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Abstract

Discharge against medical advice (DAMA) is a critical global issue in emergency departments (EDs), as it leads to adverse patient outcomes, higher readmission rates, and increased hospital costs. In Saudi Arabia, evidence on the underlying causes of DAMA and its impact on healthcare operations remains limited. This study aimed to identify the factors contributing to DAMA among Saudi patients and explore potential strategies for its reduction. A descriptive cross-sectional study was conducted in 2024 at our University Hospital using a convenience sampling method through a self-reported online questionnaire, with a response rate of 78%. A total of 297 participants were included, with females comprising 54.4% and males 45.5%. The most represented age group in the DAMA category was 31–42 years (39.5%). Educational backgrounds varied, with 18.9% having no formal education and another 18.9% holding a master's degree. Most participants (54.2%) received care at government hospitals, 72.4% lacked medical insurance, and 14.5% had previous DAMA incidents. The leading reasons for DAMA were financial burden (53.5%), lack of available beds (52.5%), and patient/relative fatigue (50.5%). Nationality was significantly associated with DAMA, with 30.2% of non-Saudis affected compared to 15.7% of Saudis (P = .038). Findings suggest that financial and systemic challenges outweigh staff-related factors, emphasizing the need for targeted interventions and policy reforms to minimize DAMA and improve patient outcomes in Saudi healthcare settings. Further longitudinal and interventional studies are recommended to evaluate the long-term impacts of DAMA and to test strategies aimed at reducing its occurrence.

Keywords

discharge against medical advice (DAMA)emergency department factors perception Saudi Arabia

Introduction

Discharge against medical advice (DAMA) occurs when a patient leaves the hospital contrary to the managing physician's recommendation.^1,2 As the emergency department (ED) plays a vital role in saving lives, DAMA remains a critical issue due to potential adverse consequences following early discharge.^3,4 The global prevalence of DAMA varies by region, ranging from 0.7% to 2% for general medical admissions, 6% to 55% for psychiatric admissions, and approximately 1% for emergency cases.^5–8 Despite the global significance of DAMA, evidence from Saudi Arabia and the broader Middle Eastern region remains limited, with few studies systematically exploring its underlying causes or consequences. DAMA rates are notably higher in developing countries, estimated to be twice as high as in developed nations.⁹ Data from 2016 to 2021 in the US and UK indicate a yearly increase in DAMA cases from 0.8% to 1.2%.¹⁰

The American College of Emergency Physicians highlights DAMA as a high-risk event for malpractice.¹¹ Thus, identifying the factors influencing DAMA is crucial to developing targeted solutions that mitigate its negative effects. Predictors of DAMA are commonly categorized into personal, demographic, clinical, and systemic factors.¹² It may be initiated by the patient, their relatives, or, in pediatric cases, by parents, making children especially vulnerable as they depend on caregivers for medical decisions.^13,14 Research on the role of age, gender, race, and ethnicity in DAMA is often constrained by small sample sizes and varying hospital characteristics.¹⁵ However, a positive correlation between DAMA and younger age or male gender has been observed.¹⁶ For physicians, DAMA disrupts patient management and causes frustration.¹⁷ Long ED wait times and overcrowding are associated with patients leaving without being seen, rather than specifically against medical advice.¹⁸ Other identified predictors include disagreement with clinicians, poor communication, dissatisfaction with healthcare, lack of a personal physician, and absence of health insurance.^4,19 Consequently, DAMA negatively impacts treatment outcomes, increases healthcare costs, and exposes providers to legal risks.^2,20 Moreover, patients discharged against medical advice often experience higher readmission rates, leading to long-term financial burdens. A study by Alfandre¹ showed that 32% of DAMA patients are readmitted within 30 days, compared to 12% of patients discharged regularly. A retrospective cohort study of 656 patients found that DAMA cases had a 12-fold increased risk of readmission and higher 12-month all-cause mortality.²¹ Despite its detrimental consequences, DAMA remains a prevalent issue in modern healthcare systems.

