Ramakrishnan Nagarajan, Ranganathan Lakshmi, Abraham Babu K, Rajagopalan Senthilkumar, Venkataraman Ramesh
Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India.
Indian J Crit Care Med. 2018 Aug;22(8):580-584. doi: 10.4103/ijccm.IJCCM_101_18.
Discharge against medical advice (DAMA) when requested by family members of patients in Indian Critical Care Units (CCUs) leads to loss of follow-up and unknown patient outcomes. Exclusion of these patients from research analysis and quality audits confounds these results. We hence explored the proportion of patients leaving DAMA, reasons, and their outcomes at 30 and 90 days.
This was a prospective study of CCU patients admitted from July 2013 to February 2014. All patients, who were DAMA during this period, were included in this study. Demographics, APACHE data, and outcomes were collected and compared to patients discharged regularly during the same period. Outcomes of DAMA patients at 30 and 90 days were gathered by telephone follow-up.
Among the 663 patients admitted to the CCU, 15.1% (100 patients) were DAMA. The baseline APACHE score of the DAMA group was higher than the regular discharge group (29.5 ± 8.6 vs. 26.1 ± 10.3; = 0.002). During the 30-day follow-up, 23% were alive, 56% dead, and 21% could not be contacted. At 90 days, mortality was 62% and survivors decreased to 14%. Common reasons for DAMA were - wanting to take the patient to another hospital (21%), reluctance for further treatments (12%), financial constraints (9%), and overall poor prognosis (7%).
A significant proportion of patients in the CCU get DAMA despite high severity of illness. Understanding the outcomes of these patients will help refine CCU quality audit reports and research study results.
在印度重症监护病房（CCU）中，当患者家属要求时，违反医疗建议出院（DAMA）会导致失去随访以及患者结局不明。将这些患者排除在研究分析和质量审核之外会混淆结果。因此，我们探讨了DAMA患者的比例、原因及其30天和90天的结局。
这是一项对2013年7月至2014年2月入住CCU的患者进行的前瞻性研究。在此期间所有违反医疗建议出院的患者均纳入本研究。收集人口统计学、急性生理与慢性健康状况评分系统（APACHE）数据及结局，并与同期正常出院的患者进行比较。通过电话随访收集违反医疗建议出院患者30天和90天的结局。
在663例入住CCU的患者中，15.1%（100例）违反医疗建议出院。违反医疗建议出院组的基线APACHE评分高于正常出院组（29.5±8.6对26.1±10.3；P = 0.002）。在30天的随访中，23%存活，56%死亡，21%无法联系到。在90天时，死亡率为62%，存活者降至14%。违反医疗建议出院的常见原因是——想将患者转至另一家医院（21%）、不愿接受进一步治疗（12%）、经济限制（9%）和总体预后差（7%）。
尽管病情严重程度高，但CCU中有相当一部分患者违反医疗建议出院。了解这些患者的结局将有助于完善CCU质量审核报告和研究结果。
