Frequency and Causes of Discharge against Medical Advice in Children View PDF

Discharge with personal consent or discharge against medical advice is one of the main problems in hospitalization when the patient leaves the hospital sooner despite the doctor’s advice [3]. This will exacerbate the disease and increase the risk of hospital readmittance. Therefore, discharge with personal satisfaction is the strongest predictor of readmission within the first 15 days of leaving the hospital, and 21% of those who are discharged with a personal consent from the hospital have been re-admitted within the above period. The rate of hospitalization in the first 7 days in patients with the discharge has been estimated as 14% and in other patients as 7%. The re-admission of these patients has been reported more or less in some countries; in Canada, 10% of the discharged patients with personal consent have been rehospitalized, in other countries up to 24.4% and in one case, 3.7%. Discharge with personal satisfaction in Canada has been accounted for 1% of the total discharge, while it is between 0.8-2.2% in the United States. 

A study on patients admitted to the psychiatric ward of the Baqiyatallah Hospital indicated that 3% of patients left theirincomplete phase of hospitalization and were discharged with personal consent [12]; while in the emergency departments this rate has been reported to be 20% [13]. The main reason for discharge with personal satisfaction in the United States is insufficiency of insurance and the economic situation [6,11]. The results from the Mitchell Toronto Hospital indicate that in 28% of the cases, the reason for the discharge with personal satisfaction has been attributed to dissatisfaction with the medical staff, personal or family problems, satisfactory feelings of satisfaction, dissatisfaction with the treatment, feeling Uniformity, boredom and fatigue from the hospital environment and the dislike of the hospital space are mentioned as other reasons for discharge with personal satisfaction [4].

In Iran, the dissatisfaction with diagnostic measures (38.2%) was the main reason for discharge with personal consent of patients [13]. On the other hand, male gender, age 49-35, mental / personality disorders, and drug abuse are also considered as other factors for discharge with personal consent [14].

Lack of complete hospitalization period is a risk factor for relapse, re-admission and increasing monetary burden [3]. Therefore, it is necessary to identify the variables related to discharge with personal consent. The issue of leaving a hospital with personal responsibility is a multidimensional phenomenon and includes factors associated with the patient, structural factors, as well as factors associated with care and treatment. It is important to examine these factors in patients who decide to leave the hospital on a personal basis, because in- depth understanding of this factors are required to identify those who are more likely to leave the hospital, leading to timely action, reducing mortality and morbidity, as well as reducing monetary burden. In this regard, we decided to root out the various causes of the discharge of patients in the pediatric ward of Amirkabir Hospital, Arak, Iran to prevent the complications of this issue.

Therefore, by this effort, it is possible to plan for reducing the risk of death and financial losses caused by the discharge without the consent of the treatment staff.

This study is a descriptive cross-sectional study. The population of this study consisted of all patients with admission in the pediatric ward of Amir Kabir Medical Center from the beginning of March to the middle of June 2014.

Inclusion criteria included:

1. Referring to the Amir Kabir Medical Education Center.
2. Having an admission order in one of the pediatric wards of Amir Kabir Hospital.
3. Consent for participation in the study.

The 4-page checklist for the various causes of “leaving the hospital against medical advice” was divided into three sections: Causes related to the patient’s own issues, causes related to the hospital staffs and the causes of the hospital situation. A page of variables included gender, age, hospitalization history and section, etc.

Patients’ regret of leaving the hospital was measured by telephone over the next two weeks. Moreover, the rate of rehospitalization with the same diagnosis was determined in the next week. Measurement of hospitalization with the same previous diagnosis was carried out on a weekly basis by reviewing the data collected and the completed forms from each department, in collaboration with the hospital admission unit. Among the factors related to the patients themselves, the economic situation, family dependency, the occupation of the patient, the patient’s fear of treatment, lack of companionship, a sense of recovery, being a traveler, etc., were included in the questionnaire, which was filled in each separate section and final evaluation took place.

The factors related to the hospital’s cadre were: lack of appropriate medical treatment by doctors and nurses, inappropriate doctor-patient relationship, inappropriate nurse-patient relationship, timely absence of a doctor, lack of mastery in nursing and medical practice, etc. which were completed and evaluated in each separate section. Regarding the factors associated with the environment and the hospital’s situation for “discharge against medical advice”; improper cleaning, inappropriate equipment, inappropriate nutrition, inappropriate environments, etc. were included and evaluated in each section. Validity of the questionnaire was performed by content validity based on a questionnaire from the professors and its reliability was measured by two-way method (r=0.78). The patient’s questionnaire information was completed by the patient’s parents.

Data analysis

Data was obtained by questionnaire after completing the informed consent form. The data were analyzed by SPSS version 21 after data collection. Descriptive statistics were used to describe the data.