In Saudi Arabia, research on DAMA remains limited despite evidence that it contributes to higher readmission rates, prolonged hospital stays, and rising healthcare costs. Previous studies have reported DAMA prevalence rates of 1.6% in neonatal intensive care units and 1% in adult ED admissions.^8,22 However, nationwide data remain scarce, and existing studies often lack contextual analysis of cultural, economic, and systemic factors unique to the Saudi or Middle Eastern setting. Sociocultural elements such as limited insurance coverage, variations in health literacy, reliance on traditional healing practices, and differing beliefs about medical interventions are particularly relevant in this context.²³ Although international interventions such as patient education and structured discharge planning show promise, their effectiveness in Saudi Arabia remains unclear. This study fills a critical gap by examining DAMA in the Saudi context, identifying contributing factors, and offering culturally and systemically tailored strategies to reduce its occurrence and improve patient care.

Methodology

Study Design

A descriptive cross-sectional study was conducted in 2024 to assess the factors influencing patients’ decisions to leave against medical advice (DAMA) from the ED at our University Hospital. The study targeted patients aged 18 years and older who opted for DAMA during their ED visit and were mentally competent. Exclusion criteria included individuals under 18 years old, those with abnormal mental health status, critically ill patients, and those with incomplete data. Ethical approval was granted by the biomedical ethical committee, ensuring adherence to ethical guidelines. Confidentiality was strictly maintained, with all information stored on encrypted hard drives accessible only to the research team. No personal identifiers were collected to preserve anonymity.

A minimum sample size of 297 participants was determined to ensure statistical significance and generalizability, accounting for potential nonresponses. A convenience sampling method was used, and the final response rate was 78%, which may introduce some nonresponse bias. Data collection was conducted through an electronic questionnaire distributed via an online platform, with informed consent obtained before participation.² The questionnaire was adapted from previous DAMA-related studies, piloted on 20 patients, and reviewed by 3 emergency medicine experts to ensure face and content validity. The survey included demographic details and factors contributing to DAMA decisions. Data were initially recorded in an Excel sheet and later transferred to a statistical database for analysis.

Statistical Analysis

Descriptive analyses summarized sociodemographic characteristics (age groups, gender, marital status, nationality, education level, treatment facility type, and insurance status) and perceptual factors influencing DAMA, presented as frequencies and percentages for all categorical variables. Associations between DAMA experience, sociodemographic, and perceptual variables were assessed using Pearson's chi-square tests. All analyses were performed in IBM Statistical Package for Social Science (SPSS) (v28.0), with statistical significance defined as P < .05.

Results

The study included 297 participants, with more females (n = 162, 54.4%) than males (n = 135, 45.5%) (Table 1). Age distribution was balanced across 4 groups: 18–30 years (n = 71, 23.9%), 31–42 years (n = 77, 25.9%), 43–54 years (n = 73, 24.6%), and over 54 years (n = 76, 25.6%). Married individuals formed the largest group (n = 83, 27.9%), followed by single (n = 75, 25.3%), divorced (n = 72, 24.2%), and widowed (n = 67, 22.6%) participants. The majority were Saudi nationals (n = 244, 82.2%), and 51.2% (n = 152) resided in Jeddah. Educational backgrounds varied, with the highest proportions holding a master's degree (n = 56, 18.9%) or having no formal education (n = 56, 18.9%). Most participants (n = 161, 54.2%) received care at government hospitals, while 72.4% (n = 215) lacked medical insurance. Additionally, 14.5% (n = 43) had a prior DAMA experience (Table 1).

Table 1.

Sociodemographic Characteristics of Study Participants with Discharge Against Medical Advice [DAMA] Experience.

