Introduction
Patient discharge from hospitals and other healthcare institutions providing primary and specialized acute care constitutes a critical component of the care delivery process. Research demonstrates that the quality of patient discharge teaching and information influences most patients’ readiness for discharge and perceptions of care [1, 2]. Effective patient discharge planning promotes full recovery, medication adherence post-discharge, and self-care management, especially for surgical patients and patients with chronic illnesses or medical conditions [3]. Also, increases in medical errors, post-discharge infections, and hospital readmissions result from poor patient discharge education and planning [4, 5], leading to high costs of care and adverse health outcomes.
Despite the positive effects of planned patient discharge on patient health outcomes and post-discharge care management, many patients and their families often request discharge against medical advice (DAMA). DAMA occurs when a patient leaves the hospital before the attending physician recommends their discharge, a phenomenon associated with hospital readmission and risks of death and frequently occurs among youth, males, homeless patients, and those with mental health conditions [6].
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The literature identifies multiple factors that push patients and their relatives to demand DAMA. In a prospective cross-sectional study, Abuzeyad et al. [7] explored the rate and reasons for DAMA among 299 emergency patients in Bahrain and reported feeling better, long wait times, disagreement with prescribed medical procedures, dissatisfaction with care, and financial obligations as reasons. Similarly, Bhoomadevi et al. [8] explored DAMA cases in a multispecialty hospital in India and discovered that out of the 200 patients admitted to the emergency department, 91 requested DAMA. High costs of care and preference for other hospitals due to easier accessibility and prior relationships with physicians were the commonly reported reasons [8].
Kwok et al. [9] studied DAMA among acute myocardial infarction patients in the United States of America (USA) to determine rates, trends, and predictors between 2010 and 2014. Analysis of data obtained from over 1.5 million patients revealed an increasing trend of DAMA among this patient population. Patients who requested DAMA were uninsured or had Medicaid, had comorbid conditions, misused alcohol, smoked, were younger men, or belonged to a lower economic class [9]. Also, Abuzeyad et al. [10] conducted a similar study in Saudi Arabia among 413 emergency patients reporting long waiting times, demands for child care, and refusal of medical procedures to influence DAMA. Abuzeyad et al.’s interaction with 41 readmitted patients who previously had DAMA revealed that many had worsened conditions and were admitted to different units, including the intensive care unit [10].
Among patients experiencing substance misuse and addiction disorder, research has identified causal factors of DAMA to include stigma, untreated withdrawal syndrome, limited methadone and opioid agonist therapy, and increased mental health disorders [11‐13]. Simon et al. [12] explored DAMA among 15 patients with substance use disorder (SUD) who indicated that many patients with SUD experience DAMA due to ongoing cravings for drugs, stigma and discrimination against them by care providers, and severe hospital restrictions [12]. In addition, Simon et al. [12] found experiences of severe and uncontrolled pain and thoughts of being incarcerated for exacerbating DAMA, especially among patients who were previously incarcerated.
In neonatal and pediatric care contexts, the incidence of DAMA has been attributed to parents’ perceptions about the children’s conditions, parents’ responsibilities towards their other children, length of hospital stay, duration of treatment, and perceptions of care satisfaction [14‐16]. DAMA in the pediatric context can be challenging given that most healthcare decisions are made by the parents and caretakers of this patient population [17, 18].
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Ambasta et al. [19, p.1] critiqued the notion of DAMA as a deviant patient behaviour among “young, male, socially isolated and economically disadvantaged individuals”, arguing that DAMA could emanate from critical gaps in the healthcare system. Ambasta et al. [19] further maintained that the rise in DAMA across different healthcare contexts could be due to ineffective and non-patient-centered care practices that disproportionately affect vulnerable patients, leading to inefficient, untimely, inequitable, and unsafe care. Inefficient care delivery practices, untimely provision of care services, inequity in healthcare access, and poor patient-provider relationships are healthcare system-level factors predisposing patients to demand DAMA [19].
DAMA occurs in some hospitals in Ghana, yet this phenomenon is understudied. A retrospective study conducted in the Tamale Teaching Hospital over two years showed a 2.5% rate of DAMA within the period where 210 out of the 8,565 admitted patients requested DAMA. Among these patients, young male patients with fractures and head injuries constituted the largest subgroup who demanded DAMA [20]. Patients’ preference for herbal treatments, domestic demands, progress in recovery, and high costs of care in the hospital were reported among the factors responsible for DAMA [20]. Similarly, in a qualitative case study about patients with high-grade intestinal obstruction, Mensah [21] explored ethical and medicolegal dilemmas that patients’ DAMA present to clinicians. Mensah (2020) noted that high medical bills and the inability of clinicians to assess the patient’s condition objectively prompted the patient and his relatives to demand DAMA with the patient later dying after discharge. Mensah [21] found that an increase in faith-based healing, costs of healthcare, and constraints in the formal healthcare system are critical factors to consider when examining DAMA cases. Furthermore, Mensah [21] recommended a legal understanding of DAMA and collaboration among doctors, faith healers, and non-governmental organizations to explore pathways to managing factors that potentiate DAMA.
