What is DAMA / LAMA?
Patients who leave against medical advice are a prevalent problem in hospitals around the world, in both wards and emergency rooms. DAMA, LAMA, and absconding are the terms used to describe such patients. DAMA, or discharge against medical advice, occurs when a patient leaves the hospital without the permission of their treating physician. LAMA, or left against medical advice, refers to a patient who leaves the hospital against the doctor's advice.
As healthcare practitioners, we like to imagine that our charisma and expertise are so valuable that no patient would ever leave the ED or hospital against our wise medical counsel! Regardless of how hard we try or how quickly we work, a few patients will always opt to leave before the evaluation is completed—and against medical advice (AMA). According to available data, around 1.2 percent of ED patients leave AMA. Patients or their relatives would want them to leave for a lot of reasons.
- their expectations have not been realized,
- they felt better,
- they changed their minds,
- and more.
There are a few subtypes to this which include:
The patient runs away from the hospital (absconded)
- The patient departed the hospital without the knowledge of the doctor or other staff members.
- The hospital is unaware that the patient left and has no idea when the patient left.
- During the subsequent rounds, they discovered the truth.
- Patients may not have addressed going out with their doctor or hospital.
- It's incorrect to say, for example, that the patient left at 7 p.m. It is not absconded if the doctor (personally or through other paramedical workers) knows when the patient went out; it is Left Against Medical Advice.
Left against Medical Advice (LAMA)
- The patient was asked to stay/continue therapy by the doctor.
- Patient or their relatives did not notify the hospital of their intention to leave, but they did so unexpectedly.
- However, the hospital was aware of their departure, and at the time the patient left, the doctor had stated that taking the patient out could endanger their life.
- Patient or their relatives did not sign anything
- The hospital may be held liable as they didn’t give any discharge summary.
Discharged against Medical Advice (DAMA)
- Even though the doctor has explicitly said that taking the patient out could threaten their life, the patient or their relatives still wish to take the patient to another hospital.
- They sign a statement acknowledging that they were told about the dangerous possibilities and that by releasing the patient from the hospital, they are instantly threatening the patient's life.
- A discharge summary is provided by the hospital.
Occasionally, the patient or his family will request that the medical device be removed (AMA). If this happens, call your doctor right away. If the physician is unable to persuade the patient to stay in the facility, he will ask the patient to sign an AMA form absolving the facility of all legal liability for any medical difficulties that the patient may encounter after discharge. If the doctor isn't present, talk to the patient about the discharge paperwork and get his signature. Do not detain the patient if he refuses to sign the AMA form. This is a breach of their legal rights. Following the patient's departure, thoroughly document the occurrence in your notes and notify the physician.
Consider the following list of Do and Don'ts as a guide to the AMA process:
- Don't dismiss a patient's desire to leave AMA. Stop what you're doing if at all possible and be prepared to deal with the problem.
- Determine the patient's decision-making capacity. Do they grasp the information and its implications, as well as the risks and rewards of the various options, and can they communicate these to you?
- Don't blame or chastise the patient or anybody else for wanting to have children.
- If the patient has been waiting or if the patient care process has been delayed, please apologize.
- Do not simply ask the nurse to have the patient sign an AMA form. As a healthcare practitioner, you must be present with the patient when they are signing the AMA/DAMA form as any kind of carelessness could put you in a spot.
- Try to persuade the patient’s relatives or friends to convince the patient to stay.
- Don't communicate your displeasure or rage to the patient. Instead, truly persuade them and tell them that their well-being is your first concern. Make sure they know you're on their side when it comes to a potential health concern.
- Do record the patient's "informed refusal" of critical diagnostic testing (e.g., blood tests or X-rays), procedures (e.g., LP to rule out meningitis or subarachnoid hemorrhage), or treatments (e.g., medicines or transfusions) with the same level of detail as an AMA.
- Don't refuse to treat the patient; this could be construed as abandonment. Give the patient whatever therapy, medicines, follow-up appointments, and discharge instructions they want.
- In the patient's chart, make a note of the details of the AMA patient encounter. Include documentation of the patient's decision-making capacity, the specific benefits of your suggested therapy and the risk of leaving AMA, what you did to persuade the patient to stay, and your compassionate desire for the patient to return for whatever reason. Have a family member or staff member witness the patient signing an AMA form that addresses these details.