Background:
The phenomenon of discharge against medical advice (DAMA) among pediatric patientsplaces pediatricians in a dilemma between respect for the parent’s decision and the desire toprovide complete care for the vulnerable child-patient. Little has been written about factorsthat affect a pediatrician’s decision to allow a parent to discharge his child against medicaladvice. This qualitative study aims to answer the question of how pediatric residents in atertiary government hospital perceive and decide on a DAMA request from a parent orprimary caregiver.
Methods:
Using a focus group discussion approach, 11 pediatric residents from a government-runtertiary hospital were recruited for the study. The session was digitally recorded anddominant themes were coded and identified.
Results:
There were three prominent themes that arose in the discussion: variability of definitions ofDAMA, factors considered before "allowing" the patient to be DAMA, and the implicationsof a DAMA request on their performance as pediatricians. Definitions vary from one residentto another based on the main reason for DAMA (terminal, cultural, or financial). A conflictwas noted in the definition of Home per Request (HPR) versus DAMA. Factors that influencea pediatrician to sign out a case as DAMA include: their ability to do something about thereason given for the DAMA request, the condition of the patient when the DAMA requestwas given, their impression of the kind of care that the parents provide, and their legalliabilities. Pediatric residents generally maintain a positive attitude towards the parents whorequest for DAMA and in the event of readmission, accept the patient into their care again.The occurrence of a variety of definitions and subcategories for DAMA may cause confusionamong the pediatricians and should be clarified. The familiarity with cultural traditionscontributes to their ability to handle situations that may lead to DAMA but this should alwaysbe considered in the context of the pediatrician’s legal liabilities. The attitude of being helpfulin spite of readmission after DAMA is an important attribute to be encouraged among newtrainees.
Conclusion:
In most reviews about the phenomenon of DAMA, patient characteristics have beenidentified that make them prone to request for DAMA however; physicians also experience acomplex process of decision-making in DAMA situations. It is therefore vital for everytraining institution to include ethical, legal and moral aspects of learning into their trainingprograms especially in dealing with cases of DAMA.