	Overall [n = 297]
Age group
18–30	71 [23.9%]
31–42	77 [25.9%]
43–54	73 [24.6%]
>54	76 [25.6%]
Gender
Female	162 [54.5%]
Male	135 [45.5%]
Marital status
Divorced	72 [24.2%]
Married	83 [27.9%]
Single	75 [25.3%]
Widow	67 [22.6%]
Nationality
Non-Saudi	53 [17.8%]
Saudi	244 [82.2%]
Residence
Jeddah	152 [51.2%]
Outside Jeddah	145 [48.8%]
Education level
Bachelor's degree	49 [16.5%]
Elementary school	41 [13.8%]
Master's degree	56 [18.9%]
Middle/high school	54 [18.2%]
PhD's degree	41 [13.8%]
Not educated	56 [18.9%]
Primary treatment facility
Government hospitals	161 [54.2%]
Private hospitals	136 [45.8%]
Medical insurance
No	215 [72.4%]
Yes	82 [27.6%]
Had DAMA experience
No	254 [85.5%]
Yes	43 [14.5%]

Participant’s Perspective on Factors Contributing to DAMA

Table 2 lists participants’ perceptions of the factors contributing to DAMA. The most frequently reported factors influencing DAMA among all participants in the study were lack of admission beds (n = 156, 52.5%), financial constraints (n = 159, 53.5%), and patient or relative fatigue (n = 150, 50.5%), with over half of participants agreeing. Long wait times were also a significant concern (n = 129, 43.4%). Conversely, most participants disagreed that DAMA was influenced by inappropriate behavior from healthcare staff (n = 153, 51.5%), lack of staff attention (n = 155, 52.2%), or inadequate communication about their condition (n = 156, 55.6%) (Table 2). Neutral responses were most frequent for familial or social issues (n = 133, 44.8%) and home responsibilities (39.4%). Factors such as feeling better (46.8%), seeking a second opinion (n = 117, 52.2%), and unexpected management plans (n = 105, 52.2%) were largely dismissed.

Table 2.

Participant’s Perspective on Factors Contributing to DAMA (n = 279).

Variable	Agree n [%]	Neutral n [%]	Disagree n [%]
Lack admission beds	156 [52.5]	49 [16.5]	92 [31.0]
Patient relative fatigue	150 [50.5]	61 [20.5]	86 [29.0]
Financial issues	159 [53.5]	54 [18.2]	84 [28.3]
Inappropriate behavior	80 [26.9]	64 [21.5]	153 [51.5]
Lack attention	89 [30.0]	53 [17.8]	155 [52.2]
Inadequate communication about condition	88 [29.6]	44 [14.8]	165 [55.6]
Long wait time	129 [43.4]	61 [20.5]	107 [36.0]
Feeling better	98 [33.0]	60 [20.2]	139 [46.8]
Relatives in the home responsibility	42 [14.1]	117 [39.4]	138 [46.5]
Familial or social issues	34 [11.4]	133 [44.8]	130 [43.8]
Another medical opinion	57 [19.2]	85 [28.6]	155 [52.2]
Unexpected management plan	37 [12.5]	105 [35.4]	155 [52.2]

Relationship Between Sociodemographic and Perceptual Factors With DAMA Experience

In our cohort, 254 (85.5%) participants had no prior DAMA experience, while 43 (14.5%) had previously experienced DAMA (Table 1). Among sociodemographic variables, nationality was the only factor significantly associated with DAMA (P = .038), with 30.2% (n = 13) of non-Saudis reporting DAMA compared to 15.7% (n = 40) of Saudis (Table 3). No significant associations were found for age, gender, marital status, residence, education, treatment facility, or insurance status (all P > .05). Participants aged 31–42 years were more prevalent in the DAMA group (n = 17, 39.5%) than in the non-DAMA group (n = 60, 23.6%). Additionally, participants with middle and high school education were overrepresented in the DAMA group (25.6% vs 16.9%). Differences in marital status and insurance coverage were minimal. Among perceptual factors, long wait times had higher agreement in the DAMA group (53.5% vs 41.7%), but this difference was not statistically significant (P = .353) (Table 3). Overall, no perceptual factors showed significant associations with prior DAMA experience (all P > .05).

Table 3.

Relationships Between Sociodemographic and Perceptual Factors With Prior DAMA Experience [n = 279].

