Thursday, August 2, 2018

Leaving against medical advice: DAMA vs LAMA vs DOPR

Patients leaving against medical advice is a common worldwide problem in hospitals, both in wards and Emergency departments. Such patients have been variously labelled as DAMA, LAMA, absconding or DOPR.

DAMA or discharge against medical advice is when the patient discharges himself from the hospital, but the discharge has not been authorized by the treating doctor.

LAMA or left against medical advice again means that the patient may leave the hospital against the advice of the doctor, but a LAMA patient may also leave without informing or the patient may walk out of the ward.

A patient who leaves the hospital without informing the ward/hospital staff can also be said to be absconding.

Discharge on patient request or DOPR is when a patient asks or requests to leave the hospital. In such a situation, the patient leaves the hospital against medical advice but with the consent of the treating doctor.

Regardless of the terminology used, such circumstances have clinical, ethical and legal implications.

The treating doctor is still liable, even in DOPR. In such cases, the doctor has a duty to ensure safe discharge. Informed consent is critical here meaning that the patient has decided to leave the hospital of his free will, without any coercion, at the same time fully understanding the risks of leaving the hospital, benefits of hospitalization, alternatives including possible consequences of refusing the doctor’s recommendations. The doctor has a duty to provide safe discharge, which also includes a follow-up advice in addition to the abovementioned.

The subsequent decision of the patient to decline the advice of the doctor is termed informed refusal, which is an integral component of informed consent.

It is not just enough to simply record that the patient has requested DOPR, it is essential to document the entire process of informed consent along with informed refusal.

Failure to obtain an informed refusal before accepting the patient’s decision to leave the hospital makes the doctor vulnerable to prosecution for medical malpractice.

Patients who leave the hospital against medical advice (DAMA/LAMA/DOPR) are at risk of adverse or poor health outcomes because of incomplete treatment, which may increase the risk of re-hospitalization or they may suffer an acute potentially life-threatening event.

A study of more than 2 million PCI procedures published in JACC Cardiovascular Interventions shows that though DAMA patients are uncommon, they are twice more likely to be re-hospitalized with an acute myocardial infarction (MI) than those discharged home or have neuropsychiatric reasons as noncardiac causes of readmission.
If DAMA patients are re-hospitalized with MI, the mortality rate is double that of non-DAMA patients readmitted with MI.

Dr KK Aggarwal
Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Immediate Past National President IMA

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