ORIGINAL ARTICLE Patients Leaving Against Medical Advice: An Inpatient Psychiatric Hospital-Based Study

ORIGINAL ARTICLE Patients Leaving Against Medical Advice: An Inpatient Psychiatric Hospital-Based Study Aalia Akhtar Hayat, Muhammad Munir Ahmed and Fareed Aslam Minhas ABSTRACT Objective: To determine the frequency of patients leaving against medical advice (LAMA) in an inpatient psychiatric facility in Rawalpindi, Pakistan. Study Design: Descriptive cross-sectional study. Place and Duration of Study: Institute of Psychiatry, Benazir Bhutto Hospital, Rawalpindi, from August 2010 to February 2011. Methodology: Patients who got admitted during study period irrespective of duration of illness and mode of admission were recruited through non-probability consecutive sampling and followed till discharge to determine their mode of leaving hospital. A thirteen-item proforma was developed and information was obtained on demographic, socioeconomic, patient related and disease related variables. Descriptive statistics were calculated on SPSS 14. Results: The total number (n) of participants was 246. Among the participants, 96 (39%) left against medical advice (LAMA) whereas 150 (61%) left on regular discharge on physician's advice. Frequency of patients who left against medical advice was found to be more in males (63.5%), younger age groups (21 30 years), lesser educated (more than half were under matric) and with the ICD-10 diagnosis of substance abuse (23.9%). About half of patients who LAMA had a prior history of psychiatric illness and a significant number (37.5%) had a history of previous psychiatric admission. Conclusion: Leaving against medical advice is a frequent problem in psychiatric inpatients and is a matter of great concern for the treating doctors. Key words: Leaving against medical advice (LAMA). Discharge against medical advice (DAMA). Self-discharges. Psychiatric admissions. Inpatients. Substance abuse. Male. Young age. INTRODUCTION In psychiatric settings, phenomenon of leaving against medical advice (LAMA) is a natural consequence of the relative increase in treatment options and patients' autonomy in making decisions about their care. However, it is a source of frustration to the mental health professionals who care for these patients as it may put patients at risk of adverse health outcomes often generating hospital re-admission. 1,2 Along with that, the responsibility that comes on doctor with such discharges; fear of legal implications are also a matter of concern for physicians. Some hospitals have even promoted policies affecting the likelihood that a patient who wants to leave early against medical advice is required to sign a formal notice of leaving against medical advice. This may reflect the extent to which physicians at the hospital are concerned about malpractice risk. 3 Leaving against medical advice had been defined in different ways by different clinicians and both its Institute of Psychiatry, Benazir Bhutto Hospital, Rawalpindi. Correspondence: Dr. Aalia Akhtar Hayat, Institute of Psychiatry, WHO Research Collaborating Centre, Benazir Bhutto Hospital, Rawalpindi. E-mail: aaliah_hayat@hotmail.com Received August 28, 2012; accepted January 28, 2013. definition and prevalence have been shaped with the advent of psychiatry. Previously, a patient was considered as left against medical advice only if he or she managed to escape from the hospital and did not return within an allotted period. LAMA has been defined, as any patient who insists upon leaving against the expressed advice of the treating psychiatrist. 2,4 Against-medical-advice-discharges continue to be a highly prevalent problem of health care quality, representing as many as 1 2% of all hospital discharges. 5-7 Psychiatrists are concerned more, where the LAMA rates have been found to exceed 20% as opposed to less than 4% for medical admissions. 8,9 Few data is also available on the estimated total costs to the health care system of such discharges, however, multiple studies have found that patients who leave against medical advice are at a risk for early readmission resulting in higher, un-necessary health care costs. 4 Understanding why patients choose to leave the hospital against medical advice has obvious importance because of the potential to identify those at higher risk. This could help to intervene earlier to prevent excess morbidity, mortality, and health care costs. 4 The following correlates of patients who leave against medical advice have been reasonably consistent over time: lower socioeconomic class, male gender, younger age, no insurance, and substance abuse. 4,6,10 342 Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23 (5): 342-346

