An evidence-based approach to reducing discharge against medical advice amongst Aboriginal and Torres Strait Islander patients

Abstract

Discharge against medical advice (DAMA), also referred to as self-discharge, occurs when an in-patient leaves a hospital or healthcare setting before discharge is advised by the treating provider. DAMA causes interruption of treatment therapies and is strongly associated with post-operative complications, increased morbidity and mortality, readmission, and increased healthcare expenditure. It is widely known that Aboriginal and Torres Strait Islander peoples suffer from increased rates of chronic disease and have poorer health outcomes than the non-Indigenous population. It is now understood that Aboriginal and Torres Strait Islander peoples are also overrepresented in self-discharge rates, especially in the rural and remote context (Wright 2009b, Katzenellenbogen et al. 2013, AIHW 2013). DAMA rates are considered a measure of the responsiveness of hospitals to the needs of their Aboriginal and Torres Strait Islander patients. Currently high levels suggest that acute care settings are not effectively addressing the concerns of Aboriginal and Torres Strait Islander patients in order to keep them engaged in care for the duration of their treatment. The literature review identified that there are a number of contributory factors associated with DAMA among Aboriginal and Torres Strait Islander peoples. Several significant factors are: institutionalised racism, a lack of cultural safety, a distrust of the health system, miscommunication, family and social obligations, and isolation and loneliness. Evidence suggests that enhancing cultural safety in hospitals is instrumental in reducing self-discharge. Cultural safety is based on partnership between provider and patient, in which shared respect underpins improved communication, treatment decisions and health outcomes (Wright 2009b). For the Aboriginal and Torres Strait Islander population, the presence of Aboriginal Health Workers (AHWs) and Aboriginal Liaison Officers (ALOs) has been demonstrated to enhance cultural safety, improve patient care, and in certain cases, significantly reduce self-discharge (Einsiedel et al. 2012, Katzenellenbogen et al. 2013). AHWs and ALOs are well placed to help reduce DAMA in the Aboriginal and Torres Strait Islander population. However, institutional changes are needed to optimise this role. Greater employment and utilisation of AHWs/ALOs in hospitals, underpinned by a nationally recognised scope of practice, can enhance their ability to provide culturally appropriate care to Aboriginal and Torres Strait Islander patients. Coordination between acute and communitybased care providers can aid in offering healthcare services that are more accessible and culturally acceptable. Improved community care and health education may encourage Aboriginal and Torres Strait Islander patients to remain in care for the duration of their treatment.