Ethical considerations

It should be noted that the consent form was completed by the participants in the study. During the study, the principles of the Helsinki Declaration and the declaration of the Medical Ethics Committee of the Arak Medical University were respected. In addition, all patient information remained confidential. It also prevented the occurrence of any kind of bias such as personality, dependency, questioning, order, numerical bias, etc.

In this study, a total of 310 personal satisfaction records were recorded for discharge in different parts of Amir Kabir Hospital. In total, 4209 patients were admitted during this period, of which 310 (7.4%) were discharged with personal satisfaction from the hospital.

Of the patients discharged with personal consent, 177 (57.1%) were female and 133 (42.9%) were boys. The mean age of mothers was 27.33 ± 5 years and the mean age of fathers was 32.62 ± 6.5 years. In terms of fathers’ education, 19% of them had middle school degree, 11.9% diplomas, 52.4% bachelors, 14.3% masters and 2.4% of them had a doctoral degree. Among the mothers, 4.8% had middle school degree, 11.9% diploma, 54.7% bachelor’s degree, 26.2% master degree and 2.4% had a doctoral degree.

In the emergency department, from 1402 admissions, 100 (7.1%) were discharged with personal satisfaction. In the pediatric ward, from 1138 admissions, 82 (7.2%) cases were discharged with personal satisfaction. In pediatric ward, out of 542 admissions, 77 (14.2%) were recorded to be discharged with personal satisfaction. In hematology and oncology wards, of the 742 admissions, 1 (0.26%) had personal satisfaction for discharge. In the neonate’s section of 385 admissions, 49 cases (12.7%) were satisfied to be discharged.

In this study, issues related to satisfaction of patients from admission were evaluated separately. These factors included factors related to the patient, health care personnel and welfare.

In terms of factors related to the patient in the emergency department, 56 cases referred to the inadequate economic situation, 26 cases were related to family dependence, 9 cases were afraid of treatment, 28 cases without patient accompaniment, 35 were feeling relieved, 24 were treated as outpatients and 2 items were also recorded as travelers.

Of the parents of children admitted to the pediatric ward, there were 52 cases of economic conditions, 24 cases of family dependence, 10 cases of fear of treatment, 21 cases without patient accompaniment, 24 cases of fleeing of recovery, and 17 outpatients. In the infectious section, 49 cases were discharged for the economic situation, 24 cases for family dependence, 4 cases for fear of treatment, 23 cases for lack of accompaniment, 17 cases for sense of recovery, and 19 cases for possibility of treatment in an outpatient setting.

In the blood sector, only 1 person was discharged with personal consent that parents indicated inadequate economic status and lack of accompaniment. In the neonatal section, 42 cases were referred to the economic situation, followed by a feeling of recovery (9 cases), the possibility of outpatient treatment (14 cases) and being a traveler (2 cases) (Figure 1-4).

In terms of the factors related to the cadre, in the emergency department, 60 cases were related to the lack of medical attention by doctors, followed by lack of appropriate attention by nurses (88 cases), , inappropriate doctor-patient relationship (60 cases), 74 inappropriate nurse-patient relationship (74 cases), inappropriate personnel relations except for doctor and nurse (42 cases), timely absence of a physician (32 cases) and lack of mastery in nursing and medical practice by physician (39 cases) (Figure 5).

Of the parents of patients admitted to the pediatric ward, 54 cases were referred to the lack of proper handling of the physician, followed by the lack of nurse handling (73 cases), inappropriate relationship of the physician with patients (44 cases), inappropriate staff relationship except physician and nurse (26 cases), lack of appropriate relationship of nursing staff with patients (54 cases), and lack of mastery of nurse and physician (21 cases) (Figure 6).

Of the parents of pediatric patients admitted to infectious diseases of child ward, 49 cases were referred to the lack of proper handling of the physician, followed by the lack of nurse handling (49 cases), inappropriate doctor-patient relationship (33 cases), inappropriate nursing staff -patient relationship (44 cases), lack of appropriated relationships of personnel except doctors and nurses (30 cases), timely absence of the doctor (52 cases), lack of mastery of nurses andphysicians (28 cases) (Figure 7).

Parents, the only admitted patient in the blood ward, referred to inappropriate staffing relationships except for physician and nurse. Among the parents of infants admitted to the neonatal department, 19 cases mentioned the lack of proper handling of the physician, followed by the lack of nurse handling (33 cases), inadequate relationship of the doctor with patient (10 cases), inappropriate nursing staff’s relationship (35 cases), lack of appropriate relationships of personnel except physician and nurse (24 cases), timely absence of physicians (30 cases), and lack of mastery of nurses and physicians (10 cases) (Figure 8). Some of the factors associated with the hospital environment were also questioned from parents, as shown in Table 1.

Patients’ regret of discharge against medical advice, was also assessed individually and one week later in each section. Additionally, the rate of re-admission of patients with the same diagnosis was measured within two weeks after discharge with the help of departmental authorities and hospital admission, as indicated in Table 2. In this study, it was asked about satisfactorily (Table 3), but in general, the satisfied person for discharge was patient’s father in 39% of cases and 61% of the patient was discharged because of mother’s satisfaction.

