There is no information available in the published literature that compares and contrasts the predictors of a discharge against medical advice in a general inpatient population from patients’ and providers’ viewpoints. We used the focus group methodology to identify reasons for DAMA from these perspectives. The use of focus groups is advantageous when collecting the desired information on a large scale is cost-prohibitive, the overall topic of interest is a sensitive one, or the intent is to identify underlying reasons for observed behavior.[22
] Both patients and providers identified similar reasons for DAMA from a Medicine service as identified in . Thus, the current study provides new evidence to support the limited literature[24
] on patient-reported reasons for DAMA in any disease setting.
The degree of consonance between patients and providers suggests that there is sufficient common ground to support a coordinated intervention effort to reduce the frequency of avoidable DAMA. The need for an intervention effort as the next step towards reducing the number of DAMA has been identified previously.[16
] A refinement suggested by the combination of patient and provider FGI data from the present study relates to the idea of a coordinated
intervention effort. A coordinated intervention effort recognizes the joint role of patients and providers in the series of events leading up to a discharge against medical advice and actively seeks both patient and provider input in designing the intervention, defining the scope of action, and identifying success metrics. A coordinated effort also builds on the themes and lessons from patient stories regarding both actual and averted DAMA, identifies and addresses disagreements within provider groups regarding which group of providers is most responsible for effectuating change, and leverages the common desire for better outcomes shared by patients and providers.
Despite the consonance in reasons, there were subtle indications of dissonance within providers regarding the party responsible for effectuating change. There was a feeling among some doctors interviewed that nurses are responsible for the breakdown in communication with patients and thus bear a larger share of the burden of improving communication with the patient; the opposite viewpoint was expressed in the nurse/social worker groups. For example, a few doctors noted that by the time they are called to speak with the patient, the situation already has progressed to a point beyond which they are able to exert a positive influence. On the other hand, participants in the nurse/social worker group would note that the long time interval between the patient’s admission and consultation with the attending physician often contributes to the patient deciding to leave against medical advice. The correlation between perceptions and reality justifies further examination into the extent to which the stated provider viewpoints are generalizable and/or may be strong enough to torpedo interventions designed to reduce DAMA.
Lastly, we examined whether the consonance in identifying potential causes translated into consonance in identifying potential solutions. Improved communication was a common solution identified across the focus groups and in previous literature[24
] but this consonance masks differences in conceptualization and implementation that have not been highlighted to date. Even when participants stated a common definition of “improved communication”, each group placed the responsibility for improving communication with others: patients looked to doctors; doctors looked to patients and to nurses; nurses looked to doctors (see ). For example, patients and providers expressed a need for more honesty in communication but did not agree on the responsible group.
Actionable solutions included: communicating with the patient in an empathetic tone and using lay English terms, nurses attending the patient-doctor consultation, educating physicians about the results from research on DAMA, providing physician education about strategies for communicating with patients likely to leave against medical advice, physician education about the consequences of leaving against medical advice, informing the patient about the patient advocate service. The solutions are directly relevant to discussions in the literature about ensuring fully informed decision making[24
] in the case of a patient who seeks to leave against medical advice. The need for communicating with the patient about the consequences of DAMA has been noted previously[16
] and the current study provides new information suggesting that, in some situations, lack of knowledge of DAMA consequences on the part of the physicians may mean that the patient is less able to make a fully informed decision about whether or not to leave against medical advice.
Some limitations to the qualitative study apply. The FGIs were conducted in a large, teaching hospital setting and the results may not generalize to community or smaller hospitals. Individuals in the patient groups may have withheld relevant information concerning the reasons for DAMA. The moderator involved all participants using direct questions; however their involvement does not guarantee that all concerns related to DAMA held by the participant were voiced. Non-response bias is a concern for this study due to the low patient participation rate. Despite the promises of anonymity in responses, the nature of the subject matter may have discouraged patients who feel embarrassed about their unauthorized discharge from responding to the request to participate in the study.