As one who has been practicing acute inpatient psychiatry for approximately 20 years, I have to take issue with “‘I want to leave now’: Handling discharge against medical advice” (Current Psychiatry, May 2007).
Psychiatrists’ power to involuntarily confine citizens needs to be exercised with the greatest care and sensitivity. Every case where a voluntary inpatient requests discharge needs to be evaluated in a careful and individualized manner that often has little to do with the items listed in the article as disqualifiers for discharge against medical advice (DAMA).
Specifically, I have seen numerous cases where patients with delusions, dementia, and even acute psychosis have been discharged despite the treatment team’s wish that they stay longer because the patients did not meet criteria for involuntary hospitalization in New York. I suspect laws in other states also would have mandated these patients’ discharge. The same situation has occurred with patients expressing homicidal or suicidal ideation. Many patients have chronic suicidal “ideation” but do not intend to act upon these thoughts.
I don’t think the table of patient characteristics that are risk factors for DAMA has much clinical value. In fact I would venture to say that a large percentage of DAMA patients have every one of the factors listed.
This is not to say that the decision to discharge these patients is made without great deliberation. The point is that looking at a few isolated symptoms often is a misleading oversimplification. The decision is a complex process focusing on acute suicidal, violent, or criminal potential that cannot be operationalized.
I agree with the authors that “DAMA does not absolve the physician of responsibility for poor out-comes.” The psychiatrist needs to carefully document the factors that lead to the decision to discharge a patient. The documentation needs to reflect that the DAMA decision was necessary given the state’s statutes.
Bennett Cohen, MD
New York, NY