The characteristics, causes and environmental factors of patients who discharge against medical advice from the emergency department: a narrative thematic review. DAMA

Discharge against medical advice accounts for 1% to 3% of all medical admissions to hospital.1 When a patient decides to discharge against medical advice (DAMA) there are potentially consequences for themselves, attending staff and healthcare organisations.2 Notably these are; exacerbations of disease, increased rate of return visits to hospital, readmissions and increased mortality. This causes financial burden on healthcare; disproportionate utilization and consumption of healthcare resources.2 This review explores patient characteristics, causes and environmental factors contributing to patients who DAMA from emergency departments.

This is a narrative thematic review conducted in accordance with International Nursing Journal Standards3 further guided by principles for systematic reviews Seven databases were searched, from 2015 to 2021, with a qualitative review question framework. Quality appraisal was conducted using appropriate tools.

Eight studies were reviewed with global reach hence, characteristics and causes for DAMA differed according to hospital type and country. Established themes are - patient characteristics, personal circumstances, and dissatisfaction with emergency care.

Typically reported were younger patients, from a poor socioeconomic status, income, and education, in need of urgent triage. Also reported were patients with cardiac conditions, who ‘falsely felt better’. Financial constraints e.g. ‘worry about loss of job’; and the need to meet family obligations e.g., ‘willingness to wait’ exacerbate DAMA. Such patients are often described negatively by healthcare staff. Dissatisfaction was attributed to anxiety provoking issues, such as, perceived excessive waiting times, poor staffing levels and inadequate communications with overcrowding an exacerbating factor.

A patient’s decision to discharge against medical advice is multifactorial, with no single prevailing cause. Understanding the typical characteristics and underlying causes of DAMA may help to identify patients most at risk, sooner, to enable appropriate strategies to improve patient safety and satisfaction.

1. Albayati A, Douedi S, Alshami A, Hossain MA, Sen S, Buccellato V, Cutroneo A, Beelitz J, Asif A. (2021) Why Do Patients Leave against Medical Advice? Reasons, Consequences, Prevention, and Interventions. Healthcare (Basel). 2021: Jan 21;9(2):111. doi: 10.3390/healthcare9020111. PMID: 33494294; PMCID: PMC7909809.
2. Yusuf M.B, Ogunlusi J.D, Popoola S.O, et al. Self-discharge against medical advice from tertiary health institution: A call for concern. The Nigerian Postgraduate Medical Journal. 2017: Jul-Sep;24(3):174-177. doi: 10.4103/npmj.npmj_88_17.
3. International Journal of Nursing. (2021). ‘Manuscript preparation guidelines’, ISSN 2373- 7662 (Print) 2373-7670 (Online). Available at: http://ijnnet.com/in/ijn/manuscript_preparation_guidelines (Accessed: 01 July 2022).