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Pearls


‘I want to leave now’: Handling discharge against medical advice

Discharge against medical advice does not absolve the physician of responsibility for poor outcomes.

Vol. 6, No. 5 / May 2007

Patients voluntarily admitted to locked psychiatric intensive care units sometimes ask to leave against medical advice. They may minimize the severity of their acute illness or deny psychiatric symptoms to obtain a discharge.

Patient characteristics and provider procedures contribute to patients’ decisions to request a discharge against medical advice (DAMA) (Table).1

Table

Risk factors for discharge against medical advice

Patient characteristics

Young (age 20 to 29)

Single marital status

Male

Comorbid personality or substance use disorder

Pessimistic attitude toward treatment

Antisocial, aggressive, or disruptive behavior

Numerous hospitalizations

History of discharge against medical advice

Provider characteristics

Failure to orient patient to hospitalization

Lack of a supportive provider-patient relationship

Discharge during evening or night shifts

Source: Reference 1

Not for everyone. Acutely psychotic, delusional, delirious, or demented patients or those with suicidal and homicidal ideation are not candidates for DAMA. For others, approach the patient calmly, explain with empathy what DAMA entails, and support the reasons for admission. Emphasize that following the treatment plan will alleviate psychiatric symptoms sooner and may shorten their stay.

Know the involuntary commitment procedures for your jurisdiction, and be prepared to discuss them with the patient. Assess the patient’s decision-making capacity, including awareness of the severity of his or her psychiatric illness and potential consequences of leaving against medical advice.

Arrange follow-up care for DAMA patients:

  • Provide the patient with a brief summary of diagnosis, medications, and follow-up plans.
  • Arrange the next available office or telephone appointment.
  • Obtain contact information of those responsible for the patient’s safety.
  • Provide the patient with emergency room and other phone numbers for crisis intervention.

DAMA does not absolve the physician of responsibility for poor outcomes. Carefully document the DAMA process because these patients are at increased risk of harm.2 Make sure the patient signs, dates, and notes the time on the DAMA request.

References

1. Brook M, Hilty DM, Liu W, et al. Discharge against medical advice from inpatient psychiatric treatment: a literature review. Psychiatr Serv 2006;57(8):1192-8.

2. Pages KP, Russo JE, Wingerson DK, et al. Predictors and outcome of discharge against medical advice from the psychiatric units of a general hospital. Psychiatr Serv 1998;49(9):1187-92.

Ms. Vanega is a nurse, Mental Health and Behavioral Science Department, Veterans Affairs Medical Center, Omaha, NE.
Dr. Ramakrishnan is a resident at Creighton University department of psychiatry, Omaha.
Dr. Ramaswamy is a director of psychopharmacology research, Creighton University, Omaha.

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