		Prior DAMA experience
		No	Yes	Total	P
Total n [%]		254 [85.5]	43 [14.5]	297
Age group	18–30	62 [24.4]	9 [20.9]	71 [23.9]	.177
	31–42	60 [23.6]	17 [39.5]	77 [25.9]
	43–54	65 [25.6]	8 [18.6]	73 [24.6]
	>54	67 [26.4]	9 [20.9]	76 [25.6]
Gender	Female	141 [55.5]	21 [48.8]	162 [54.5]	.517
	Male	113 [44.5]	22 [51.2]	135 [45.5]
Marital status	Divorced	64 [25.2]	8 [18.6]	72 [24.2]	.552
	Married	68 [26.8]	15 [34.9]	83 [27.9]
	Single	66 [26.0]	9 [20.9]	75 [25.3]
	Widow	56 [22.0]	11 [25.6]	67 [22.6]
Nationality	Non-Saudi	40 [15.7]	13 [30.2]	53 [17.8]	.038
	Saudi	214 [84.3]	30 [69.8]	244 [82.2]
Residence	Jeddah	132 [52.0]	20 [46.5]	152 [51.2]	.619
	Outside Jeddah	122 [48.0]	23 [53.5]	145 [48.8]
Education level	Bachelor's degree	43 [16.9]	6 [14.0]	49 [16.5]	.740
	Elementary school	37 [14.6]	4 [9.3]	41 [13.8]
	Master's degree	48 [18.9]	8 [18.6]	56 [18.9]
	Middle/high school	43 [16.9]	11 [25.6]	54 [18.2]
	PhD's degree	36 [14.2]	5 [11.6]	41 [13.8]
	Uneducated	47 [18.5]	9 [20.9]	56 [18.9]
Primary treatment facility	Government hospitals	136 [53.5]	25 [58.1]	161 [54.2]	.694
	Private hospitals	118 [46.5]	18 [41.9]	136 [45.8]
Medical insurance	No	182 [71.7]	33 [76.7]	215 [72.4]	.613
	Yes	72 [28.3]	10 [23.3]	82 [27.6]
Lack admission beds	Agree	135 [53.1]	21 [48.8]	156 [52.5]	.619
	Neutral	43 [16.9]	6 [14.0]	49 [16.5]
	Disagree	76 [29.9]	16 [37.2]	92 [31.0]
Patient relative fatigue	Agree	131 [51.6]	19 [44.2]	150 [50.5]	.248
	Neutral	54 [21.3]	7 [16.3]	61 [20.5]
	Disagree	69 [27.2]	17 [39.5]	86 [29.0]
Financial issues	Agree	135 [53.1]	24 [55.8]	159 [53.5]	.458
	Neutral	49 [19.3]	5 [11.6]	54 [18.2]
	Disagree	70 [27.6]	14 [32.6]	84 [28.3]
Inappropriate behavior	Agree	68 [26.8]	12 [27.9]	80 [26.9]	.925
	Neutral	54 [21.3]	10 [23.3]	64 [21.5]
	Disagree	132 [52.0]	21 [48.8]	153 [51.5]
Lack attention	Agree	77 [30.3]	12 [27.9]	89 [30.0]	.657
	Neutral	47 [18.5]	6 [14.0]	53 [17.8]
	Disagree	130 [51.2]	25 [58.1]	155 [52.2]
Failure inform condition	Agree	79 [31.1]	9 [20.9]	88 [29.6]	.400
	Neutral	37 [14.6]	7 [16.3]	44 [14.8]
	Disagree	138 [54.3]	27 [62.8]	165 [55.6]
Long wait time	Agree	106 [41.7]	23 [53.5]	129 [43.4]	.353
	Neutral	54 [21.3]	7 [16.3]	61 [20.5]
	Disagree	94 [37.0]	13 [30.2]	107 [36.0]
Feeling better	Agree	85 [33.5]	13 [30.2]	98 [33.0]	.395
	Neutral	48 [18.9]	12 [27.9]	60 [20.2]
	Disagree	121 [47.6]	18 [41.9]	139 [46.8]
Relatives in the home responsibility	Agree	37 [14.6]	5 [11.6]	42 [14.1]	.860
	Neutral	99 [39.0]	18 [41.9]	117 [39.4]
	Disagree	118 [46.5]	20 [46.5]	138 [46.5]
Familial or social issues	Agree	32 [12.6]	2 [4.7]	34 [11.4]	.264
	Neutral	114 [44.9]	19 [44.2]	133 [44.8]
	Disagree	108 [42.5]	22 [51.2]	130 [43.8]
Another medical opinion	Agree	48 [18.9]	9 [20.9]	57 [19.2]	.952
	Neutral	73 [28.7]	12 [27.9]	85 [28.6]
	Disagree	133 [52.4]	22 [51.2]	155 [52.2]
Unexpected management plan	Agree	34 [13.4]	3 [7.0]	37 [12.5]	.193
	Neutral	85 [33.5]	20 [46.5]	105 [35.4]
	Disagree	135 [53.1]	20 [46.5]	155 [52.2]

