Indian Journal of Critical Care Medicine

Register      Login



Volume / Issue

Online First

Related articles

VOLUME 23 , ISSUE 3 ( March, 2019 ) > List of Articles


Patients Leaving Against Medical Advice–A National Survey

PL Gautam, Rubina Khullar Mahajan, Nikhil Gautam, Suresh Ragavaiah

Citation Information : Gautam P, Mahajan RK, Gautam N, Ragavaiah S. Patients Leaving Against Medical Advice–A National Survey. Indian J Crit Care Med 2019; 23 (3):143-148.

DOI: 10.5005/jp-journals-10071-23138

License: CC BY-NC 4.0

Published Online: 01-04-2019

Copyright Statement:  Copyright © 2019; The Author(s).


Background: Leaving against medical advice (LAMA) is a common health concern seen worldwide. It has variable incidence and reasons depending upon disease, geographical region and type of health care system. Methods: We approached anaesthesiologists and intensivists for their opinion through ISA and ISCCM contact database using Monkey Survey of 22 questions covering geographical area, type of health care system, incidence, reasons, type of disease, expected outcome of LAMA patients etc. Results: We received only 1154 responses. Only 584 answered all questions. Out of 1154, only 313 respondents were from government medical colleges or hospitals while remaining responses were from private and corporate sector. Most hospitals had >100 beds. ICUs were semi-closed and supervised by critical-care physicians. LAMA incidence was maximum from ICU (45%) followed by ward (32%) and emergency (25%). Most patients of LAMA had ICU stay for >1week (60%). 80% of the respondents opined that financial constraints are the most common reason of LAMA. Unsatisfactory care was rarely considered as a factor for LAMA. Approximately 40% patients had advanced malignancy or disease. Nearly 2/3rd strongly believed that insurance cover may reduce the LAMA rate. Conclusion: Most patients get LAMA from the ICU after a stay of week. Financial constraints, terminal medical illness, malignancy and sepsis are major causes of LAMA. Remedial methods suggested to decrease the incidence include a good national health policy by the state; improved communication between the patient, care givers and heath-care team; practice of palliative and end-of-life care support; and lastly, awareness among the people about advance directives.

PDF Share
  1. Dubow D, Propp D, Narasimham K: Emergency department discharges against medical advice. J Emerg Med. 1992;10:513-6
  2. Aliyu ZY. “Discharge against medical advice: socio demographic, clinical and financial perspectives,” International Journal of Clinical Practice. 2002;56:325-7
  3. Paul G, Gautam PL, Khullar RM, Paul BS. Prospective Evaluation of Patients Leaving against Medical Advice of a Tertiary Care Hospital: Comparison of Emergency and Intensive Care Units Int J Med. Public Health. 2018; 8:18-23
  4. Green P, Watts D, Dhopesh. “Why patients sign out against medical advice (AMA): factors motivating patients to sign out AMA,” The American Journal of Drug and Alcohol Abuse. 2004;30:489-93
  5. Jeremiah J, O'Sullivan P, Stein M. Who leaves against medical advice? J Gen Intern Med. 1995;10:403-5
  6. Dubow D, Propp D, Narasimham K: Emergency department discharges against medical advice. J Emerg Med. 1992;10:513-6
  7. Wong TW, Lee KM, Chan R, Lau CC: A Study of patients who leave an accident and emergency department against medical advice. Hong Kong J Emerg Med.2000;7:22-6
  8. Hwang S W, Li J, Gupta R, Chien V, Martin R E. “What happens to patients who leave hospital against medical advice?” Canadian Medical Association Journal. 2003;168:417-20.
  9. Southern WN, Nahvi S, Arnsten JH: Increased risk of mortality and readmission among patients discharged against medical advice. Am J Med. 2012;125:594-602
  10. 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 The Scientific World Journal. 2015;314817
  11. Ti L, Milloy M-J, Buxton J, McNeil R, Dobrer S, Hayashi K, et al. Factors Associated with Leaving Hospital against Medical Advice among People Who Use Illicit Drugs in Vancouver, Canada. PLoS ONE 10(10): e0141594.
  12. Duno R, Pousa E, Sans J, Tolosa C, Ruiz A. Discharge against medical advice at a general hospital in Catalonia. Gen Hosp Psychiatry. 2003;25:46-50
  13. Lorenzi E, Da RC, Lorenzoni L, Massaria G, Aparo U L. Characteristics of voluntarily discharged patients: some reflections and a proposal. Annali di Igiene. 2000;12:513-21
  14. Naderi S, Acerra J R, Bailey K, Mukherjee P, Taraphdar T, Pal A, et al. Patients in a private hospital in India leave the emergency department against medical advice for financial reasons. International Journal of Emergency Medicine. 2014;7:13
  15. Ibrahim SA, Kent Kwoh C, Krishnan E. Factors Associated With Patients Who Leave Acute-Care Hospitals Against Medical Advice Am J Public Health. 2007;97:2204–08
  16. Riviello ED, Letchford S, Achieng L, Newton MW. Critical care in resource-poor settings: Lessons learned and future directions. Crit Care Med. 2011;39:860-7
  17. Manouchehr J, Goodarzy nejad H, Khoshgoftar Z, Sheikh Fathollahi M, Abyaneh AM. Discharge against Medical Advice among Inpatients with Heart Disease in Iran. J Tehran Heart Cent. 2012;7:72-7
  18. Nasir AA, Babalola OM: Clinical spectrum of discharges against medical advice in a developing country. Indian J Surg. 2008;70:68-72
  19. Gursahani R. Palliative care and the Indian neurologist. Ann Indian Acad Neurol 2016;19:40-4
  20. Bandewar SV, Chaudhuri L, Duggal L, Nagral S. The Supreme Court of India on euthanasia: Too little, too late. Indian J Med Ethics. 2018;3:91-94.
  21. Mercadante S, Gregoretti C, Cortegiani A. Palliative care in intensive care units: why, where, what, who, when, how. BMC Anesthesiology 2018;18:106
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.