This article presents clinical cases of DAMA from the Yendi Hospital to understand the underlying reasons for patients’ and their families’ requests for DAMA. Limited qualitative research and understanding of this phenomenon in the Ghanaian setting make this study unique. We present five clinical cases of DAMA and explore the embodied factors that gave rise to DAMA in those cases. Based on our findings and evidence from the extant literature, we argue for the need to reconceptualize DAMA from a person-centered care (PCC) perspective.
Theoretical and conceptual framework
Our analysis and interpretation of the findings are influenced by Purnell’s [22, 23] cultural competence and Kwame and Petrucka’s [24] person-centered care and communication continuum (PC4) models. Purnell’s [22, 23] cultural competence model recognizes the relevance of culture and cultural values on health behaviour and interpersonal interactions in healthcare contexts. The model conceives cultural competence in care as providing care that respects clients’ cultures in a conscious and nonlinear process [22]. When healthcare providers are culturally competent, they do not allow their own cultures, including professional cultural socialization, to unduly influence their practices, behaviours, and relationships with others. A culturally competent care provider will go beyond a superficial understanding of DAMA, as patient behaviour of leaving care when they are not fully recovered and formally discharged by a physician, to explore the situated and contextual determinants driving this phenomenon. Also, Kwame and Petrucka’s [24] PC4 model requires that care and communication processes consider the health needs, values, perspectives, and circumstances of the patient and their family. When care delivery and communication in patient-family-provider interactions are person-centered, respectful, and dignified, issues driving DAMA would be minimized or eliminated. These models recognize the values of effective communication and cultural diversity as crucial to understanding patients and their decisions to discharge from hospitals, especially in Ghana. Additionally, the models demand that care providers understand what is meaningful to patients and work with them to achieve that.
Methodology
Data reported in this article came from a doctoral research project conducted in Ghana. Qualitative research designs were implemented in the broader project, including institutional ethnography, critical discourse analysis, and interpretive phenomenology. However, the data used in this paper aligned more with the institutional ethnographic perspectives. Institutional ethnography is a critical qualitative theory and methodology that explores people’s everyday local experiences and the norms and practices that influence the everyday lives of people [25, 26]. By engaging in this line of inquiry, we explored how healthcare institutional culture, practices, and norms mediate social interactions and healthcare outcomes. Observations were undertaken to understand how the everyday healthcare institutional norms, contextual factors, and communication practices determine interactions among patients, caregivers, nurses, and clinicians. As Kearney et al. [25] argue, in institutional ethnography, the emphasis is to understand what people do, say, and know as well as explore the social relations that organize people’s experiences in the institutional setting. Most DAMA cases reported in this article were gathered through ethnographic participant observations.
Study setting and participants
The broader study was conducted in the Yendi Municipal Hospital in northern Ghana. The hospital is a referral facility serving several district hospitals in the region. Our study participants included nurses, patients, and caregivers, and were recruited using purposive sampling. Nurses must have served in the hospital for at least three years and provided voluntary consent to participate in the study. Patients were included if they could engage in individual interviews for at least 20 min and provide voluntary consent to participate in the study. Caregivers were included if they had stayed in the hospital for at least a day, were willing to share their own experiences, and provided voluntary consent. All included participants were 18 years and older. These inclusion/exclusion criteria enabled the recruitment of participants with in-depth knowledge and experiences about patient-provider interactions and communication practices in the hospital. Eleven (11) nurses, 11 caregivers, and 21 patients participated in the broader study.
Data collection
In-depth individual interviews, focus groups, and ethnographic participant observations were used to gather data. Informal chats with nurses, a few caregivers, and three hospital unit heads provided additional data. We conducted all interviews with nurses and some patients and caregivers in English. Interviews with other patients and caregivers were conducted in Dagbani, the dominant native language of the region. Thirty-nine (39) in-depth individual interviews, one focus group, and over 400 h of participant observations (an average of 5 h of daily observations for 5 months) were conducted from December 2021 to April 2022.