Discharge with personal consent is one of the problems of the system of treatment in all over the world from the point of view of task duplication, burden of disease and its harmful effects on the disease, which leads to the patient deterioration or death [15,16]. This issue needs more attention in children, because they are not able to understand the above meaning or participate in decision making. With personal consent, the treatment may be discontinued, and the patient may become worse, or worse conditions can be occurred such as death, or complications that cannot be compensated for in the long term.

Table 1. Factors related to the hospital from the point of view of parents.

Table 2. Degree of regret and percentage of re-admission with the same previous diagnosis

Table 3. Satisfactory percentage in different wards

However, if the child is brought back to the hospital because of an exacerbation of the disease, this task duplication can be debatable in the entire cycle of treatment costs throughout the country. On the other hand, the treatment staff can only provide the patient or parents with explanations about the discontinuation of treatment and the consequences of discharge with personal satisfaction and in general cannot prevent her leaving the hospital. The second admission may also be associated with more complex complications that will last longer than the first one. In this regard, we looked at the roots of various causes of the discharge of patients in the pediatric ward of the hospital.

The results of this study showed that 4.7% of all hospital admissions in Amir Kabir Hospital during the months of March to mid-May resulted in discharge with personal satisfaction. In terms of education, most parents had a bachelor’s degree (53.5%). According to the factors related to the patient in all wards, the most frequent were the unsatisfactory economic situation (201 cases), the feeling of recovery (86 cases), family dependence (75), lack of patient accompaniment (56 cases), fear of the treatment (23 cases) and being a traveler (4 cases).

The most frequent factors related to the health care personnel were the following: the lack of nurse handling (243 cases), the lack of good relationship of nursing staff (207 cases), the lack of physician handling (182 cases), timely absence of physicians (159 cases), Inappropriate relationship of doctor with patients (147 cases), Inappropriate relationship of the staff except the physician and nurse (124 cases), and the lack of mastery of the nurse and physician (98 cases). In terms of hospital issues, 256 were also referred to as lack of proper welfare services, followed by inappropriate food (179 cases) and cleaning (33 cases). In the present study, during the 3 months and a half, approximately 7.4% of hospital admissions resulted in discharge with personal satisfaction. Meanwhile, in a study by Kabir Zadeh and et al. this rate was about 2.2% in a one-year period [17]. This case was studied by Duno over a two-year period that has been attributed to a prevalence of 34% discharge [18], Abdulrasheed in a one-year investigation showed a prevalence of 2.4% [19], followed by Berger (1%) [20], Seaborn (0.57% during 2 years), [14], and Fiscella (0.07%), [21].

Although the rate of discharge with personal satisfaction in our study is much higher than other studies in this regard, it should be noted that the existence of a holiday on admission days is one of the most important factors that according to Kabirzadeh [17] has a significant relationship with discharge due to personal satisfaction. Since the present study coincided with the holidays of the end of March and the New Year holidays, this difference seems logical, and maybe, in the case of a one-year study, similar results will be achieved with other studies. In the present study, 201 cases (67.7%) of parents mentioned economic issues as one of the reasons for early discharge. Meanwhile, in two studies conducted in the United States, patients also reported the most important discharge factor with personal satisfaction including lack of insurance and low economic status (6,10), which is consistent with the results of our study. In the present study, a high percentage of parents (approximately 50%) were dissatisfied with the medical staff, including the physician and nurse. In the study of the Rangraz, 24.9% of the patients left the hospital due to dissatisfaction with the medical staff [26]. Hwang also reported that 28% of discharge cases were provided with personal satisfaction due to dissatisfaction with the treatment [4]. Other studies have attributed the reasons for discharge with personal satisfaction to a weak relationship of the doctor and medical staff with the patients [22,23], which is consistent with the results of the present study. Considering the relationship between physician and patient plays an important role in patient satisfaction, follow-up of treatment, faster recovery, and lower hospitalization costs, treatment and clinical adequacy of doctors [24,25]. Therefore, more attention of physicians and medical staff is needed for better communication with patients and providing necessary information for patients should be taken into consideration to reduce discharge with personal satisfaction.

In this study, 82.5% of parents referred to the lack of proper welfare facilities in hospitals as a factor for discharge with personal satisfaction. In the study of the Rangraz, 14% of the patients left the hospital for reasons related to the hospital situation, of which 62.1% left the hospital because of the poor environment [26]. In the Hwang study, 14.3% of the patients reported that they generally did not like the hospital environment and therefore left the hospital with their personal consent [4].

It seems that economic issues are the most important factor for leaving the hospital with personal satisfaction. On the other hand, factors such as inappropriate relationship of nurses and doctors play a crucial role in this phenomenon. Parents who are under intense psychological pressure due to their many economic problems and their sick child illness are at risk of developing this phenomenon in the absence of appropriate intellectual and psychological support.

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