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

Abstract

Background: Patients who leave against medical advice (LAMA) is a universal problem. Neonates being unable to decide for their own, are dependent on parents for all decisions for their treatment. LAMA is a sensitive issue in neonatology practice with ethical and medico legal ramifications. This study was done to evaluate the factors associated with the decision of LAMA by care givers in our special newborn care unit (SNCU).Methods: This is a retrospective hospital based observational study and was conducted in SNCU of HNB Base Teaching Hospital, Srinagar, Garhwal. Data pertaining to LAMA between 1st August 2017 and 31st July 2018 was retrieved. Information obtained included place of birth, gestational age, weight, diagnoses, duration of hospital stay and reasons for LAMA. Data were entered into a Microsoft Excel Spread Sheet and analyzed using software. Graph Pad Prism v 7.04. Chi-Square test was used to test for significant difference among various groups.Results: Out of 689 neonates admitted in SNCU during the study period, 167 (24.24%) took LAMA. Male to female ratio of 1:1.1. 102 (61%) were inborn and 65 (39%) were out born. Term babies constituted 62.87%. 78.44% neonates were discharged within 7 days of admission. 58 (34.73%) neonates had sepsis and 30 (17.96%) had birth asphyxia. The commonest reason in 25.15% for taking LAMA was to take the neonate to better equipped facility followed by false perception that the baby is well enough to be discharged.Conclusions: Multiple factors contribute for getting a neonate discharged against medical advice. Improvement of infrastructure, training of health care staff for proper counselling, sensitivity and empathy towards neonate and the care givers can decrease the rate of LAMA.

Discharge against medical advice in Special Care Newborn Unit in Chattogram, Bangladesh: Prevalence, causes and predictors

“…The prevalence of DAMA in this study was found to be very high at 25.7%. This finding is similar to the 22.24% and 25.4% reported from NICUs in India [ 12 , 13 ] but higher than Nepal (18%) [ 1 ] and Nigeria (11.2%) [ 3 ]. Emergency admission and admission to the neonatal intensive care unit itself was reported as a significant independent risk factor for DAMA [ 2 , 8 ].…”

“…DAMA was more on festive and weekends than any other days of the week. Similar findings were found by Kumar et al and Turkistani et al [ 13 , 18 ] Discharge decisions were typically made by the mid level doctors with the consent of consultants on the morning following the round. Due to a lack of staff and hospital policy, the discharge rate with advice was lower in the evening and almost zero at night.…”

“…It was challenging for the neonates to stay here because their moms were either at another hospital or home. Most of the DAMA neonates had full-term gestation and standard weight at admission which matched with studies in India and Saudi Arabia [ 13 , 18 ]. Many parents had the wrong perception that a baby who was big and born at term was healthy [ 18 ].…”

“…Prejudiced decision making by the family members contributed to increase DAMA among neonates [ 17 ]. The rate of DAMA differs with study setting; the time of the study, economic status and socio-cultural factors also influence the rate [ 13 , 18 ]. A retrospective review of 10 years of medical records of neonates found only 1.6% DAMA at a university hospital NICU in Saudi Arabia [ 18 ].…”

“…Prematurity (25.8%) exceeds PNA (23.9%) and sepsis (22.6%) in Nigeria [ 3 ]. Another two studies found additional causes of low birth weight (10.2%) and neonatal jaundice (10.2%) [ 13 ]: major congenital malformations (58%) and perinatal asphyxia (14%) [ 21 ]. Common congenital anomalies which lead to DAMA were congenital anorectal malformations, esophageal atresia/tracheoesophageal fistula, and congenital intestinal atresia [ 2 ].…”