ORIGINAL

Niger J Paed 2013; 40 (1): 40 –44

Eke GK

Opara PI

Discharge against medical advice

amongst patients admitted into the

Paediatric wards of the University

of Port Harcourt Teaching Hospital

DOI:http://dx.doi.org/10.4314/njp.v40i1,7

Accepted: 20th June 2012

Abstract Objectives: To identify the

characteristics of patients and fac-

tors contributing to DAMA in pae-

diatric patients admitted into the

University of Port Harcourt Teach-

ing Hospital and to determine ways

to reduce its prevalence.

Method: This was a retrospective

study of children admitted into the

paediatric wards of the Hospital.

Case files of affected patients over a

two year period were reviewed and

relevant information obtained and

analyzed.

mission. Majority of patients were

from low (35.3%) and middle

(41.3%) income classes. The com-

monest reasons for DAMA were

lack of funds (26.6%) and no im-

provement (26.6%), necessitating

need to seek alternative therapy.

The discharge document was signed

by the father in 61.3% of cases.

Conclusion: Children who were

DAMA suffered from common

causes of childhood mortality. Lack

of funds, no improvement and lack/

low decision making power of

mothers were contributory factors.

There is need for more universal

implementation of the National

Health Insurance Scheme; effective

communication between medical

team and parents and female em-

powerment to reduce rates of

DAMA in our environment.

Eke GK

(

) Opara PI

Department of Paediatrics and

Child Health

University of Port Harcourt Teaching

Hospital, Port Harcourt

Nigeria.

Tel: +2348037097981.

E-mail: kergracia@yahoo.com

Results: There were 150 of 3981

patients admitted over the period

giving a prevalence rate of 3.8%.

There were 86 (57.3%) males and

6

4 females (42.7%) with a male:

female ratio of 1.3:1. Neonatal sep-

sis, birth asphyxia and prematurity

were the commonest diagnosis in

neonates whilst severe malaria,

meningitis and bronchopneumonia

were the commonest in other chil-

dren. Most discharges (54%) oc-

curred within the first week of ad-

Key words: Discharge against

medical advice, children, paediatric

wards.

Introduction

With an estimated one milli₁o₁n children dying each year

before their fifth birthday and a limited access to

1

2

Discharge against medical advice (DAMA) is an adverse

clinical event that culminates in the patient’s withdrawal

of their initial voluntary consent for hospitaliza_,t₂ion and

health, it is important that children who get to health

facility be discharged when they have recovered from

their illnesses. Various studies, however, have docu-

1

7-10,13

abrupt termination of in-patient medical care. It is a

mented that up to 7% of children are DAMA.

worldwide phenomenon with great variation in inci-

dence, ranging between >20% in large urban hospitals

to <1% in small rural hospitals and medical wards, de-

These children, especially the under-fives, are victims

because they do not take decisions, cannot understand or

contribute to these decisions and are thereby exposed to

increased morbidity and mortality.

3

pending_,₄upon patient population and type of treatment

3

setting. A well recognized problem in medical prac-

tice, it has important health consequences as these pa-

tients are exposed to the risks of inadequately treated

medical problems, including increased risk of r₅e_,₆-

admission with its consequent higher health care cost.

The aims of the study were to identify the characteristics

of patients and the factors contributing to DAMA

amongst paediatric patients admitted into the University

of Port Harcourt Teaching Hospital (UPTH) and to iden-

tify the factors that can reduce its prevalence

Despite its poor health indices, DAMA has also been

1

,2,7-10

reported in Nigeria in both children and adults.

4

1

Patients and Methods

Table 1: Age and gender of study population

Age at admission

Number

Percentage

The case records of patients who signed against medical

advice amongst children admitted into the various paedi-

atric wards of the UPTH, over a 2-year period (January

0 – 28 days

60

45

24

4

11

6

40

30

16

2.7

7.3

4

1

3

5

– 12 months

3 – 36 months

7 – 59 months

– 10 years

2

007 – December 2009), were retrieved from the Re-

cords Department and reviewed.

>

10 years

The UPTH serves as a general/referral centre for neo-

nates and children in Port Harcourt and its environs.

There are three major wards where children are admitted

in the hospital. These are the Special Care Baby Unit,

where neonates are admitted; the Children Emergency

Ward, where emergencies beyond the neonatal period

are admitted and stabilized before being moved into the

Children’s medical wards.

Total

150

100

Sex of patients

Male

Female

86

64

150

57.3

42.7

100

Total

Table 2: Commonest diagnosis among children who

were DAMA

In the event of a request for DAMA in any of these

wards, the attending physician and/or the most senior

nurse on duty, are called in to discuss with, and counsel

the parents/caregivers on the need for continued hospi-

talization. When they insist on discharge despite coun-

seling, they are made to sign the discharge document

which has provision for reasons for the request, after

which they pay outstanding bills before leaving hospital.

