How to deal with DAMA patients in Hospital?
DR Madhav Madhusudan Singh
In the last 7 days, I was reading about the legality of DAMA in India and found some interesting cases of DAMA and good practices followed by some hospitals, including my alma mater, AIIMS, New Delhi, that are worth sharing. Often, we have to make decisions in the middle of the night, and clinicians call us and ask what to do.
Discharge against medical advice (DAMA) refers to the situation where a patient leaves a healthcare facility before the treating physician has authorized discharge. This can occur for various reasons, such as a patient's desire to leave early or a disagreement between the patient and the healthcare provider. While DAMA is generally not recommended as it can lead to adverse outcomes, it is legally permissible in India under certain circumstances.
Reasons for DAMA Cases in India:
Patients may choose to leave the hospital early for various reasons, including financial constraints, fear of contracting infections in the hospital, dissatisfaction with the treatment provided, and lack of trust in healthcare providers. In India, where healthcare costs are rising, patients may be forced to leave the hospital early due to financial difficulties. Patients may also be afraid of contracting infections in the hospital, which is a common concern in India, where hospitals have been known to have poor hygiene practices.
Another reason why patients choose to leave the hospital early is dissatisfaction with the treatment provided. Patients may feel that they are not receiving adequate care or that their medical condition is not being properly diagnosed or treated. This is particularly true in India, where healthcare providers are often overburdened and may not have the time or resources to provide individualized care to each patient. Finally, patients may lack trust in healthcare providers, which can lead them to seek alternative treatments or leave the hospital early.
Risks Associated with DAMA:
There are several risks associated with DAMA cases. One of the primary risks is that patients may not receive proper treatment, which can lead to complications or even death. In India, where healthcare providers are already overburdened, DAMA cases can put additional strain on the system, as patients who leave the hospital early may require readmission or emergency care.
Another risk associated with DAMA cases is that patients may not receive adequate follow-up care. Patients who leave the hospital early may not receive proper instructions for home care or medication management, which can lead to complications or a worsening of their condition.
Legal and Ethical Considerations:
In India, healthcare providers must take legal and ethical considerations into account when dealing with DAMA cases. One of the most important considerations is informed consent. Patients must be fully informed about their medical condition, the risks and benefits of treatment, and the potential consequences of leaving the hospital early. If a patient chooses to leave the hospital early, they must sign a DAMA form, which acknowledges that they understand the risks associated with leaving against medical advice.
Another important consideration is patient autonomy. Patients have the right to make their own healthcare decisions, even if those decisions go against the advice of their healthcare providers. However, healthcare providers have an obligation to provide patients with accurate information and to encourage them to make informed decisions about their healthcare.
Finally, healthcare providers must consider the potential legal consequences of DAMA cases. If a patient suffers harm as a result of leaving the hospital early, healthcare providers may be held liable for medical malpractice. Healthcare providers must ensure that they have documented the patient's decision to leave the hospital early and that they have provided the patient with appropriate instructions for follow-up care.
The legal framework surrounding DAMA in India is complex and has evolved over time. Initially, DAMA was considered illegal in India due to the potential for harm to patients who left against medical advice. However, over time, the courts have recognized that patients have the right to make decisions about their own health, including the decision to leave a healthcare facility. This has led to a shift in the legal framework surrounding DAMA in India.
One of the most important cases related to DAMA in India is the case of Aruna Ramchandra Shanbaug v. Union of India, which was decided by the Supreme Court of India in 2011. In this case, the court held that patients have the right to refuse medical treatment, including the right to leave a healthcare facility against medical advice. The court also held that healthcare providers have a duty to inform patients of the risks associated with leaving against medical advice and to obtain informed consent from patients before they do so.
The court also recognized that patients who leave against medical advice may be at increased risk of harm, and therefore, healthcare providers have a duty to take steps to minimize this risk. This includes providing patients with information about their condition and treatment options, ensuring that patients understand the risks associated with leaving against medical advice and documenting these discussions in the patient's medical record.
Another important case related to DAMA in India is the case of Rattan Singh v. State of Punjab, which was decided by the Supreme Court of India in 1964. In this case, the court held that patients have the right to refuse medical treatment, even if doing so may result in their death. The court recognized that the right to refuse treatment is an integral part of the right to life and personal liberty guaranteed by the Indian Constitution.