Patients leaving against medical advice Not much has been done in our region in terms of research in this area so far and the purpose of this study was to determine the magnitude of problem of patients leaving against medical advice in psychiatric population and to explore any existing association with demographic and disease related variables. The information obtained would help clinicians in early identification of patients at higher risk for such discharges. This in turn would allow clinicians to intervene earlier to initiate preventive measures in order to prevent excess morbidity and health care costs, decrease un-necessary attrition and improve utilization of treatment resources. METHODOLOGY Following departmental research committee and institutional ethical board approval, written informed consent was obtained from consecutive patients admitted from August 2010 to February 2011 of all ages, irrespective of duration of illness and mode of admission (Emergency or OPD) by medical officer on duty. Patients who were admitted by the physician but went away prior to reporting in the ward were excluded. The research was conducted by a team of 5 doctors, including principal author along with 4 house officers. At the time of admission, data was collected using a 13-item proforma consisting of some demographic variables and some admission related variables. Most of information was filled in at time of admission, however, some variables namely, date of discharge, duration of stay and their mode of discharge was left blank and filled in at the time of discharge by the medical officer incharge. In case of emergency admission, medical officer on call made a differential diagnosis according to ICD-10 classification of mental and behavioural disorders 11 and initiated treatment after discussing it with consultant on call. In case of OPD admission, patient was seen by medical officer and discussed with the consultant and treatment initiated. In subsequent days during clinical ward rounds, clinical diagnosis was reviewed and updated on the research proforma. Daily clinical rounds were conducted during which patients to be discharged were decided with the mutual consensus of the treating team of doctors along with patient and his attendants. In case a patient was found out of bed, without any knowledge of duty medical officer and his attendants were also found missing from ward, that was reported to medical officer by the house officer on duty or staff nurse. His name was displayed on notice board and he was waited for, while enquiry about his whereabouts was made from other patients and their attendants in the same ward. If he did not show up within 24 hours, he was declared as LAMA. In case a patient requested to get discharged from ward through treating doctors who thought otherwise, reasons of such request were explored. He and his carers were educated about pros and cons of such a decision and if they decided to leave despite the counselling, a discharge on request was made, however, patient was declared as LAMA. In case some severely disturbed or agitated patient left the ward and was not brought back by attendants, he was also declared as LAMA. Before finally entering data, a cross-check was made to validate the data by matching it with the patients' record that were maintained in the record room in the form of a file for every patient who was admitted in institute. All data collected was entered and analyzed in Statistical Package for Social Sciences (SPSS) version 14.0. Simple frequencies and proportions were calculated for categorical variables whereas mean and standard deviation were calculated for age, duration of illness and duration of stay. RESULTS The total number of patients was 246. The mean age of the sample was 33.30 (S.D ± 13.053), with an age range of 12 75 years. Among the participants, 146 (59.3%) were males. Of all, 62 (25.2%) had no formal education while 124 (40.5.5%) were under matric. Thirty three point seven percent of sample had history of previous admission in psychiatry. Two hundred and forty five participants were divided into 10 groups according to their diagnoses. Diagnostic breakup of sample is shown in Table II. Table I: Showing frequency and percentages of gender distribution, education status, previous history, past admission and type of admission of study participants n = 246 and percentage of the same variables in LAMA patients. Frequency and percentages Percentages of patients LAMA of total participants (n = 246) (n = 96) Gender Male 146 (59.3%) 63.5% Female 100 (40.7%) 36.5% Education Uneducated 62 (25.2%) 22.9% Under matric 124 (50.5%) 51.0% Matric 35 (14.2%) 14.5% Graduate 18 (7.3%) 9.3% others 7 (2.8%) 0.02% Previous admission Yes 83 (33.7%) 37.5% No 163 (66.3%) 62.5% Past history Yes 122 (49.6%) 49% No 124 (50.4%) 51% Type of admission Outpatient 177 (71.95% 66.67% Emergency 69 (28.05%) 33.33% Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23 (5): 342-346 343

