Discharge Against Medical Advice (DAMA):Day 2(A Three days series)

21 April, 2018


1. Understanding the Patient
  • Some patients wish to leave the hospital because they are angry about a long wait for medical treatment
  • Some may fear a prolonged or expensive hospitalization, or they anticipate unnecessary and painful procedures
  • Others are afraid to learn of a serious diagnosis or are anxious about children left at home. Those who do not speak English may be especially frightened.
  • Still others may fear teaching institutions in particular because they believe that students or residents “practice” on patients. 
  • Understandably, families may be less trusting of a hospitalist doctor with whom they are not familiar.

2. Providing Treatment
  • In case of emergency, prompt medical intervention should be provided even over family objections. In fact, the legal risk is much greater if emergency care is not given
  • The hospital should first try to learn why the patient or family wishes to leave the hospital. If the patient or family seems angry, the doctor should allow him or her to express concerns without interruption. The hospital staff should remain courteous, concerned, and flexible in the treatment plan
  • If a language barrier is a factor in the misunderstanding, a competent translator should be provided
  • The doctor must be sure the family of the patient understand the risks and benefits of treatment and the risks of refusing treatment
  • Allow the patient and family to consider options in a low-pressure atmosphere so that they can make a rational decision
3. Documenting Events
  • If a patient still wishes to leave the hospital despite all efforts to reach an agreement, the patient or the family should be asked to sign a statement releasing the doctor and the hospital from all liability. Such statements have limited usefulness, however, because they can later claim that they did not fully understand the risks involved in leaving DAMA. However, a signed statement witnessed by one or two staff members may shift some responsibility to the family in the event of an adverse outcome
  • Exactly what was done for the patient and the reason for leaving DAMA should be documented in the hospital records, as well as the risks of refusing treatment as they were explained to the patient or his family
  • They should be told (and it should be documented) that they can always return to the hospital for re-evaluation if they change their minds or if the patient's condition worsens. This shows a sincere interest in the patient and may prevent litigation
  • A life-threatening medical problem also mandates immediate medical care. It is always better to win the cooperation of the patient and his family

4. Informed Consent

  • Informed consent in deciding to leave DAMA is one of the most important elements of care for patients who make this decision
  • An informed decision means that the patient has arrived at the decision in consultation with his or her doctor without being subjected to coercion and with a full understanding and appreciation of the risks, benefits, and alternatives of the decision
  • A clear conversation with the patient, followed by clear documentation of the answers in the medical record, ensures the best care possible for the patient and may reduce liability
  • Finally, doctors should pay attention to the relative health literacy of patients being discharged DAMA. Reasonable efforts should be made to ensure that patients clearly understand the terminology and language used in the discharge discussion
  • Even in ideal settings, patients can be confused about discharge medications and plans. Therefore, providing clear instructions during an untimely discharge is all the more important

5. Follow-up

  • After a patient has fully discussed the discharge with his or her doctor and made an informed decision to leave DAMA
  • The doctor's responsibility is to ensure that the discharge is as safe and appropriate as possible under the circumstances. This responsibility includes helping the patient to follow up after discharge.
Severity of illness/urgency of treatment
Decision‐making capacity (treat underlying cause if impaired)
Degree of risk to patient's health and welfare
Patient's reason for leaving
Comfort (symptom management)
Communication regarding care plan
Withdrawal syndromes
Pressing responsibilities like child, elder, or pet care issues
Allies such as primary care provider or family member
Offer maximal necessary treatment acceptable to patient
Provide prescriptions for medications as indicated
Provide optimal follow‐up plan and discharge instructions
Original treatment plan risks and benefits
Specific dangers of failing to follow proposed plan
Alternative plan
Discharge instructions including reasons to return
That the patient is welcome to return at any time
Efforts to locate if no discharge conversation occurred
Discharge instructions including when to return
Alternative plan with risks and benefits
Efforts to negotiate, recruit family/friends
Discussion of patient refusal and reasoning
Discussion of initial treatment offered
Decision‐making capacity assessment
Medical screening exam
DAY 1 (Series DAMA) - Reasons, Outcomes, Do’s & Don'ts
DAY 2 (Series on DAMA) - Strategies to be adopted by Doctors/Hospitals
DAY 3 (Series on DAMA) - Case Law & Things to Remember
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