The court also recognized that healthcare providers have a duty to inform patients of the risks associated with refusing medical treatment and to obtain informed consent from patients before they do so. However, the court held that healthcare providers cannot force treatment on a patient against their will, even if doing so would be in the patient's best interests.
Some important court cases related to Discharge Against Medical Advice (DAMA) in India:
1. P. Sreekumar v. Apollo Hospital, Chennai (2008): In this case, the Supreme Court of India held that a patient has the right to leave the hospital against medical advice, but that the hospital has the right to inform the patient of the potential consequences of their decision.
2. Parmanand Katara v. Union of India (1989): In this landmark case, the Supreme Court of India held that the right to life under Article 21 of the Constitution includes the right to medical treatment and that hospitals have a duty to provide emergency medical care to all patients, regardless of their ability to pay.
3. State of Punjab v. Ram Lubhaya Bagga (1998): In this case, the Supreme Court of India held that a patient who leaves the hospital against medical advice is not entitled to compensation for any harm that they suffer as a result of their decision.
4. Arvind Kumar Mishra v. Union of India (2015): In this case, the Delhi High Court held that a hospital has a duty to provide adequate medical treatment to a patient who is admitted to the hospital and that the patient cannot be discharged against medical advice if the hospital is unable to provide such treatment.
5. Dr. B. K. Sharma v. State of U.P. (2004): In this case, the Allahabad High Court held that a patient who leaves the hospital against medical advice is liable for any harm that they suffer as a result of their decision.
6. Sita Ram v. Indraprastha Apollo Hospital, New Delhi (2013): In this case, the Delhi State Consumer Disputes Redressal Commission held that a hospital has a duty to inform a patient of the potential consequences of leaving the hospital against medical advice, and that the hospital can be held liable for any harm that the patient suffers as a result of their decision.
7. Dr. Pramila Vishwanath Rao v. Dr. Hemant Suryavanshi (2013): In this case, the Maharashtra State Consumer Disputes Redressal Commission held that a patient who leaves the hospital against medical advice is not entitled to a refund of any fees that they have paid for medical treatment.
8. Dr. B. P. Bohra v. State of Rajasthan (2010): In this case, the Rajasthan High Court held that a patient who leaves the hospital against medical advice is liable for any harm that they suffer as a result of their decision, and that the hospital cannot be held liable.
9. Sudha Devi v. State of Uttar Pradesh (2013): In this case, the Allahabad High Court held that a hospital has a duty to inform a patient of the potential consequences of leaving the hospital against medical advice and that the hospital can be held liable for any harm that the patient suffers as a result of their decision.
10.Dr. G. P. Sabharwal v. State of Rajasthan (2008): In this case, the Rajasthan High Court held that a patient who leaves the hospital against medical advice is liable for any harm that they suffer as a result of their decision, and that the hospital cannot be held liable.
Despite the legal recognition of the right to DAMA in India, there are still concerns about the potential for harm to patients who leave against medical advice. Patients who leave against medical advice may be at increased risk of complications or may not receive the necessary follow-up care. Therefore, healthcare providers in India are encouraged to take steps to minimize the risk of harm to patients who leave against medical advice.
In India, DAMA cases are common, especially among patients from lower socio-economic backgrounds, who may not have the means to afford prolonged hospitalization. It is important for hospitals to handle such cases with care, ensuring that the patient is fully informed about the risks and consequences of leaving the hospital against medical advice.
The steps that hospitals in India should follow in DAMA cases:
Step 1: Documentation
The first step that hospitals should follow in DAMA cases is to ensure that all the necessary documentation is in place. This includes obtaining the patient's signature on a DAMA form, which states that the patient is leaving the hospital against medical advice and assumes full responsibility for any adverse consequences that may arise. The form should also include a statement that the medical staff has informed the patient about the risks and consequences of leaving the hospital before the completion of the treatment.
Example: The Manipal Hospital in Bangalore has a well-defined DAMA policy that includes obtaining the patient's signature on a DAMA form. The hospital also requires the medical staff to document the reasons for the patient's decision to leave the hospital against medical advice.
Step 2: Counselling
The second step that hospitals should follow in DAMA cases is to provide counselling to the patient and their family members. The medical staff should explain the risks and consequences of leaving the hospital before the completion of the treatment and should also discuss the alternative options available to the patient.