Aalia Akhtar Hayat, Muhammad Munir Ahmed and Fareed Aslam Minhas Table II: Showing specific psychiatric diagnosis of patients admitted n = 246 and of patients LAMA within a specific diagnosis. Current diagnosis Frequency and percentage of Left against medical advice Percentage of LAMA within specific psychiatric diagnosis in a specific diagnosis (n = 246) Yes No (n = 96) Depressive illness 86 (35%) 17 69 17.7% Schizophrenia 12 (4.9) 1 11 0.01% OCD 1 (0.4) 0 1 0% Bipolar affective disorder 29 (11.8) 11 18 11.4% Dissociative disorder 33 (13.4%) 20 13 20.8% Epilepsy 1 (0.4%) 1 0 0.01% Organicity 14 (5.7%) 5 9 5.2% Personality disorder 7 (2.8%) 3 4 3.1% Others Substance abuse 37 (15.1%) 23 23 23.9% Acute stress reaction 4 (1.6%) 1 0 0.01% Learning disability 4 (1.6%) 0 4 0% Dementia 1 (0.4%) 0 4 0% Autism 1 (0.45%) 0 4 0% Undiagnosed 16 (6.5%) 14 2 14.5% Total 246 96 150 Table III: Showing duration of illness and mode of discharge in a crosstab (n = 246). Duration of illness Left against medical advice Total Yes No Less than a week 29 13 42 Less than 2 weeks 31 16 47 Less than 3 weeks 15 59 74 More than 3 weeks 21 62 83 Total 96 150 246 Among the participants, 96 (39%) left against medical advice (LAMA) and age range in which maximum patients LAMA was found to be 21 30 (48/96). Amongst 96 patients who left against medical advice, 61 (63.5%) were males and 35 (36.5%) were females and majority patients (49) had less than matriculation education. Diagnostic breakup of LAMA patients is shown in Table II. A high percentage of LAMA patients (23.96%) had a diagnosis of substance abuse. Amongst those who got LAMA, 64 (66.67%) were admitted from out-patients and 32 (33.33%) from emergency; 36 (37.5%) had a previous history of psychiatric admission. Out of 96 patients who LAMA, 47 (49%) had previous history of psychiatric disorder (Table I). Mean duration of illness for sample was 380 whereas mean duration of illness for LAMA patients was 172 (Table III). In patients who left against medical advice (96), 62.5% patients had been ill for less than 13 days (29+31) and mean duration of stay was 5.30 ± 5.60. Out of these, 33 left on admission day and maximum number of patients i.e. 36 left in the next 5 days. Amongst the patients of dissociation disorder who LAMA (20), 5 left on admission day and 9 within 1 st week. In cases with depression, who LAMA, 14 did so within 1 st week of admission. Amongst patients of drug abuse, however, maximum number of patients (10) left on the day of admission and a high number left within first week of admission i.e. 10 (1 st day) and 9 (within first week of admission) out of 23. DISCUSSION Duration of stay in hospital is a matter of concern for patients and their families. Discharge or leaving against medical advice (LAMA) is a common phenomenon in hospitals and patients in psychiatric units are more likely to LAMA than patients on medical or surgical units. 4 The literature, however, is limited primarily to medical record reviews and retrospective analyses of factors related to LAMA discharges. 4 In terms of outcome, it is worse in patients who leave against medical advice than the patients with regular discharges. LAMA patients tend to respond poorly to inpatient care, show reduced benefits from treatment and re-hospitalized sooner and more frequently. 4,12,13 Amongst psychiatric inpatients, more frequently identified reasons for leaving against medical advice are found to be personal matters, financial strains, dissatisfaction with treatment received, illness factors and preference for a nearby hospital. 14,15 Amongst illness factors, it was found that patients with a diagnosis of substance abuse, psychotic illness, depressive illness and patients with passive aggressive traits had increased frequency of LAMA. 2,16,17 This study examines the problem of LAMA and frequency of such discharges in a psychiatric health care facility. It revealed that frequency of patients leaving against medical advice was 39%. This is in line with the results of other studies, including local and international literature. 2,9,19 344 Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23 (5): 342-346

