ ations where patients consider leaving or do leave before their evaluations and urgent treatment are complete. The goal is to maximise patient outcomes, minimise legal risk and encourage a consistent and ethical approach to these vulnerable patients.

Although we are unable to follow-up this set of the patient to find out what become of them, 77.1% of our patients volunteered that they would continue their care at TBS place. This is higher than 62.1% among the DAMA patients in Popoola et al.[14] study in Benue, Nigeria. The 16% of our patients that volunteered going to another hospital for further care could possibly get substandard care or end up at TBSs place too. The Discharged against medical advice behaviour seems to be influenced primarily by factors occurring either at the time of admission or early in the course of hospitalisation,[15] this brings to the fore, the possible role played by patient relations or canvassers for TBS. Patients coming from TBS usually present with worse complications.

Ibrahim et al.[16] presumed that higher rates of discharges against medical advice in general or in special populations (e.g., racial/ethnic minorities) may signify shortcomings of the system that need to be addressed to improve quality of care for all patients. From our study, 8 (6.1%) took DAMA because of poor attention from health worker, positive attitudinal change towards patient could stem down the trend of DAMA. Although this study did not look at the effect of frequent strike by health workers and paucity of equipment on the rate of DAMA. Less disruption of health-care services and well-equipped health facility will enhance the confidence patient have in our health system. One other strong shortcoming in our setting is the low level of health insurance coverage which could make patients to look for an apparently cheaper alternative.

  Conclusion Top

The rate of DAMA is quite high in our centre and large number of our patients prefers seeking further care from TBS after stabilisation of their acute condition. Wider coverage of health insurance scheme to reduce out of pocket payment for health services and public enlightenment on the advantages of hospital management of limb injury are important to stop this trend.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Henry B, Dunbar T, Barclay L, Thompson R. Self-Discharge Against Medical Advice from Northern Territory Hospitals: Prevalence Rates, Experiences and Suggestions, Economic Implications and Recommended Strategies for Improvement. Darwin: Charles Darwin University; 2007.  Back to cited text no. 1
Henson VL, Vickery DS. Patient self discharge from the emergency department: Who is at risk? Emerg Med J 2005;22:499-501.  Back to cited text no. 2
Shaw C, Scholar D. An Evidence-Based Approach to Reducing Discharge Against Medical Advice Amongst Aboriginal and Torres Strait Islander Patients. Charles Darwin University, Australia: Deeble Institute Issues Brief; 2016.  Back to cited text no. 3
Hwang SW, Li J, Gupta R, Chien V, Martin RE. What happens to patients who leave hospital against medical advice? CMAJ 2003;168:417-20.  Back to cited text no. 4
Eze B, Agu K, Nwosu J. Discharge against medical advice at a tertiary center in Southeastern Nigeria: Sociodemographic and clinical dimensions. Patient Intell 2010;2:27-31.  Back to cited text no. 5
O'Hara D, Hart W, Robinson M, McDonald I. Mortality soon after discharge from a major teaching hospital: Linking mortality and morbidity. J Qual Clin Pract 1996;16:39-48.  Back to cited text no. 6
Aliyu ZY. Policy mapping for establishing a national emergency health policy for Nigeria. BMC Int Health Hum Rights 2002;2:5.  Back to cited text no. 7
Jimoh BM, Anthonia OC, Chinwe I, Oluwafemi A, Ganiyu A, Haroun A, et al. Prospective evaluation of cases of discharge against medical advice in Abuja, Nigeria. ScientificWorldJournal 2015;2015:314817.  Back to cited text no. 8
Udosen AM, Glen E, Ogbudu S, Nkposong E. Incidence of leaving against medical advice (LAMA) among patients admitted at the accident and emergency unit of the University of Calabar Teaching Hospital, Calabar, Nigeria. Niger J Clin Pract 2006;9:120-3.  Back to cited text no. 9
Pages KP, Russo JE, Wingerson DK, Ries RK, Roy-Byrne PP, Cowley DS, et al. Predictors and outcome of discharge against medical advice from the psychiatric units of a general hospital. Psychiatr Serv 1998;49:1187-92.  Back to cited text no. 10
Aliyu ZY. Discharge against medical advice: Sociodemographic, clinical and financial perspectives. Int J Clin Pract 2002;56:325-7.  Back to cited text no. 11
Clark MA, Abbott JT, Adyanthaya T. Ethics seminars: A best-practice approach to navigating the against-medical-advice discharge. Acad Emerg Med 2014;21:1050-7.  Back to cited text no. 12
Orimolade EA, Adegbehingbe OO, Oginni LM, Asuquo JE, Esan O. Reasons why trauma patients request for discharge against medical advice in Wesley Guild Hospital Ilesha. East Cent Afr J Surg 2013;18:71-5.  Back to cited text no. 13
Popoola SO, Onyemaechi NO, Kortor JN, Oluwadiya KS. Leave against medical advice (LAMA) from in-patient orthopaedic treatment. SA Orthop J 2013;12:58-61.  Back to cited text no. 14
Steinglass P, Grantham CE, Hertzman M. Predicting which patients will be discharged against medical advice: A pilot study. Am J Psychiatry 1980;137:1385-9.  Back to cited text no. 15
Ibrahim SA, Kwoh CK, Krishnan E. Factors associated with patients who leave acute-care hospitals against medical advice. Am J Public Health 2007;97:2204-8.  Back to cited text no. 16


  [Figure 1]

  [Table 1], [Table 2], [Table 3]

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