Discharge against medical advice in pediatrics: A review and recommendation of a five-component approach

Abstract

Patients who are discharge against medical advice (DAMA) present significant challenges on clinical, ethical, financial, and legal levels. Despite its multilevel impact, the factors explaining and predicting DAMA in different regions of the world remain underevaluated, especially in pediatrics. This article aims to provide a scope of review of the phenomenon of DAMA in pediatrics and guide healthcare providers on how to deal with common scenarios of DAMA requests through a five-component approach. A literature search was performed using PubMed with the following keywords: “leave against medical” OR “discharge against medical” AND “pediatrics” OR “child*” without a time limit. This search yielded 30 articles, and two more were added as secondary sources. DAMA is associated with several health adverse outcomes such as a higher prevalence of morbidity, complications, and even mortality. Financial burden associated with medical care seems to be a major factor driving the parental decision as well as difficulties in arranging care for other siblings, the perception that the child’s condition has improved sufficiently to be discharged, parental preferences for traditional or alternative medicine, and dissatisfaction with treatments. Dealing with DAMA requests requires skilled communication paired with a good understanding and the ability to translate the concepts of informed consent and shared-decision making into clinical practice.