Patients leaving against medical advice LAMA is not a rare phenomenon and it occurs frequently all over the world, even in the most developed and equipped medical centres. Brooks et al. found its prevalence to be ranging from 3 51%, with a mean rate of 17%. 2 The percentage of LAMA found in this study falls within this range, however, there could be several possible reasons for being this percentage towards the upper limit. The above mentioned study is a review of articles of past 50 years so there is a variation of findings from different studies. Also the authors stated that they found the prevalence of this phenomenon to be increasing over time and since that review was published in 2006, this could be a possible reason of our finding to be higher than the mean (17) whereas remaining between the ranges (3 51). Franks et al. found that LAMA rates for psychiatric patients exceed 20% whereas percentage of LAMA has typically been less than 4% for medical admissions. 9 The results are in line with the findings of this study. Possible reason is the similarity in patient variables that LAMA in both the studies as they are one of the strong predictors of assessing patients at risk of LAMA. Franks et al. also found that hospital risk factors for LAMA included location of hospital in large urban areas. 9 The hospital in which this study is conducted also falls under this domain and, therefore, higher rates of LAMA are found in this study affirming this finding. In a review article by Brooks et al. looking at LAMA over past 50 years reviewing 61 articles, most common predictors amongst patient factors were young age; single marital status; male gender and diagnosis of personality or substance use disorders. 2 Similarly, in this study, age range in which maximum patients (> 50%), got LAMA was found to be 21 30 years, 63.5% were males. However, there was an unequal distribution of gender in admissions where males were already in higher proportion which might have led to a higher representation in LAMA group. Alfandre et al. in his study based on retrospective cohort studies, found younger age, no insurance, male gender, and current or a history of substance or alcohol abuse to be predictors of LAMA discharge. 4 Similarly, in this study, amongst patients who LAMA, most common diagnosis was substance abuse (23.39%). Twenty point eight three percent of patients had dissociation and 17.70% suffered from depressive illness. Most researchers like Dalrymple et al. 18 and Franks et al. have found admissions for alcohol, drug abuse, and psychiatric problems, to be associated with LAMA where the rates have been found to exceed 20% that is consistent with the results of this study. In a regional study by Syed done at a University Hospital in Pakistan, 19 and by Shirani in Tehran, 20 frequency of LAMA amongst patients admitted through emergency was quite high. Similar results were revealed through this study where 46.2% of all emergency patients LAMA as compared to 36.2% of patients admitted throughout. Shorter hospital stay is also a predictor of leaving against medical advice in some cases as discussed by Devitt et al., Ibrahim et al. and Tulloch et al. 3,6,21 Similarly, in this study, 51.04% of patients LAMA within 1 st week of admission. Amongst patients of substance abuse, maximum number of patients who LAMA, did so on 1 st day of admission and a significant number left within 1 week of admission (19/23) as found in a French study by Mabiala-Babela where 34.8% left on 1st day of admission. 22 This study has several limitations. Problem of LAMA is associated with type of hospital setting, staffing pattern and admission and discharge policies, 6,19,23 so generalizing this finding to another psychiatric setting is difficult. Also this study determined the frequency of LAMA and its relations only to a few demographic and illness related variables but did not look into any statistical associations. Ideally all variables i.e. patient related and temporal should be considered along with patients' perspective and reason given to LAMA. Despite these limitations, findings suggest that leaving against medical advice continues to be a quite frequent problem for patients and their physicians. Attempts at devising measures capable of identifying patients at greater risk for discharge against medical advice should be