Discussion

While the demand for high-quality, safe, and affordable healthcare is universally acknowledged, many patients remain dissatisfied with the services provided, contributing to DAMA, particularly in ED.¹⁵ Factors influencing DAMA continue to be explored across both developed and developing nations to assess the effectiveness of interventions aimed at reducing patient departures. This study highlighted the key perceptual factors influencing DAMA within the ED setting, considering sociodemographic backgrounds. Among all contributors, younger participants under 42 years and predominantly Saudi nationals were more prevalent in the DAMA group. The most commonly reported factors influencing DAMA included lack of admission beds, financial constraints, patient or relative fatigue, and long wait times (Table 2). Although long wait times were identified as a major concern, they did not significantly influence DAMA rates (Table 3). This finding differs from prior Saudi studies where wait times were strongly associated with DAMA,^2,24 suggesting that other systemic pressures, such as limited bed capacity and financial burden, may play a stronger role in our context. Patients who perceive prolonged waiting as inconvenient or as an indication of inadequate care may be more prone to leave prematurely, seeking alternative medical opinions or attempting self-care. Alhajeri et al²⁴ analyzed 120 DAMA cases, revealing that the majority (81%) occurred at night and were associated with extended ED wait times.

On the other hand, many participants disagreed that DAMA was influenced by inappropriate behavior from healthcare staff or a lack of staff attention (Table 2). These findings suggest that structural and systemic barriers, such as hospital capacity and financial constraints, play a more substantial role in DAMA decisions than interpersonal issues with healthcare providers. This aligns with prior research indicating that DAMA is often driven by dissatisfaction with healthcare services, overcrowding, and long wait times rather than specific grievances with medical staff.¹⁵ Alsharif et al² conducted a cross-sectional study in a tertiary hospital ED to identify factors influencing DAMA. More than 50% of participants faced long waits, disrespectful staff interactions, and inadequate explanations of medical conditions as significant concerns. The study concluded that reducing wait times and improving patient–provider communication could help decrease DAMA rates in emergency settings.² The discrepancy between our results and such findings may be due to contextual differences in patient populations, hospital size, or cultural expectations, underscoring the complexity of DAMA's underlying drivers.

Assessing the association between sociodemographic patterns and factors affecting DAMA in our study, we found that approximately 30% of non-Saudis reported DAMA compared to 15.7% of Saudis (Table 3). This finding is significant as it highlights nationality as the predominant sociodemographic factor influencing DAMA within our facility. The specific reasons behind this discrepancy remain unclear, but financial barriers, differences in healthcare expectations, or a lack of social support among expatriate populations may contribute. A previous study has indicated that socioeconomic disparities influence higher DAMA rates, particularly among uninsured and low-income populations or when comparing nationals to expatriates.¹⁷ The fact that insurance status was not significantly associated with DAMA in our study may reflect broader challenges in healthcare accessibility and affordability rather than a direct financial burden for insured individuals. The lack of associations with other variables such as age, gender, or marital status suggests that structural issues within the healthcare system may exert greater influence than individual demographics. This highlights the importance of system-level reforms over targeting isolated patient groups.

