Discharges against medical advice: time to take another look. A retrospective review of discharges against medical advice focused on prevention

ABSTRACT

Background

Discharges against medical advice (DAMA) increase the risk of death.

Methods

We retrieved DAMA from five hospitals within a large health system and reviewed 10% of DAMA from the academic site between 2016 and 2021.

Results

DAMA increased at the onset of the pandemic. Patients who discharged AMA multiple times accounted for a third of all DAMA. Detailed review was completed for 278 patients who discharged AMA from the academic site. In this sample, women comprised 52% of those who discharged AMA multiple times. Relative to the proportion of all discharges from the academic site during the study period, Black patients were overrepresented among DAMA (21% vs. 34%, p < .05). Patients with multiple AMA discharges were younger, more likely to be unmarried, or have substance use disorders (SUD) than those who discharged AMA once. The most common reason for requesting premature discharge noted in n = 77, 28% of instances was related to patient obligations outside the hospital. Hospital policies and procedures contributed in n = 29, 10% of instances. Reasons for requesting premature discharge and documentation of key safety processes were similar by gender and race however the sample may be underpowered to detect differences. Capacity was evaluated in 109 (39%). Among those who consumed alcohol (n = 81 (29%)) or had SUDs (n = 112 (40%)), information on the amount or timing of last use was missing in n = 39 (48%) and n = 74 (66%), respectively. Critical tools to manage illness were provided in 45 (16%) of DAMA reviewed.

Conclusions

Drivers of AMA discharge may differ by AMA discharge frequency. Recognition of the common reasons for requesting premature discharge may help destigmatize AMA discharges and also identifies early assessments by social work colleagues as an important prevention strategy. Opportunities also exist in anticipating and preventing withdrawal symptoms and in revising hospital practices that contribute to DAMA.

KEYWORDS:

• Against medical advice
• premature discharge
• patient discharge
• discharge processes
• social work

Declaration of financial/other relationships

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

Sections of this data have been presented at the annual Society of General Internal Medicine meeting in 2022, 2023, the American College of Physicians meeting in 2023, and at the HEAL-R conference in Indianapolis in November 2023.

Author contributions

Jaydev: data collection, analysis, reviewing and editing. Warren Gavin: data collection, analysis, writing, reviewing, and editing. Jason Russ: data collection, analysis, writing, reviewing and editing. Emily Holmes: writing, reviewing and editing. Joshua Sadowski: data collection, visualization, reviewing and editing. Areeba Kara: conceptualization, methodology, analysis, writing, reviewing and editing, supervision.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/21548331.2023.2287431

Additional information

Funding

This paper was not funded.