Pearls

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

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


 

References

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.

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