There remains a lack of prospective, randomized trials assessing the effectiveness of interventions aimed at reducing DAMA.^6,19,25 However, available data suggest that targeted interventions, such as financial assistance and family counseling, may help decrease DAMA rates.²⁶ The factors influencing DAMA in Saudi Arabia mirror those observed globally, including financial constraints, dissatisfaction with healthcare services, and social obligations.¹⁹ This issue is prevalent in Saudi Arabia, as many patients seeking treatment in private hospitals lack personal medical insurance. Moreover, in some Saudi populations, traditional medical beliefs and perceptions of hopelessness regarding clinical conditions have also been identified as contributing factors.²³ These culturally specific elements—such as reliance on traditional treatments and variations in health literacy—represent real-world challenges that require tailored public health interventions and community education programs to mitigate DAMA's impact.

Albayati et al¹⁹ explored DAMA as a persistent healthcare challenge affecting both patients and providers, conducting a literature review of 49 studies. Patients may leave hospitals due to disagreements with their physician's clinical judgment or conflicts with caregivers. A major concern is the lack of coordination among healthcare providers, leading to fragmented care, overutilization of resources, prolonged hospital stays, and financial burdens. This disjointed approach often leaves patients confused about their treatment plans, contributing to dissatisfaction and premature hospital discharge.^3,27,28 Additionally, mistrust in the healthcare system due to negative past experiences can further drive DAMA.²⁷ Other contributing factors include perceived poor customer service and lack of respect, influencing healthcare perceptions.²⁹ Nurses also play a crucial role in identifying at-risk patients of DAMA and developing early intervention strategies. Collaborative efforts between nurses and physicians may reduce DAMA rates through proactive patient engagement and targeted interventions.^30,31

Several strategies have been proposed to reduce DAMA rates. Integrating a DAMA checklist during patient admission may help identify high-risk individuals and trigger early interventions or referrals to addiction services where applicable. Shared decision-making approaches have been shown to improve patient–provider communication, increase adherence, and reduce decisional conflict.³² In the Saudi context, initiatives aimed at improving patient education and addressing financial concerns may help mitigate DAMA rates. Emerging technologies, such as telemedicine and virtual wards, could also play a role in enhancing follow-up care and reducing DAMA-related complications.³³ Healthcare professionals often face ethical dilemmas when managing DAMA cases, as they must balance patient autonomy with beneficence. Avoiding blame and fostering a supportive environment for at-risk patients is crucial. Concrete steps that Saudi hospitals can adopt include expanding insurance coverage for expatriates, improving bed management to reduce crowding, and training staff in culturally sensitive communication. Linking these interventions with known adverse outcomes of DAMA—such as higher readmissions and increased healthcare costs—provides actionable insights for healthcare policy.

Future research should move beyond descriptive surveys to prospective, multicenter cohort studies and interventional designs. Specific questions include whether targeted financial support reduces DAMA rates among expatriates, whether culturally tailored education programs can improve patient adherence, and how digital health interventions can sustain follow-up care. Longitudinal studies would also help clarify the long-term health and economic impacts of DAMA in Saudi Arabia.

Limitations

This study has several limitations. Multivariate analysis, such as logistic regression, was not performed because the study was exploratory and the dataset lacked continuous outcome variables appropriate for regression modeling. As a descriptive cross-sectional study conducted at a single center, the findings may not be fully generalizable to other hospitals in Saudi Arabia. Reliance on self-reported data through an electronic questionnaire may also introduce recall bias. Moreover, while important factors influencing DAMA were identified, the study did not capture long-term patient outcomes after discharge. Future research with multicenter collaboration and longitudinal follow-up is needed to provide a broader understanding of DAMA patterns and effective interventions.