conducted in future. Prospective studies of psychiatric patients, focusing on patient, physician, and hospital variables, are most likely to reveal reliable and valid data about how best to address, prevent, and treat the LAMA behaviour. CONCLUSION The problem of LAMA continues to be quite frequent in the patient population coming to a government funded psychiatric facility. Efforts to combat this problem, as well as research exploring the possible solutions are warranted. Such information could help devise preventive strategies at the national level in Pakistan. REFERENCES 1. Saia M, Barra S, Mussi A, Mantoan D. Discharge against medical advice in Veneto Region. Ann Ig 2008; 20:171-8. 2. Brook M, Hilty DM, Liu W, Hu R, Frye MA. Discharge against medical advice from inpatient psychiatric treatment: a literature review. Psychiatr Serv 2006; 57:1192-8. 3. Devitt PJ, Devitt AC, Dewan M. An examination of whether discharging patients against medical advice protects physicians from malpractice charges. Psychiatr Serv 2000; 1:899-902. 4. Alfandre DJ. I'm going home: discharges against medical advice. Mayo Clin Proc 2009; 84:255-60. Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23 (5): 342-346 345

Aalia Akhtar Hayat, Muhammad Munir Ahmed and Fareed Aslam Minhas 5. Schaefer GR, Matus H, Schumann JH, Sauter K, Vekhter B, Meltzer DO, et al. Financial responsibility of hospitalized patients who left against medical advice: medical urban legend? J Gen Intern Med 2012; 27:825-30. 6. Ibrahim SA, Kwoh CK, Krishnan E. Factors associated with patients who leave acute-care hospitals against medical advice. Am J Public Health 2007; 97:2204-8. 7. Myers RP, Shaheen AA, Hubbard JN, Kaplan GG. Characteristics of patients with cirrhosis who are discharged from the hospital against medical advice. Clin Gastroenterol Hepatol 2009; 7:786-92. 8. Levine LJ, Schwarz DF, Argon J, Mandell DS, Feudtner C. Discharge disposition of adolescents admitted to medical hospitals after attempting suicide. Arch Pediatr Adolesc Med 2005; 159:860-6. 9. Franks P, Meldrum S, Fiscella K. Discharges against medical advice: are race/ethnicity predictors? J Gen Intern Med 2006; 21:955-60. 10. Choi M, Kim H, Qian H, Palepu A. Readmission rates of patients discharged against medical advice: a matched cohort study. PLoS One 2011; 6:e24459. 11. WHO. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization; 1992. 12. Kenne DR, Boros AP, Fischbein RL. Characteristics of opiate users leaving detoxification treatment against medical advice. J Addict Dis 2010; 29:383-94. 13. Khan NU, Razzak JA, Saleem AF, Khan UR, Mir MU, Aashiq B. Unplanned return visit to emergency department: a descriptive study from a tertiary care hospital in a low-income country. Eur J Emerg Med 2011; 18:276-8. 14. Teja VD, Sudha T, Lakhshami V. Emergency department based HIV screening: an opportunity for early diagnosis in high prevalent areas. Indian J Med Microbiol 2008; 26:167-71. 15. Rehmani R. Emergency section and overcrowding in a university hospital of Karachi, Pakistan. J Pak Med Assoc 2004; 54:233-7. 16. Berger JT. Discharge against medical advice: ethical considerations and professional obligations. Hosp Med 2008; 3:403-8. 17. Glasgow JM, Vaughn-Sarrazin M, Kaboli PJ. Leaving against medical advice (LAMA): risk of 30-day mortality and hospital readmission. J Gen Intern Med 2010; 25:926-9. 18. Dalrymple AJ, Fata M. Cross-validating factors associated with discharges against medical advice. Can J Psychiatry 1993; 38: 285-9. 19. Syed EU, Mehmud S, Atiq R. Clinical and demographic characteristics of psychiatric inpatients admitted via emergency and non-emergency routes at a university hospital in Pakistan. J Pak Med Assoc 2002; 52:456-9. 20. Shirani F, Jalili M, Asl-E-Soleimani H. Discharge against medical advice from emergency department: results from a tertiary care hospital in Tehran, Iran. Eur J Emerg Med 2010; 17:318-21. 21. Tulloch AD, Fearon P, David AS. Length of stay of general psychiatric inpatients in the United States: systematic review. Adm Policy Ment Health 2011; 38:155-68. 22. Mabiala-Babela JR, Nika ER, Ollandzobo LC, Samba Louaka C, Mouko A, Mbika Cardorelle A. Discharge of children against medical advice at CHU of Brazzaville (Congo). Bull Soc Pathol Exot 2011; 104:331-5. 23. Onukwugha EC, Shaya FT, Saunders E, Weir MR. Ethnic disparities, hospital quality, and discharges against medical advice among patients with cardiovascular disease. Ethn Dis 2009; 19:172-8. 346 Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23 (5): 342-346