Indian Journal of Critical Care Medicine

Register      Login



Volume / Issue

Online First

Related articles

VOLUME 22 , ISSUE 8 ( 2018 ) > List of Articles


What happens to patients discharged against medical advice?

Senthilkumar Rajagopalan

Keywords : APACHE score, Critical Care Unit, discharge against medical advice, mortality, standard mortality rate

Citation Information : Rajagopalan S. What happens to patients discharged against medical advice?. Indian J Crit Care Med 2018; 22 (8):580-584.

DOI: 10.4103/ijccm.IJCCM_101_18

License: CC BY-ND 3.0

Published Online: 01-09-2018

Copyright Statement:  Copyright © 2018; The Author(s).


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.

PDF Share
  1. Al Ayed I. What makes patients leave against medical advice? J Taibah Univ Med Sci 2009;4:16-22.
  2. 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.
  3. Ba L, Zhang M, Su L, Cheng Z, Xu Y. Nine-year change of mortality and discharge against medical advice among major trauma patients in a Chinese Intensive Care Unit. Eur J Trauma Emerg Surg 2016;42:47-53.
  4. Saitz R, Ghali WA, Moskowitz MA. The impact of leaving against medical advice on hospital resource utilization. J Gen Intern Med 2000;15:103-7.
  5. Aliyu ZY. Discharge against medical advice: Sociodemographic, clinical and financial perspectives. Int J Clin Pract 2002;56:325-7.
  6. Fiscella K, Meldrum S, Barnett S. Hospital discharge against advice after myocardial infarction: Deaths and readmissions. Am J Med 2007;120:1047-53.
  7. Naderi S, Acerra JR, Bailey K, Mukherji P, Taraphdar T, Mukherjee T, et al. Patients in a private hospital in India leave the emergency department against medical advice for financial reasons. Int J Emerg Med 2014;7:13.
  8. Seaborn Moyse H, Osmun WE. Discharges against medical advice: A community hospital's experience. Can J Rural Med 2004;9:148-53.
  9. Baptist AP, Warrier I, Arora R, Ager J, Massanari RM. Hospitalized patients with asthma who leave against medical advice: Characteristics, reasons, and outcomes. J Allergy Clin Immunol 2007;119:924-9.
  10. Noohi K, Komsari S, Nakhaee N, Yazdi Feyzabadi V. Reasons for discharge against medical advice: A case study of emergency departments in Iran. Int J Health Policy Manag 2013;1:137-42.
  11. Weingart SN, Davis RB, Phillips RS. Patients discharged against medical advice from a general medicine service. J Gen Intern Med 1998;13:568-71.
  12. Shirani F, Jalili M, Asl-E-Soleimani H. Discharge against medical advice from emergency department: Results from a tertiary care hospital in Tehran, Iran. Eur J Emerg Med 2010;17:318-21.
  13. Alfandre DJ. “I'm going home”: Discharges against medical advice. Mayo Clin Proc 2009;84:255-60.
  14. Dalrymple AJ, Fata M. Cross-validating factors associated with discharges against medical advice. Can J Psychiatry 1993;38:285-9.
  15. Green P, Watts D, Poole S, Dhopesh V. Why patients sign out against medical advice (AMA): Factors motivating patients to sign out AMA. Am J Drug Alcohol Abuse 2004;30:489-93.
  16. Franks P, Meldrum S, Fiscella K. Discharges against medical advice: Are race/ethnicity predictors? J Gen Intern Med 2006;21:955-60.
  17. Karimi SA, Saravi BM, Farahabbadi EB, Zamanfar D, Fallah M, Abokheily MA, et al. Studying the rate and causes of discharge against medical advice in hospitals affiliated to mazandaran university of medical sciences. Mater Sociomed 2014;26:203-7.
  18. Fatemeh RJ, Maryam RJ, Rezaeiimofrad M. Patients' reasons for discharge against medical advice in university hospitals of Kashan university of medical sciences in 2008. Hakim Health Sys Res 2010;13:33-9.
  19. Ikefuna A, Emodi I. An assessment of factors influencing hospital discharges against medical advice of paediatric patients in enugu: A review of 67 cases. Niger J Paediatr 2002;29:1-4.
  20. Ding R, Jung JJ, Kirsch TD, Levy F, McCarthy ML. Uncompleted emergency department care: Patients who leave against medical advice. Acad Emerg Med 2007;14:870-6.
  21. Nasir AA, Babalola OM. Clinical spectrum of discharges against medical advice in a developing country. Indian J Surg 2008;70:68-72.
  22. Tabatabaei SM, Sargazi Moakhar Z, Behmanesh Pour F, Shaare Mollashahi S, Zaboli M. Hospitalized pregnant women who leave against medical advice: Attributes and reasons. Matern Child Health J 2016;20:128-38.
  23. 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.
  24. Link K, Brody CE, Chan J. Leaving a medical service against advice. Va Med 1983;110:100-2.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.