Prospective Evaluation of Patients Leaving against Medical Advice of a Tertiary Care Hospital: Comparison of Emergency and Intensive Care Units

Background: Leaving against medical advice (LAMA) is a common but undesirable clinical situation seen worldwide. We planned to determine the incidence and factors responsible of LAMA in the emergency and intensive care unit of our multidisciplinary tertiary care hospital. Methods: All consecutive patients who left against medical advice from the emergency and surgical intensive care units were included in the study. We prospectively collected data on patients demographic profile, diagnosis, duration of hospital stay, reasons for DAMA and socio-economic status using the Kuppuswamy’s Socio-Economic Status Scale (modified in 2014, Appendix1) to categorize the patient’s socio-economic status. Results: The rate of DAMA from emergency and ICU was 2.4% and 15%, respectively. The mean age of the study patients was 50.4 +17.39 years (range: 14-94 years)) with a male-to-female ratio of 2:1. In our study findings the major reasons to leave DAMA in decreasing order of frequency were lack of improvement in patient’s condition or terminal illness, financial constraints, attending to family matters, dis-satisfaction with treatment and tendency to seek alternative therapy. Dis-satisfaction with the management plan was more common in ICU than emergency (p=0.00001). About 40% of the DAMA patients from emergency were semi-skilled and unskilled workers with an average income of <10,000/month whereas the average monthly income of patients going DAMA from ICU was up to 40,000/month in all except 14.2% cases. In our study population, patients leaving the ICU were more educated (p=0.000007) and belonged to the upper socioeconomic status (p=0.46) as compared to those in emergency who mainly belonged to the upper lower class (p=0.0004). Conclusion: The number of people leaving AMA from the ICU is relatively high. To reduce LAMA rate, it is important to have a good knowledge of reasons for LAMA and understanding the problem in context to disease, outcome and socioeconomic status. Communication with the patient and family extensively with respect to all facets of care is the corner-stone to deal with this problem.