Conclusion

This study provides key insights into the factors influencing DAMA in a Saudi ED setting, emphasizing the need for targeted interventions to address financial constraints, long wait times, and hospital capacity challenges. While similar issues have been observed globally, further research is needed to evaluate the effectiveness of specific strategies in reducing DAMA rates. A comprehensive approach, including policy reforms, patient education, and improved healthcare provider training, is essential to improving patient outcomes and optimizing resource utilization. Although nationality was significantly associated with DAMA, financial and systemic barriers played a more dominant role. Future studies should focus on evidence-based interventions that enhance patient care, streamline hospital operations, and reduce DAMA-related complications. Addressing DAMA effectively requires collaborative efforts between healthcare institutions and policymakers to implement sustainable solutions that minimize its impact on healthcare systems.

Footnotes

Acknowledgments

None.

Author Contributions

All authors have contributed to drafting, editing, and revising the manuscript, and approved it before submission.

Declaration of Conflicting Interests

The authors declared no potential conflict of interest with respect to research, authorship, and/or publication of this article.

Ethical Consideration

This study was approved by the biomedical ethical committee at King Abdulaziz University, Jeddah, Saudi Arabia (Reference no. 111-25).

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Informed Consent Statement

Informed consent was obtained from all participants involved in the study.

ORCID iDs

Safinaz M Alshiakh

Abdullah S Algarni

References

Alfandre

. “I’m going home”: discharges against medical advice. Mayo Clin Proc. 2009;84:255‐260.

Alsharif

Ala-tawi

Alqahtani

Alufi

Alghamdi

. Factors influencing patients to decide to discharge themselves against medical advice at tertiary hospitals: a cross-sectional study. Int J Clin Med. 2023;14:163‐174.

Noohi

Komsari

Nakhaee

Feyzabadi

. Reasons for discharge against medical advice: a case study of emergency departments in Iran. Int J Health Policy Manag. 2013;1:137‐142.

Adefemi

Adeleke

Gara

Ghaney

OOA

Omokanye

Yusuf

AMJ

. The rate, reasons, and predictors of hospital discharge against medical advice among inpatients of a tertiary health facility in north-central Nigeria. Am J Health Res. 2015;3(1):11‐16.

Spooner

Salemi

Salihu

Zoorob

. Discharge against medical advice in the United States, 2002–2011. Mayo Clin Proc. 2017;92:525‐535.

Alfandre

. Reconsidering against medical advice discharges: embracing patient-centeredness to promote high-quality care and a renewed research agenda. J Gen Intern Med. 2013;28:1657‐1662.

Duñó

Pousa

Sans

Tolosa

Ruiz

. Discharge against medical advice at a general hospital in Catalonia. Gen Hosp Psychiatry. 2003;25:46‐50.

El-Metwally

Suliman Alwallan

Amin Alnajjar

Zahid

Alahmary

Toivola

. Discharge against medical advice [DAMA] from an emergency department of a tertiary care hospital in Saudi Arabia. Emerg Med Int. 2019;1:4579380.

Fadare

Jemilohun

. Discharge against medical advice: ethico-legal implications from an African perspective. S Afr J Bioeth Law. 2012;5:98‐101.

10.

Jaydev

Kara

Sadowski

. Discharges against medical advice-trends and implications. J Gen Intern Med. 2022;37(Suppl 2):S180.

11.

Shirani

Jalili

Asl-e-Soleimani

. Discharge against medical advice from emergency department: results from a Tertiary Care Hospital in Tehran, Iran. Eur J Emerg Med. 2010;17:318‐321.

12.

Saia

Salmaso

Bellio

, et al. Hospital readmissions and mortality following discharge against medical advice: a five-year retrospective, population-based cohort study in Veneto region, Northeast Italy. BMJ Open. 2023;13:e069775.

13.

Eze

Agu

Nwosu

. Discharge against medical advice at a tertiary center in southeastern Nigeria: socio-demographic and clinical dimensions. Patient Intell. 2010;2:27‐31.

14.

Macrohon

. Pediatrician’s perspectives on discharge against medical advice [DAMA] among pediatric patients: a qualitative study. BMC Pediatr. 2012;12:75.

15.

Bhoomadevi

Baby

Keshika

. Factors influencing discharge against medical advice [DAMA] cases at a multispecialty hospital. J Family Med Prim Care. 2019;8(12):3861‐3864.