All interviews were audio recorded with participants’ consent. Interviews recorded in English were transcribed verbatim while those conducted in Dagbani were listened to and transcribed in English, while retaining important Dagbani words and concepts that could not be translated without losing significant meaning. A focus group was conducted with four surgical maternity patients. The field researcher who conducted data collection and analysis is a native speaker of Dagbani and has in-depth knowledge of the culture and language use practices.
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Participant ethnographic observations were conducted across nine patient wards. These observations targeted spatial organization, patient-provider interactions, communication and language use practices, access to care services across different periods, and everyday social interactions outside clinical spaces. These included activities of petty traders and caregiver interactions outside the patient wards. Field notes were written for each observation session and organized according to patient wards. A whole week was dedicated to each patient unit after which different units were visited randomly at different times to gather first-hand experiences of actual behaviours rather than reported behaviours. The interviews, focus group, and participant observation data reported in this article were gathered for a doctoral research project, hence, some of the data are reported in a previous study [27].
Data analysis
Data collection and analysis were iterative. Since interviews and observations were conducted concurrently, initial interviews were transcribed before subsequent interviews were conducted. All interview transcripts and field notes were manually inductively coded. Interview transcripts for nurses, patients, and caregivers were coded separately to identify participant experiences.
Inductive coding generated categories including beliefs, cost of care, language barriers, patient rights, discharge types, and power dynamics. Related codes were grouped to form themes using Braun and Clarke’s [28‐30] reflexive thematic analytic and critical discourse analytic techniques [31, 32] to identify power and ideological issues in patient-provider language use and communication practices. The field notes were also coded and analyzed to identify institutional practices, including healthcare management routines, everyday interactional patterns, and patient-provider behaviours that determine care delivery and social relationships. These analytic approaches helped us identify critical cases of patient discharge reported in this paper.
Ethical approvals
The research project part of whose data is reported here gained the University of Saskatchewan ethics approval (Beh-ID: 2690) and the Ghana Health Service ethics clearance (GHS-ERC:005/11/21). Local institutional and Dagbon cultural protocols were also observed. Participants signed, thumb-printed, or orally provided their voluntary consent to participate in the study. Anonymity and the confidentiality of the data were enhanced by deidentifying participants’ information using serial numbers and pseudonyms.
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Results
Patient discharge types
Based on participant observation and interview data, three types of patient discharge were documented, which are presented here to help us reconceptualize DAMA with the range of types of discharge.
Regular discharge
With this type, the patient is fully recovered, and the doctor or clinician is satisfied that the patient has recovered. The patient is then clinically approved to leave the hospital. Nurses take the patient through discharge medication planning regarding how to use the medicines and education around self-care management post-discharge.
Discharge against medical advice
In this discharge scenario, the patient is not fully recovered, and requires monitoring and medical care; however, the patient or their relatives want the patient discharged so that they can continue with home treatment. This type of discharge often occurs when patients or their relatives suspect that the patient’s condition is a spiritual illness or when they think that traditional remedies could be successful. The patients or their relatives are requested to write a formal letter requesting discharge against medical advice. The letter is kept in the patient’s folder, and they are discharged so that if anything happens to the patient later, the relatives and the patient cannot hold the hospital or the medical officer responsible.
Patient absconded
A patient may run away from the hospital without any formal discharge. For patients who were unable to cover the cost of care or when the providers do not address their demands/requests, this kind of discharge may result. Also, when clinicians refuse to discharge the patient because they think the patient is not well enough, the patient might run away without being formally discharged. Furthermore, a patient may abscond without the formalities of discharge because they choose to leave usually without settling their bills.
The cases
In this section, we present five cases of DAMA to understand the underlying factors in patients’ decision to terminate care in the hospital.
Case 1: a male ward patient
This case is about a 62-year-old male patient admitted into the male ward, presenting with severe chest pains. He narrated that he first went to a district hospital in his hometown and was admitted for three days. His condition was not improving so he asked for discharge, which was granted. After staying home for another day, he decided to come to the Yendi Hospital, as explained below.
My illness is chest pains. It started from around my left lungs and went up to my chest region making it hard for me to breathe. When it started, I went to X hospital (hospital name withheld for anonymity reasons). I am a resident of that town. I stayed in the hospital for three days. I felt so much pain and couldn’t sleep on the third day. So, I pleaded with them to discharge me, which they did. But still, I couldn’t sleep when I went home. So, I came to this hospital yesterday, and I thank Allah for the care and support so far. (Patient interview data)
The requested discharge in the above case could be considered a DAMA, given that the patient had not fully healed. Nevertheless, it was a negotiated act. The intention to go to another hospital, which often comes up in the DAMA literature (as a preference for another healthcare facility or physician), is not fully explored to understand the nuances of patients’ requests for discharge.