Diagnosis

Number

Percentage

Neonates (n=60)

NNS/infections

Birth asphyxia

21

17

35

28.3

Prematurity

Neonatal jaundice

15

5

25

8.3

Cong anomalies

4

6.6

Older children (n=90)

Malaria

Meningitis with sequalae

Children who were DAMA in all the wards were identi-

fied from the Nurses records and case notes retrieved.

Information obtained included biodata, diagnosis, dura-

tion of hospital stay, Socio-economic status, reasons for

DAMA and signatory to the discharge document. Pa-

tients were grouped₄into social classes according to the

20

16

22.2

17.7

Bronchopneumonia

13

14.4

AIDS

Sickle cell anaemia

9

8

10

8.8

1

system of Oyedeji using educational levels and occu-

pation of parents. Those in Socioeconomic classes I and

II were grouped as high; those in III as middle and those

in IV and V as low income groups.

Data were entered into a Microsoft Excel Spread Sheet

and analyzed using SPSS version 15.0. Chi-Square test

was used to test for significance. P values < 0.05 were

considered significant.

Table 3 shows duration of hospital stay. The average

duration of stay in hospital was 5.9±4.6 days in neonates

and 8.9±5.2 days in older children. Majority of DAMA

(54%) occurred in the first week of admission, 50% of

which were neonates.

Table 3: Duration of hospital stay of children DAMA

Duration of stay

Frequency

Percentage

≤

2

8

>

1 day

12

8

– 7 days

– 14 days

14 days

69

46

Results

53

35.3

10.7

100

16

In the two year period under review, 150 children were

DAMA out of 3981 admitted, of which 1481 were neo-

nates, giving a prevalence rate of 3.8%. There were 86

Total

150

(

of 1.3:1. The ages of the patients ranged from one day to

1

4

57.3%) males and 64 females (42.7%) with a M:F ratio

Table 4 shows the socioeconomic status of the parents/

care givers and signatories to the discharge document.

Sixty-two (41.3%) and fifty-three (35.3%) of the pa-

tients were from middle and low income classes respec-

tively. The discharge document was signed by the father

in 61.3% of cases, and the mother in 18%. Others were

grandfathers/mothers, uncles and cousins. In 23 (15.4%)

of cases the discharge document was signed but the rela-

tionship between the signatory and the patient was not

stated.

4 years. Majority were Under-fives (88.7%), of which

0% were neonates. (Table 1)

Neonatal sepsis, birth asphyxia and prematurity were the

commonest diagnoses in neonates that DAMA whilst

severe malaria, meningitis and bronchopneumonia were

the commonest in older children, as shown in Table 2.

Some children had more than one diagnosis.

4

2

Table 4: Socioeconomic status of parents/ care givers

and signatories to the discharge document

Neonatal sepsis, birth asphyxia, prematurity and neona-

tal jaundice, also identified as com₁monest causes of

1

deaths amongst newborns in Nigeria and in developing

Socioeconomic status

Frequency

Percentage

1

9

countries, were the commonest diagnoses amongst

High

Middle

Low

23

62

53

15.4

41.3

35.3

neonates DAMA. This finding was similar to o_,t₈her stud-

7

ies but the orders of frequency were different. Malaria,

meningitis with sequalae and bronchopneumonia ac-

counted for 70% of DAMA in older children. This can

somewhat be compared with the study of Ikefuna and

Emodi in Enugu where infections accounted for more

Unknown

Total

12

150

8

100

Signatories to the discharge document

9

than 50% of cases of DAMA, and is in agreement with

Father

92

27

8

23

150

61.3

18

5.4

15.3

100

that of Okechukwu in Abuja who reported malaria, pro-

tein-energy malnutrition and gastroenteritis with dehy-

Mother

Others

Not stated

Total

10

dration as commonest diagnosis of DAMA in children.

These are all life threatening conditions and well recog-

nised causes of mortality₁a₁mongst children in Nigeria,

especially the Under-fives.

Table 5 shows reasons for DAMA. The commonest rea-

sons for DAMA were lack of funds (26.6%), no im-

provement (26.6%) and perceived improvement

It was observed in this study that the majority of chil-

dren, including neonates, were DAMA within the first

week of admission, which is similar to other reports sug-

gesting that these children left the₉_,₁h₀o_,₁s₃pital prior to hav-

The step follow-

(

22.6%). In 12% of cases, reasons were not stated. Un-

acceptability of treatment for religious reasons (refusal

of blood transfusion) was an important but uncommon

reason for DAMA (3.3%). Some had more than one

reason for DAMA.

ing received adequate treatment.

ing DAMA, to find out where caregivers were taking

these patients was not explored in this study, being ret-

rospective. However, possibilities are that these patients

would seek alternative care either in the private sector

with its intending higher cost, in churches with no medi-

cal intervention, or may end up with traditional healers

Table 5: Reasons for requesting for DAMA

Reasons

Frequency

Percentage

1

5

or are abandoned to their fate.

