CHAPTER ONE

INTRODUCTION

1.1.      Background of the Study

The process of discharge is a critical phase in hospital management, and correct discharge is a major strategy around which all hospital functions are defined and implemented (Corley and Link, 2018). Every year in our region, thousands of patients leave the hospital before the treating physicians recommend their discharge (Alfandre, 2009). Variously abbreviated as DAMA (discharge against medical advice), SAMA (signing against medical advice), LAMA (leaving against medical advice), or DAOR (discharge against own risk), the phenomenon poses serious clinical, ethical, and legal challenges to the individual physician as well as the hospital (Bioku et al., 2015). Discharge Against Medical Advice (DAMA) is a situation in hospitalization of patient in which a patient despite medical advice leaves the hospital earlier than due time (Carrese, 2016). 

DAMA has been documented in numerous healthcare settings and accounts for 3 – 26% of the discharges of general medical patients worldwide and affecting 1 out of every 50 hospital visits (Al-Ghafri, Al-Bulushi, and Al-Qasmi, 2016; Brook et al., 2011). DAMA is accounted for one percent of total discharges in Canada and varies from 0.8% to 2.2% in the US (Mohseni et al.,

2015). DAMA rate of 7.2% to 11.1% have been reported in Nigeria (Olasinde, Aloa and Agelede,

2020; Onankpa, Ali and Abolodje, 2014). There is considerable variation in the prevalence rate of DAMA, ranging from 0.7% to 2.2% among general hospital patients, but may reach up to 25.9% in other centres. Also some studies have documented a higher rate of DAMA in developing than developed countries (Bioku, 2015), where it is more complicated especially because of communal models of decision making (Fadare and Jemilohun, 2012). No data has been seen about the prevalence and pattern of DAMA in Cameroon.

Generally, once a patient or their family insists on DAMA, a form is completed which must be signed by both the patient/caregiver and the responsible physician. The reason for the discharge is usually then recorded in the hospital’s electronic system by the physician. The signed DAMA form exists to protect the treating team and their medical institution from legal liability; good clinical practice and thorough documentation remain the best legal protection in cases of DAMA (Devitt, Devitt, and Dewan, 2012). The key point in a medical discharge plan is the exchange of information between patient and physician or the medical staff (Taylor, Lillis, and Lemone, 2014), which can be attained through teaching, providing necessary information about illness, its side effects and treatment (Ashghly et al., 2016).

The reasons often cited by patient for DAMA include dissatisfaction with the care received secondary to nurse-patient relationship, high cost of health care services or inability to pay for treatment (Mokhtari, Korami, and Madadi, 2016), lack of improvement in the medical condition for which the patient is hospitalized, perceived improvement in clinical state (a sense that their health has improved), (Estebsari et al., 2016), family responsibilities, preference for alternative therapists  e.g. traditional medicine (Nasir and Babasola, 2008), and long stay in hospital (AlAyed, 2017; Jones and Himmelstein, 2014). If medical staffs are able to detect patients with high risk of DAMA, they will then provide necessary advice and steps to continue treatment (Hwang et al., 2013).

The outcomes of DAMA for the patient can be deterioration of his/her situation, even up to the point of death, expose a patient to risk of inadequately treated medical problems and render the therapeutic result unsatisfactory (Rangraz et al., 2015). According to Corley and Link, (2018) patients who discharge themselves against medical advice still need further care. This is so because there is lack of follow-up care, which place most of these patients at increased risk of morbidity and mortality.  Failure to complete hospitalization can lead to re-lapse of disease, readmission, and increase in medical costs for the patient (Kabirzadeh et al., 2016; Hwang et al., 2013; Glasgow, Vaughn-Sarrazin, and Kaboli, 2010).  Moreover, readmission of the patient because of his/her condition imposes extra costs on the health care system and the family and the individuals (Hwang et al., 2015). 

1.2.       Statement of the Problem

The hospital is a second home for the sick and DAMA signifies a problem which may be patient based or hospital based. DAMA has been documented in numerous healthcare settings and accounts for 3 – 26% of the discharges of general medical patients worldwide and affecting 1 out of every 50 hospital visits (Al-Ghafri, Al-Bulushi, and Al-Qasmi, 2016; Brook et al., 2011). In many DAMA cases, a patient is not medically fit to be discharged; however, the treating team are not able to oppose the wishes of a patient or their caregiver. Feeling better or personal/financial obligations are some of the reasons for DAMA reported in the literature (Estebsari et al., 2016; Glasgow, Vaughn-Sarrazin, and Kaboli, 2010). When patients choose to leave the hospital before the recommendation of a treating physician, the consequences can involve risks associated with inadequately treated medical conditions, the need for readmission and sometimes loss of life (Kabirzadeh et al., 2016). DAMA often result in readmission and complications, longer hospital stays, and higher costs of treatment. As a form of non-compliance by the patient, it limits the effectiveness of appropriate and comprehensive treatment given at the hospital, thwarts the relationship between the patient and the care-team, adversely affects the morale of the health team, and can expose the hospital to legal liability. Such patients may face many personal, economic and social pressures, but may also be subject to factors that are provider and hospital environment related. Very limited information has been documented on the above phenomenon in Cameroon.

Thus, this study aimed to investigate the factors associated with DAMA among Patients in the

Buea Regional Hospital. 

1.3.       Research Questions

1. What is the prevalence of patient Discharge Against Medical Advice in Buea Regional

Hospital? 

2. What are the factors associated with Discharge Against Medical Advice among patients in

Buea Regional Hospital? 

3. What are the preventive measures for Discharge Against Medical Advice at the Buea

Regional Hospital? 

1.4.       Research Objectives

1.4.1.General Objective

The main objective of this study is to determine Prevalence and Factors associated with Discharge

Against Medical Advice among patients in Regional Hospital Buea 

1.4.2.Specific Objectives

1. To determine the prevalence of discharge against medical advice among patients in Buea Regional Hospital
2. To find out the factors associated with discharge against medical advice among patients in Buea Regional Hospital
3. To identify the preventive measures for discharge against medical advice at the Buea

Regional Hospital