Case 2: a maternity patient
This case involved a 36-year-old maternity patient presenting at the hospital with an over-term pregnancy and high blood pressure. The patient was admitted into the maternity ward and requested to go and retrieve her folder from the records unit. The patient went and never returned to the ward. The physician and nurses were worried about what happened. The following day the patient returned to the ward and was questioned. The midwives and attending physician scolded her for running away when she was admitted the previous day. The field researcher was informed about this incident when he entered the ward to observe patient-provider interactions. The lady was unhappy, so the researcher interacted briefly with her to hear her story. The patient revealed that when she went for her folder, she waited for several hours and there was no staff at the patient records unit to serve her. While waiting for the folder, she had a phone call and was informed about the passing (death) of her husband’s relative. Additionally, she needed to go and pick up her son from school. Because of these events, she decided to leave the hospital and return the next day, instead of wasting her time at the patient records unit. The lady was crying for being scolded because she felt she had done the right thing by not wasting her whole day in the hospital. On the other hand, the healthcare providers were unhappy because the patient did not recognize the severity of her condition (over-term pregnancy and high blood pressure).
From the above case, it could be determined that long waiting times, social responsibilities, mismatched perspectives regarding illness severity, and health literacy were the underlying factors contributing to the patient leaving the hospital.
Case 3: emergency patient with a stroke
This case involved a 34-year-old male patient brought to the emergency ward from a nearby community. The patient could not speak or stand unassisted. He could not move his right leg. When the nurses asked the patient what happened to him, he struggled to talk but could not. The relatives explained that he was resting on a couch and suddenly fell when he tried to get up. Clinical examination revealed that the patient had suffered a mild stroke. The patient was then put on a stroke management plan and the relatives were informed about the diagnosis. An hour later, they requested the researcher conducting participant observation in the ward to tell the nurses and the attending physician that the patient should not be injected. According to the relatives, this request was based on phone consultations with other elderly family members. The following morning when the researcher returned to the ward, he learned that the patient’s relatives had asked for a discharge to seek traditional healing for the stroke. The field researcher asked the patient’s brother why they wanted a discharge, and he said late the previous night, he went to use the washroom and when he returned the patient had fallen off the bed and was lying on the floor, with a cut on his forehead. There was no nurse, so they (the patient’s relatives) managed to put the patient back on the bed. According to the caregiver, the nurses did not even ask about what caused the cut on the patient’s head. Also, the caregivers claimed that the patient was not improving from his condition. At last, a clinician came, reviewed the patient’s folder, and discharged him according to the family’s wishes. This field note was documented on Friday, January 14, 2022.
This case highlights the following as the underlying factors for the request for discharge. Health beliefs about stroke, perceptions of no progress in the patient’s condition, an assumption of lack of proper care because the patient fell off his bed and had a cut, and no nurse was aware or inquired about the cause of the cut.
The nurses had a different opinion about this DAMA request. They believed that it was not right for the relatives to take the patient home for traditional treatment. One of them indicated that usually patients with similar conditions get worse and may have to return to the hospital. The nurses said a similar DAMA case occurred in the ward involving a patient who had comorbid stroke conditions, but the relatives took him home and when the condition was not improving, they brought the patient back, but unfortunately, the patient later died.
Case 4: emergency patient with a fracture
This is a case of a 25-year-old male patient with a fracture that was brought to the emergency unit. A nurse narrated the case as follows.
I can recall a day when a patient came with a clavicular fracture, and then the relatives wanted to send the patient home for local treatment, we were advising them to stay for further management in the facility or possibly a referral because, in the hospital, we can’t do a CT (computerized tomography) scan to ascertain the degree of the fracture, but the relatives had a different perception or view about hospital treatment with cases like that, so they didn’t agree with us. They wrote against medical advice and sent the patient home (voice lowered). The patient too wasn’t talking though he was over 18 years old, he could consent to his treatment. But the fracture affected him, and he couldn’t consent. We thought the patient wasn’t well enough to go home. We wanted the patient to stay so we could observe his progress before discharge. But the relatives too in one way or the other, you know the culture and their beliefs, you can’t ignore their beliefs. But we couldn’t have discharged the patient without them bringing in a letter that says they are seeking the patient’s discharge. (Nurse [N6] interview data)
Based on the above narrative, two critical factors were noted: the lack of specialized medical tools and specialists, and the caregivers’ health beliefs were the reasons for requesting discharge.