Example: The All-India Institute of Medical Sciences (AIIMS), New Delhi, has a dedicated counselling team that provides support to patients who are considering leaving the hospital against medical advice. The team comprises trained counsellors who help patients and their families to understand the risks and consequences of their decision, and also provide guidance on the alternative options available to them.
Step 3: Risk assessment
The third step that hospitals should follow in DAMA cases is to assess the patient's risk of adverse outcomes. The medical staff should evaluate the patient's condition and determine the likelihood of complications arising from leaving the hospital before the completion of the treatment. The staff should also provide the patient with information on how to recognize the signs and symptoms of potential complications and when to seek medical help.
Example: The Max Super Specialty Hospital in Delhi has a dedicated risk assessment team that evaluates the patient's condition and provides guidance on the potential risks and complications associated with leaving the hospital against medical advice. The team also educates the patient on how to recognize the signs and symptoms of potential complications and when to seek medical help.
Step 4: Discharge planning
The fourth step that hospitals in India should follow in DAMA cases is to develop a discharge plan that outlines the patient's post-discharge care. The medical staff should provide the patient with information on the medications and treatments that they need to continue, as well as any follow-up appointments that they need to schedule. The staff should also provide the patient with information on how to manage their symptoms and prevent further complications.
Example: The Apollo Hospitals in Chennai has a dedicated discharge planning team that works with patients who are considering leaving the hospital against medical advice. The team develops a discharge plan that outlines the patient's post-discharge care, including the medications and treatments that they need to continue, as well as any follow-up appointments that they need to schedule.
Step 5: Informed consent
The fifth step that hospitals in India should follow in DAMA cases is to obtain informed consent from the patient before they leave the hospital against medical advice. The medical staff should ensure that the patient fully understands the risks and consequences of their decision and that they have made an informed choice.
Example: The Tata Memorial Hospital in Mumbai has a well-defined informed consent policy for DAMA cases. The hospital requires the medical staff to explain the risks and consequences of leaving the hospital against medical advice to the patient and their family members and to ensure that the patient fully understands the implications of their decision.
Step 6: Communication
The sixth step that hospitals in India should follow in DAMA cases is to communicate with the patient and their family members. The medical staff should ensure that the patient and their family members understand the reasons for the decision to leave the hospital against medical advice and should also provide them with information on the potential risks and consequences of their decision.
Example: The Fortis Hospital in Gurgaon has a dedicated communication team that works with patients who are considering leaving the hospital against medical advice. The team provides support to the patient and their family members and ensures that they fully understand the reasons for their decision and the potential risks and consequences of leaving the hospital before the completion of the treatment.
Step 7: Follow-up care
The seventh step that hospitals in India should follow in DAMA cases is to provide the patient with follow-up care after they leave the hospital. The medical staff should ensure that the patient is able to access the necessary healthcare services and should also monitor their condition to prevent further complications.
Example: The Kokilaben Dhirubhai Ambani Hospital in Mumbai has a dedicated follow-up care team that works with patients who have left the hospital against medical advice. The team ensures that the patient is able to access the necessary healthcare services, and also monitors their condition to prevent further complications.
Step 8: Quality improvement
The eighth step that hospitals in India should follow in DAMA cases is to evaluate the reasons for the patient's decision to leave the hospital against medical advice, and to develop strategies to prevent such cases in the future. The hospital should conduct regular quality improvement initiatives to identify the root causes of DAMA cases and to develop effective interventions.
Example: The Apollo Hospitals in Hyderabad has a dedicated quality improvement team that works to prevent DAMA cases. The team conducts regular audits to identify the root causes of such cases and to develop effective interventions.
DAMA is legally permissible in India under certain circumstances. Patients have the right to make decisions about their own health, including the decision to leave a healthcare facility against medical advice. Healthcare providers have a duty to inform patients of the risks associated with leaving against medical advice and to obtain informed consent from patients before they do so. However, healthcare providers also have a duty to take steps to minimize the risk of harm to patients who leave against medical advice. This includes providing patients with information about their condition and treatment.
Dr Madhav Madhusudan Singh MBBS, MHA, MBA , Ph.D.
https://twitter.com/madhavsingh1972
https://www.linkedin.com/in/dr-madhav-madhusudan-singh-07139a26/
No comments:
Post a Comment