Lack of funds

40

34

10

9

26.6

22.6

6.6

6

Low socioeconomic status was a common feature re-

ported by the majo₇r_,₉i_,t₁y₀_,₁o₃f authors who studied DAMA in

No improvement

Perceived improvement

Not convenient

Not necessary

Religion

Nigerian children,

and who also identified poverty

as the key factor. It is therefore not surprising that finan-

cial constraints was the foremost reason cited for

DAMA in this study. A s₀imilar reason was also reported

5

3.3

12

2

in Bouaké, Côte d'Ivoire where it was observed that an

Stigma/ cannot cope

Not stated

5

increase in paediatric ward DAMA occurred simultane-

ously with serious budgetary shortfalls in the hospital

resulting in inadequacy of medicines and basic equip-

ment. Subsequently, families were seen to be unable to

afford the purchase of medicines and supplies necessary

for inpatient treatment. Where₂a₁s lack of funds was the

second reason in Brazzaville and ranked third in

18

Discussion

8

Okoromah et al's report, one of the few Nigerian stud-

Discharge against medical advice of child₁₅ren, also con-

sidered a form of child abuse and neglect, is an

ies where it was not mentioned as the first reason, it was

the fourth reason in a study in Teheran, Iran where

nearly all parents lacking health insurance coverage

unpleasant experience for both physicians and children

as these constitute a vulnerable group and are taken

away without considerations of the subsequent medical

problems that may a₆rise, including increased risk of dy-

1

8

cited financial problems as a reason for DAMA; it was

not mentioned at all in more developed countrieswhere

main reasons included dissatisfaction with inpatient

care, wanting to observe₂s₂y_,₂m₃ ptoms at home and non

1

ing post discharge. The prevalence of DAMA in the

present study was 3.8% and wa₇s_-₁₀w_,₁₇i_,t₁h₈in the range of

medical personal reasons.

It is noteworthy that other

other DAMA studies in children.

lower than that found by Okechukwu whose study

It was however

important reasons for DAMA in this study, no improve-

ment (26.6%) and perceived improvement (22.6₁%₈_,₂)₁,

were also reported in some developing countries

1

0

1

3

covered a one year period only and Onyiriuka whose

study was limited to under-five children. Neonates ac-

counted for 40% of DAMA, a finding similar to previ-

ous studies highlighting_,₈neonates as a high risk group

8

,9,13

17,22

as well as in developed ones.

including Nigeria,

This may largely be an indication of failure of or no

counseling of patients admitted, which is essential to

enable them understand the illness and recovery process.

7

for DAMA in Nigeria, though the difference in this

study was not significant (p=0.48).

4

3

Moreover, it has been shown that well-informed care-

givers are more likely to take_,r₈ational health decisions

signed the discharge document in 61% of cases, whereas

mothers who usually stay with the child on admission

and are more in contact with attending physicians were

signatories in only 18%.

3

concerning their sick children. It is therefore possible

that effective communication/counseling between medi-

cal staff and the parents/ caregivers could have pre-

vented some cases of DAMA among children.

Religion was another uncommon but important reason

for DAMA. This involved members of a religious sect

who for religious beliefs, forbade their children from

receiving blood transfusion and subsequently had to

DAMA. This again buttresses the fact that children are a

vulnerable group subject to adult decisions irrespective

of the adverse effects of those decisions on them. With

regard to religious based refusal of blood products by

parents, courts in the western world are of the opinion

that the₄ child’s welfare is paramount and blood can be

Conclusion

Children who were DAMA suffered from common

causes of childhood mortality. Lack of funds, wrong

perception of illness and recovery process, and lack/low

decision making power of mothers were contributory

factors.

Conflict of interest: None

Funding: None

2

given. They reiterate that consideration should be

given to parental views and treatment moderated where

possible but if conflict occurs, the child’s interests al-

ways come first. Declaration of children as wards of

court wh₅en necessary exists in the Child Rights Act of

Recommendations

2

Nigeria, but to what extent these laws are enforced

There is need for more universal implementation of the

National Health Insurance Scheme; effective communi-

cation between medical team and parents and female

empowerment to reduce rates of DAMA in our environ-

ment.

remains to be explored.

