Correspondence Address:
B Nanda Kishore
Department of Dermatology, Venereology and Leprosy, Father Muller Medical College, Mangalore, Karnataka
India

Full Text

Most of the patients ask, when they get admitted "How long will I need to be here?" while many are apprehensive of a long stay in the hospital,some may feel that they may be discharged early. In general, it is believed and interpreted that shorter the stay, more favorable is the outcome both in terms of cost and the disease outcome. [1]

Leave against medical advice (LAMA) can be defined broadly as patient's insistence upon leaving the hospital against the expressed advice of the treating team. [2] LAMA is a matter of concern and challenge for the health-care providers as this has adverse medical outcomes in terms of morbidity and mortality. It reflects a failure of the consensus and understanding between the attending physician and the patient regarding the need for continued hospitalization. [3]

One of the undesirable consequences apart from the misunderstanding between the patient's party and the treating physician is the subsequent readmissions and the greater expenses. [4] The study revealed that the risk of readmission among general medical patients is mainly within the first 2 weeks of discharge. [5]

The phenomenon of LAMA is world-wide, including, both rural and urban hospitals. There is a great variation in its incidence depending upon the patient population and the health-care providing set-up. The incidence of LAMA ranges from > 20% in large urban hospitals especially, among alcoholics, drug abusers to < 4% in small rural hospitals and for medical admissions. [3]

The predictors of LAMA from patients perspective depends on the socio-demographic characteristics, nature of diagnosis, treatment history, behavior, and attitudes toward treatment. Hospital settings, staffing patterns, admission discharge policies, physician's attitude, and experience are the probable reasons for LAMA from the perspective of the health-care provider. [2] Regarding the patients, younger age, male gender, people without medical insurance, low socio-economic status, alcohol, and drug abuse, psychiatric problems form the risk-factors for LAMA. Among the variables attributable to health-care providers, improper appraisal of the patient regarding his illness and treatment plan, punitive or threatening atmosphere, poor doctor-patient relationship, and inadequate staffing patterns have been mentioned as some of the contributing factors. [6] There have been instances of severe life-threatening conditions, who have left against medical advice.

While going through these variables or predictors of LAMA, we can understand that, dissatisfaction with the health-care provided, stay getting longer than expected, feeling better although, not medically fit for discharge, family or financial problems, lack of adequate medical/nursing care, preference for another hospital, belief that the condition is a terminal illness, dislike of the hospital environment, not wanting to be used for learning/teaching purposes are some of the major reasons for LAMA. [2] Some children are taken home earlier because of the care needed for the other siblings at home. [7]

Saitz states that the most important void in the literature on discharges against medical advice is the lack of understanding of why patients choose to leave. Patients need to be interviewed to know what motivates them to LAMA. Drug users, particularly injection drug users, show lack of trust in the medical- care providers mainly because of the attitude of the health-care providers toward these abusers. [1]

Most of the hospitals have a release form for the patients to read and sign if they are undergoing LAMA, which mentions that medical staff and the hospital, is not responsible for any consequences as a result of LAMA. However, this may not provide total immunity against any further litigation. In terms of general medical litigations, obstetrics tops the list followed by surgery, internal medicine, and pediatrics. [8]

The legal standard for protection from law suits continues to be good clinical practice with thorough documentation. The sicker the patient, the more comprehensive and detailed should be the progress notes. [9]

It is important to identify the probable patients of LAMA during their hospital stay to decrease the risk of non-compliance by communicating extensively, avoiding conflict and providing a caring and consoling atmosphere for the patient. Patients often blame doctors not so much for the original mistakes, as for a lack of openness or willingness to explain. Words are as necessary as drugs in the treatment of patients. [10]

References