Case 5: pediatric patient
On Monday, February 28, 2022, while the field researcher was undertaking participant observation, a young mother and her son were admitted into the children’s ward 2. The child had severe anemia and needed immediate medical attention and close monitoring, so he and his mother were admitted. The next day, the mother requested that her son be discharged. She indicated that they were not residents of Yendi. They visited a friend when the baby got ill. So, she didn’t have enough money to stay for long or cover the cost of care, even though she had valid national health insurance coverage. She revealed that she had no relatives in Yendi, except the friend she visited. The charge nurse advised her to stay another day for the pediatrician to monitor her son. The lady pretended to agree with the nurse but absconded from the ward later that day.
When the field researcher interacted with the nurse about this case, the nurse said many mothers feared the bills they would get, especially if the patient were non-insured. The nurse said the fear of high medical bills makes many mothers dislike long stays in the ward with their sick children.
The above instance of DAMA relates to high costs of care. However, other underlying factors are discernible, including accessing healthcare in a hospital far away from the patient’s place of residence and lack of family support. Even though the lady had health insurance coverage for her son, medical bills that were not covered by health insurance, the cost of living, and the lack of family support could have forced the mother to abscond, despite being advised to stay another day for further treatment. Improvement in the child’s condition may have also motivated the mother to demand her son’s discharge.
Underlying reasons for requesting discharge in the above cases
This section explores the significant underlying factors responsible for patient discharge in the above cases. We found that health beliefs and cultural norms, costs of care, health literacy, length of hospital stay, and recovery outcomes were primary reasons for these DAMA cases.
Health beliefs and cultural values
People’s health beliefs and cultural perceptions about illnesses influence their health-seeking behaviours. Among many cultural groups in northern Ghana, certain illnesses are believed to be treated better by traditional healers; as a result, when such illnesses are diagnosed in the hospital, patients and their relatives may refuse certain treatment procedures or request discharge for home treatment. Some Dagomba believed that when a person has a stroke, s/he must not be injected because doing so could worsen the patient’s condition. There are other beliefs and perceptions about treating fractures in the hospital, including beliefs around shared dairi (spiritual dirt). Hence, health beliefs and perceived cultural norms led to DAMA in Cases 3 and 4. The following excerpts further support our interpretation.
Most cases we get here include fractures. We even have one patient now that we are preparing to refer to Tamale Teaching Hospital (TTH). Sometimes, some of them, like the one here, have a clavicular fracture, and in many cases, we’ve referred most of them to TTH, and mostly, some of them will say, ‘No, I am not going to TTH, I am going to a local bonesetter.’ And usually, when they go for local healing, it doesn’t help them. (Nurse [N1] interview data)At times, patients come with cases, and you want to refer them for further management, like to TTH, and they will tell you they want to do divination to ascertain whether it is safe for the patient to be taken there. Sometimes, a patient will come with a fracture and because we don’t have an orthopedic surgeon, you want to send the patient to Tamale to see a specialist, and the relatives will tell you they want to go for a local treatment. They believe in local treatment rather than going to Tamale for the orthopedic specialist to see the patient. (Nurse [N4] interview data)
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These narratives support our analysis that health beliefs and cultural norms about illnesses drive patients to demand discharge for alternative healing. Some healthcare providers may lack cultural competency to fully appreciate these beliefs and norms to dialogue meaningfully with the patient or the caregivers. Cultural competence training and PCC practices can empower healthcare providers to engage patients with these beliefs.
High costs of care
Cost of care also seems to present significant challenges to many patients and their relatives, forcing them to request discharge from the hospital when healthcare providers feel that further treatment would have been better. Case 5 shows how the cost of care can push patients and their relatives to demand discharge. As a nurse noted, patients can also request discharge when referred to other facilities they feel are costly.
Sometimes clinicians write medications for patients or their relatives to go and buy and they will tell you that they want to take the patient home for treatment. Or when they refer the patient to TTH, they will say you should discharge them so that they manage the illness at home. (Nurse [N4] interview data)
Another request for discharge due to high healthcare cost was noted during participant observation in the maternity ward.
A maternity caregiver requested from the ward in charge that he wanted his wife discharged so that they could manage her home. The patient had a low blood count and was given three bags of blood but still needed one or two more, so, the patient’s relatives were asked to look for more blood. The charge nurse told the caregiver that the patient could not be discharged. She said patients with low blood count and high blood pressure must be kept in the ward for as long as it takes to stabilize them. The midwife believed that if the patient was discharged, and taken home, the husband would not do anything about the patient’s low blood count problem. However, it was discovered that the relatives could no longer afford the cost of providing more blood for their patients, which was why they wanted the patient discharged. (Field notes, documented on Friday, January 28, 2022).
