Discharge against Medical Advice at Neonatal Intensive Care Unit in Gujarat, India

Abstract

Objective. We explored reasons for discharged against medical advice (DAMA) of neonates from a neonatal intensive care unit (NICU) through in-depth interviews of the parents/guardians. Methods. Of 456 babies admitted to NICU during April 2014 to March 2015, 116 babies were DAMA. Parents of randomly selected 50 babies of these 116, residing within 50 kilometers, were approached for in-depth interviews at their homes. Audio recordings were done and manually transcribed, analyzed in detail to explore common threads leading to DAMA. Basic demographic information of the newborns was retrieved from hospital records. Results. The prevalence of DAMA was 25.4%. Of 50 parents approached, 41 in-depth interviews were completed. Nonaffordability (38.6%), no improvement (14.6%), poor prognosis (12%), and inappropriate behavior of the patient relation office personnel (10.6%) were major factors contributing to DAMA. Parents of 6.6% neonates wanted guarantee of survival and 5.3% parents reported poor behavior of nurses. No gender bias was observed related to DAMA. One-third of neonates (34.1%) were DAMA on first day of admission. Conclusions. The issue of DAMA needs attention. Besides nonaffordability and clinical characteristics of the baby, communication (breaking bad news, counseling, etc.) and lack of adequate infrastructure for relatives emerged as modifiable factors leading to DAMA.

Leave against medical advice from SNCU of a teaching hospital in Garhwal, Uttarakhand, India

“…Most of the studies reported financial constraints as one of prominent reasons for requesting LAMA which is quite different in present study as treatment in SNCU is free of cost. 4,12,14 Self-discharge to take the neonate to a better equipped facility was the commonest reasons cited in the present study. This may be because of the impending fear of deterioration of the neonate and lack of a nearby referral centre with difficult roads and unavailability of vehicles at odd times which may impede timely referral as and when required.…”

“…This study showed that sepsis and birth asphyxia were the common causes, this is corroborated by other studies. 4,8,11 Hatim in his study found transient tachypnea of neonates and suspected sepsis to be the common morbidities in neonates being taken LAMA.…”

“…The prevalence of LAMA in neonates in the present study was 24.23 % which corresponds to the prevalence of 25.4% reported by Devpura. 4 Rate of LAMA differs with study setting; time of study and socio-cultural factors also influence the rate. Prevalence of LAMA in present study is higher than those reported by other studies 8.32% by Rakholia and 9.63% as reported by Modi R et al 5,6 A systematic review of studies conducted in Iran revealed that the prevalence of DAMA varies from 4% to 35% in clinical departments with the lowest rate was related to patients in departments of pediatrics.…”

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“…It is interesting to note the 10% rate of parents leaving the NICU with their infant against medical advice. A Saudi Arabian study demonstrated a rate of 1.6% [18], while a study in India showed a rate of 25.4% [19]. In the latter study, economic considerations were the most commonly indicated reason by parents, followed by lack of improvement and poor prognosis [19].…”

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“…In addition, they also undergo financial and social turmoil. The attitudes of a poorly-adjusted family will definitely impact the treatment of the child with a congenital anomaly, and as often happens, they will likely be denied care since healthcare is mostly an out-of-pocket expense in India (20).…”