16.

Tawk

Freels

Mullner

. Associations of mental, and medical illnesses with against medical advice discharges: the National Hospital Discharge Survey, 1988–2006. Adm Policy Ment Health. 2013;40(2):124‐132.

17.

Jeremiah

Stein

O’Sullivan

. Who leaves against medical advice? J Gen Intern Med. 1995;10:403‐405.

18.

Ding

Jung

Kirsch

Levy

McCarthy

. Uncompleted emergency department care: patients who leave against medical advice. Acad Emerg Med. 2007;14:870‐876.

19.

Albayati

Douedi

Alshami

, et al. Why do patients leave against medical advice? Reasons, consequences, prevention, and interventions. Healthcare (Basel). 2021;9(2):111.

20.

Aliyu

. Discharge against medical advice: sociodemographic, clinical and financial perspectives. Int J Clin Pract. 2002;56:325‐327. doi:10.1111/j.1742-1241.2002.tb11268.x

21.

Choi

Kim

Qian

Palepu

. Readmission rates of patients discharged against medical advice: a matched cohort study. PLoS One. 2011;6:e24459.

22.

Al-Turkistani

. Discharge against medical advice from neonatal intensive care unit: 10 years’ experience at a university hospital. J Family Community Med. 2013;20:113‐115.

23.

El Malek

Alexander

Al Anezi

. Discharge against medical advice among children admitted into pediatric wards at Al-Jahra Hospital, Kuwait. Kuwait Med J. 2014;46:28‐31.

24.

Alhajeri

Atfah

Bin Yahya

, et al. Leaving against medical advice: current problems and plausible solutions. Cureus. 2024;16(7):e64230.

25.

Onukwugha

Alfandre

. Against medical advice discharges are increasing for targeted conditions of the medicare hospital readmissions reduction program. J Gen Intern Med. 2019;34:515‐517.

26.

Bosco

Shashidhar

Rees

Wheeler

Britto

Suman Rao

. Reducing rates of discharge against medical advice in the neonatal intensive care unit in a tertiary care hospital in South India: a mixed-methods study. Trop Med Int Health. 2021;26:743‐752.

27.

Labbé

Herbert

Haynes

. Physicians’ attitude and practices in sickle cell disease pain management. J Palliat Care. 2005;21:246‐251.

28.

Singh

Haywood

Beach

, et al. Improving emergency providers’ attitudes toward sickle cell patients in pain. J Pain Symptom Manag. 2016;51:628‐632.e3.

29.

Ibrahim

Kwoh

Krishnan

. Factors associated with patients who leave acute-care hospitals against medical advice. Am J Public Health. 2007;97:2204‐2208.

30.

Bartley

. Against medical advice. J Trauma Nurs. 2014;21:314‐318.

31.

Brenner

Joslin

Goulette

Grant

Wojcik

. Against medical advice: a survey of ED clinicians’ rationale for use. J Emerg Nurs. 2016;42:408‐411.

32.

De Nunzio

Presicce

Lombardo

, et al. Patient centred care for the medical treatment of lower urinary tract symptoms in patients with benign prostatic obstruction: a key point to improve patients’ care – a systematic review. BMC Urol. 2018;18:62.

33.

Norman

Bennett

Vardy

ERLC

. Virtual wards: a rapid evidence synthesis and implications for the care of older people. Age Ageing. 2023;52:afac319.

Factors Influencing Patient Decisions to Discharge Against Medical Advice from Hospital Emergency: Insights From a Saudi Tertiary Hospital

Abstract

Keywords

Introduction

Methodology

Study Design

Statistical Analysis

Results

Participant’s Perspective on Factors Contributing to DAMA

Relationship Between Sociodemographic and Perceptual Factors With DAMA Experience

Discussion

Limitations

Conclusion

Footnotes

Acknowledgments

Author Contributions

Declaration of Conflicting Interests

Ethical Consideration

Funding

Informed Consent Statement

ORCID iDs

References