These above excerpts point to the impact of costs of care on DAMA cases.
Health literacy
Health literacy in this context means people’s abilities to receive, process, understand, and make healthcare decisions based on available health information, which determines health behaviour, including DAMA cases. Low health literacy may correlate with low education and affect people’s capacity to understand and act on health information. It can prevent people from assessing and understanding a patient’s health conditions, and what management is required. We argue that low health literacy influenced Cases 2, 3, and 4. A clinician commented on DAMA and health literacy:
A patient was discharged against medical advice two days ago. Now he is back in the hospital. I am not happy with the patient. Sometimes the relatives make these demands without the patient’s consent. They may either be ignorant about the condition or because of the cost involved. These requests are a daily experience here, which we are not happy about. (Field note documented on Friday, February 25, 2022).
The clinician also blamed the frequent requests for DAMA on low health literacy, claiming that many patients and caregivers who asked for discharge were often illiterate.
Patients’ length of hospital stay and recovery outcomes
Some cases suggest that when patients experience long stays in the hospital or when their conditions do not improve, they or their relatives demand discharge to access alternative treatment or use other facilities. Case 1 illustrated how perceptions around recovery outcomes had influenced the patient to ask for discharge. Another observation to support this perspective is noted below:
During a participant observation of nurse-patient interaction in the emergency ward, a visitor came in to see a patient. After interacting with the patient, the visitor interacted with the field researcher when he learned about our research. He said he brought his son to the patient unit a week ago and for several days his son was not recovering so he requested a discharge and took him to another hospital. He blamed his son’s lack of recovery on the hospital’s lack of specialists and medical equipment. (Field notes documented Monday, January 10, 2022).
Prolonged hospital stays and perceptions of recovery outcomes may frustrate patients or their families, forcing them to request discharge.
Other factors
Other less obvious factors, including social responsibility demands (in Case 2), lack of medical specialists, and specialized medical equipment, seemed influential in DAMA requests. The hospital lacked medical specialists and equipment, such as CT scans and an orthopedic nurse specialist; hence, severe fracture cases could not be properly treated. Moreover, on Monday, February 7, 2022, a surgical patient was in the male ward for four days and the only medical doctor in the hospital was yet to attend to the patient. The patient complained to the nurses and threatened to go home the next day if no doctor came to see him.
Discussion
In this paper, we explore clinical cases that illustrate patient DAMA, discuss the underlying factors that drive these incidents, and argue for constructing a new understanding of DAMA. Analysis of the presented cases revealed a complex web of social determinants of care that influence patients and their families to discontinue care and demand discharge.
Our results showed that health beliefs and cultural norms about certain illnesses force patients and/or their families to request discharge. The prevalence of DAMA in the hospital, especially around fractures, stroke, and other illnesses, was persistent. Yet, some healthcare providers continue to perceive these incidents from their frame of medical training and knowledge, rather than considering the cultural factors and beliefs that drive patients and caregivers to request discharge. Our results support previous studies on the impact of health beliefs on DAMA and other health-seeking behaviours in Africa [20, 33]. As found in our study, some reasons for DAMA require cultural competence and PCC practices from healthcare professionals.
We believe that less adherence to PCC and the lack of close attention to or limited knowledge about cultural differences in the care delivery process could prevent engagement with patients or their families to explore cultural beliefs further while managing patients’ illnesses in the hospital. The Yendi Hospital had an alternative medicine unit to provide herbal medicine and other alternative medical services. Yet, patients who access traditional medical services before reporting to the hospital or use traditional medicines while seeking care in the hospital are often scolded or verbally abused. Such incidents reflect a lack of sensitivity to cultural values underlying people’s health beliefs. It further demonstrates the need for cultural competence and PCC training for care providers.
High cost of care is a significant factor in DAMA incidents in our study setting and across other countries [33, 34]. When patients or their families cannot cover the costs of medical treatments or referrals, the easy way out is to demand discharge. Even when patients have health insurance coverage, they could still engage in DAMA, as in Case 5, or refuse to honour transferal arrangements to facilities with specialists and better equipment, as in Case 4. Moreover, the high cost of care often forces patients to abscond from many hospitals in Ghana [35].