1

3

As reported by another Nigerian author fathers in this

study, as principal and often sole decision makers and

custodians of the family’s resources in our environment,

References

1

.

Eze B, Agu K, Nwosu J. Dis-

charge against medical advice at a

tertiary center in Southeastern

Nigeria: sociodemographic and

clinical dimensions. Patient Intel-

ligence 2010; 2: 27-31

Alebiosu CO, Raimi TH. A study

of hospital patients’ discharge

against medical advice in the

Ogun State University Teaching

Hospital, Sagamu, Nigeria. Nig

Med Pract 2001; 40: 33-35

Ayed IA. What make patients

leave against medical advice? JTU

Med Sc 2009; 4: 16-22

Jeffer EK. Against medical advice:

Part I, A review of the literature.

Mil Med 1993; 158: 69-73

8. Okoromah CN, Egri-Qkwaji MT.

15. Osifo OD, Oku OR. Causes, spec-

trum and effects of surgical child

abuse and neglect in a Nigerian

city. West Afr J Med 2009; 28 (5):

313-317

16. WHO. Moïsi JC, Gatakaa H, Berk-

ley JA, Maitland K, Mturi N, New-

ton CR, et al. Excess child mortal-

ity after discharge from hospital in

Kilifi, Kenya: a retrospective co-

hort analysis. Bull WHO

Profile and control measures for

paediatric discharges against medi-

cal advice. Niger Postgrad Med J.

2004; 11: 21-5

9. Ikefuna AN, Emodi IJ. An assess-

ment of factors influencing hospital

discharges against medical advice

of paediatric patients in Enugu: A

review of 67 cases. Niger J Paed

2002; 29: 1-4

10. Okechukwu AA. Discharge against

medical advice in children at the

University of Abuja Teaching Hos-

pital, Gwagwalada, Nigeria. J Med

Med Sci 2011; 2(7): 949-954

11. Federal Ministry of Health. Intro-

duction: Integrated Maternal, New-

born and Child Health Strategy.

Abuja, Nigeria 2007: 9-13

12. National Bureau of Statistics. Ni-

geria Core Welfare Indicator Ques-

tionnaires 2006. Core Welfare Indi-

cators Questionnaire Survey

13. Onyiriuka AN. Discharge of hospi-

talized under-fives against medical

advice in Benin City, Nigeria. Nig

J Clin Pract 2007; 10:200-204

14. Oyedeji GA. Socioeconomic and

cultural background of hospitalized

children in Ilesha. Nig J Paediatr

1985; 12: 111-117

2

.

2011;89:725-732A

3

4

5

.

17. Al-Jurayyan NAM, Al-Nasser

MNS. Children’s discharge against

medical advice: is it a problem?

Saudi Med J1995; 16 (5): 391-393

18. Roodpeyma S, Eshagh Hoseyni

SA. Discharge of children from

hospital against medical advice.

World J Pediatr 2010; 6(4): 355-

356

19. Lawn JE, Cousens S, Zupan J. 4

million neonatal deaths: when?

Where? Why? Lancet 2005; 365:

891-900

Alfandre DJ. “I am going home”:

Discharge against medical advice.

Mayo Clin Proc 2009; 84(3): 255-

2

60

6

7

.

Carrese JA. Refusal of care: pa-

tients’ well being and physicians’

ethical obligations: “But doctor, I

want to go home”. JAMA 2006;

20. Gloyd S, Koné A, Victor AE. Pedi-

atric discharge against medical

advice in Bouaké Cote d'Ivoire,

1980-1992. Health Policy Plan

1995; 10 (1): 89-93

2

96(6): 691-695

Ibekwe CR, Muoneke VU, Nnebe-

Agumadu UH, Amadife MU. Fac-

tors influencing discharge against

medical advice among paediatric

patients in Abakiliki, Southeastern

Nigeria. J Trop Pediatr 2009; 55:

3

9-41

4

2

1. Mabiala-Babela JR, Nika ER,

Ollandzobo LC, Louaka CS,

Mouko A, Mbika AC et al. Dis-

charge of children against medical

advice at CHU of Brazzaville

23. Wong TW, Lee KM, Chan R, Lau

CC. A study of patients who leave

an Accident & Emergency depart-

ment against medical advice. Hong

Kong J Emerg Med. 2000; 7: 22-26

24. Woolley S. Children of Jehovah’s

witnesses and adolescent Jeho-

vah’s witnesses: What are their

rights? Arch Dis Child 2005; 90:

715-719

(Congo). Bull Soc Pathol Exot Dec

25. Child’s Right Act 2003. http://

www.placng.org/lawsofnigeria

2

011

2. Moy E, Bartman BA. Race and

discharge against medical advice.

J Natl Med Assoc 1996; 88: 658-

6

60