The length of hospital stay and perceptions about recovery outcomes determine patients’ ability to continue treatment in hospitals [36]. When patients and their caregivers have stayed in the hospital for several days, weeks, or months and do not see significant progress in their patient’s health, DAMA appears the only choice. As seen in this study, the male ward patient (Case 1) and the emergency patient with a stroke (Case 3) employed discourses of lack of progress in recovery to demand discharge. These cases position patients as powerful agents who value their health and will do anything to have that restored, even if it means leaving the hospital. Therefore, the notions of deviancy or seeing patients as being ignorant about their healthcare needs, as current definitions of DAMA seem to suggest, are problematic [19].
This study found low health literacy as an underlying reason for DAMA, as reported in other studies across sub-Saharan Africa [34]. Toluse et al. [34] reported that many patients requesting DAMA had limited or no formal education, suggesting that DAMA among this patient population was significantly associated with low health literacy. In our study context, low health literacy was understood to mean patients’ inability to assess the severity of their illnesses or medical conditions, thereby not appreciating treatment recommendations given by healthcare providers. Our results suggest that healthcare providers must embrace PCC and communication to engage and empower patients to understand the medical perspectives they bring into the care process. When patients’ circumstances are assessed, understood, and respected, care providers can appreciate patients’ or caregivers’ fear, lack of knowledge, and misperceptions [24]. Moreover, patients and caregivers are more receptive to health education when healthcare providers respect them as persons, communicate effectively, and treat them with dignity [37]. Lack of effective communication, non-PCC practices, and negative attitudes of healthcare providers are cited among the reasons why patients and their families request DAMA [19].
Long waiting times and lack of medical specialists and equipment are healthcare system-level factors influencing patients’ decisions to quit hospital care and request discharge [7]. When patients or their families feel that a hospital does not have the specialists and/or equipment to treat an illness or realize that they must wait for a long period to access care services, they may choose to seek discharge to access care elsewhere. Although healthcare staff shortages and other resource constraints are beyond the provider’s reach, healthcare managers and institutional leaders can promote patient rights to prompt care by not delaying access to appropriate care [27]. Patients should be appropriately transferred to facilities where they can promptly access the needed care.
Lastly, patients’ social responsibility demands were found to incite them to leave the hospital at some point during treatment. Research shows that patients’ social responsibilities and childcare demands, especially for single-parent patients, mostly force them to request DAMA [38].
Reconceptualizing DAMA
Based on our data, we argue that DAMA needs redefining. A more comprehensive definition of DAMA must capture some intricacies around the different patient discharge types (i.e., against medical advice and patient abscond). We reasoned that perceiving DAMA as a deviant patient behaviour seems shallow and does not consider patients’ contextual circumstances and rights. Moreover, current understandings of DAMA suggest that patients are un- or under-informed about their care needs. In the extant categorization of DAMA, patients are rendered powerless regarding their decisions to continue or terminate care. This situation leads us to ask this question. What happens when a patient is discharged but s/he feels they still need to stay in the hospital?
Thus, we suggest that DAMA should be understood simply as a patient’s decision to discontinue care based on their personal or familial circumstances at any point in time in the care delivery process. This conceptualization embraces the individual patient’s desire to discontinue care and/or the patient’s family’s request to terminate care for the patient, due to the underlying reasons identified in the clinical cases presented in this study or as reported in the literature. Besides, our reconceptualization of DAMA is supported by research evidence showing that many patients return to the same or a different hospital after DAMA or even after regular discharge with the same condition.
Implications for healthcare practice and research
Our results show that health beliefs and cultural norms, high costs of care, length of hospital stay, perceptions of recovery, low health literacy, long waiting times, and social responsibilities are underlying factors that push many patients and caregivers to request discharge when the patient is not fully recovered. We examine the implications of these findings for health policy, practice, and management.
Patients and their families seek healthcare services in hospitals because they feel they need help and hope healthcare providers will support them to achieve their health goals. However, when some patients and their caregivers request DAMA, it presupposes they no longer have hope of receiving the needed support to achieve their health goals. Within this premise, we argue that the conceptualization of DAMA must shift. As DAMA is seen as a patient decision to terminate care based on personal and familial circumstances, healthcare providers and healthcare systems can embrace PCC and engage patients and their families more in the care process. From this understanding Mylod and Lee’s [39] Hope Theory becomes relevant. By hoping for better healthcare outcomes, healthcare providers must change or lift patients’ and their families’ beliefs that a meaningful positive outcome is attainable [39], and to achieve that hope, they must pay attention to patients’ and caregivers’ cultural beliefs, and ensure that respectful and dignifying care is provided based on a patient’s unique needs. Mylod and Lee [39, p.3] argue that “the notion of Hope encompasses both the belief that what is dreaded may be avoided … [and] what is desired may occur.” Creating and sustaining this hope demands that care providers understand patients’ goals and partner with them and caregivers to achieve those goals, which must be considered within a reconceptualization of DAMA.
Effective person-centered communication, a component of the PC4 model [24], is critical in DAMA discussions. Healthcare providers must take their time, be sensitive to patients’ beliefs and values, and communicate therapeutically by addressing patients’ and their relatives’ fears, frustrations, expectations, and misunderstandings at the point of DAMA requests. Given the social determinants of health that escalate the failure of the care relationship towards DAMA, respectful and dignifying communication is crucial to help care providers dialogue with patients and their families to deal with the underlying factors that may lead to DAMA. Machin et al. [40] advised care providers to exercise empathy and to enhance dialogue when interacting with patients who demand DAMA since patients may be reclaiming their agency and voice. Even in “normal” patient discharge, patients and their families desire care providers to listen to them, involve them in discharge decision-making, and consider their social circumstances and health literacy levels [41]. All these relate to valuing effective communication and PCC.
Based on our findings and evidence from the literature, we have reconceptualized DAMA to capture the nuances and complexities it entails. Defining DAMA as “a situation in which a patient decides to leave the hospital against the recommendation of the treating physician” [15, p. 153] is inadequate. Ambasta et al.’s [19, p.1] conception of DAMA as “the choice of a competent patient to decline further inpatient treatment” is adequate, but less comprehensive compared to our definition of DAMA as a patient’s decision to discontinue care based on their personal or familial circumstances at any point in time in the care delivery process. When patients request DAMA it could be due to several factors, some of which are healthcare system-related or the inability of healthcare providers to understand patients’ perspectives and contextual circumstances – hence less equipped to support patients/caregivers navigate this critical healthcare challenge. Understanding DAMA in this light makes it a normal, although unusual, part of the care delivery process, to offer healthcare providers, managers, and administrators the opportunity to gain feedback on these incidents. As Ambasta et al. [19, p.2] advised, “these irregular discharges should raise questions about potential quality gaps in our healthcare systems patients [experienced] that may subsequently impact patient safety”. By seeing patients’ decision to discharge as part of the care process, an opportunity is created for clear documentation of DAMA processes and not just a request for a signed formal letter from patients and their families that absolves physicians and healthcare institutions of any future harms of DAMA to patients [19].
Healthcare providers must embrace cultural competency and cross-cultural communication skills and training to equip themselves with the knowledge to engage with patients and their families on cultural issues and health beliefs that impact healthcare behaviours [42]. Especially in contexts where multiculturalism is a norm, healthcare providers cannot afford to disregard sensitivity to cultural differences and PC4 dimensions in the healthcare context and their impact on care access/delivery [42]. The need for cultural competence becomes crucial in situations where the request for discharge is coming from the patient family.
Furthermore, some instances of DAMA are requested not by the patients themselves. Whether the patient would have desired discharge in such cases is a dilemma, lying at the nexus of medical ethics, patient autonomy, and family responsibility toward the patient [16, 38, 43, 44]. Hendizadeh et al. [44, p. 4] recommend that healthcare institutions create “a shared decision-making framework that provides clearly defined roles for the medical team and the patient”, where a duty to care is central. This recommendation supports Kwame and Petrucka’s [24] PCC requirements.
Study limitations
A major limitation of this study is that clinicians’ and doctors’ perspectives were not drawn for many of the cases reported, although nurses’ viewpoints were noted. It will be insightful to examine DAMA cases from patients’/caregivers’ and clinicians’/doctors’ perspectives. Also, since this was a qualitative study, the findings may not be generalized across Ghana. However, given the diversity of the study participants, similar views are likely to be drawn from other healthcare facilities in Ghana. Lastly, data for the cases reported in this paper were drawn largely from participant observations, although interview data complemented and added rich nuances to the underlying reason for DAMA in the hospital.
Acknowledgements
We express our gratitude to all the research participants and the management of the Yendi Hospital for their support during the data collection of the doctoral project, part of which is reported in this manuscript. We are also grateful to the doctoral research advisory committee.
Declarations
Ethical approval
The study gained institutional ethics approval from The University of Saskatchewan in Canada (Beh-ID: 2690) and from the Ghana Health Service ethics clearance (GHS-ERC:005/11/21), which are duly reported in the manuscript. Participation was voluntary and all participants provided their free informed consent. All ethical protocols were observed.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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