Journal of Current Emergency Medicine Reports


Factors Influencing People to Leave Against Medical Advice in a Tertiary Care Centre in New Delhi, India

Surjeet Acharya1*ORCID ID, Anita Rawat2, and Kishalay Datta3

1Post Graduate trainee, Emergency Medicine, Max Super speciality Hospital, Shalimar Bagh, Delhi, India

2Senior Consultant, Emergency Medicine, Max Super Speciality Hospital, Shalimar Bagh, Delhi, India

3Director and HOD, Emergency Medicine, Max Super Speciality Hospital, Shalimar Bagh, Delhi, India

*Corresponding Author: Acharya S, Emergency Medicine Resident, Department of Emergency Medicine Max Hospital, Shalimar Bagh, New Delhi, India. E-mail:

Citation: Acharya S, Rawat A and Datta K. Factors Influencing People to Leave Against Medical Advice in A Tertiary Care Centre in New Delhi, India. Journal of Current Emergency Medicine Reports. 2021;1(2):1-6.


Copyright: © 2021 Acharya S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Received on: 13th July, 2021     Accepted on: 11th August, 2021    Published on: 24th August, 2021


When a patient, who is already admitted in the hospital wishes to leave against the clinician’s advice, it is referred to as discharge against medical advice (DAMA) or leave against medical advice (LAMA). These patients are often ill at the time of leaving against medical advice as of the disease process itself along with incomplete treatment. The study conducted here is a prospective study enlisting all the causes forcing the patients to leave the hospital against medical advice from the door of the emergency room. We will further try to find out the best ways possible to reduce the number of patients leaving the healthcare facilities against the medical advice.

Keywords: Leave against medical advice (LAMA), discharge against medical advice (DAMA), poor financial status for admission, cost of healthcare


In this article, we analyse the LAMA records over a period of 4 months (March 2021 to June 2021) of the patients visiting the ER of our multi-speciality hospital with any primary complaint and willing to go LAMA for various reasons ranging from financial issues to inadequate treatment.

Review of Literature

Leaving against medical advice (LAMA) is a common health concern seen all over the world. It has variable incidence and reasons depending upon disease, geographical region and type of health care system [1,2]. There is very limited data available in literature on this topic. This study will be useful to identify loopholes in the organisation of care and also help to identify targets which helps in the development of interventions that will reduce the rate of patients leaving against the medical advice. The data will also provide a baseline estimate for the prevalence and severity of the problem for the higher authorities.

In a study it was found that leaving against medical advice continues to be a highly prevalent problem in healthcare quality, representing as many as 2% of all hospital discharges [3].  Multiple studies have found that patients taking LAMA are at risk of early readmission, [4,5] adding a burden to their pockets and healthcare infrastructure. The following correlates with AMA discharges had reasonably consistent results over time: lower socioeconomic status, male gender, young age, no insurance, and substance abuse. The most common reasons found in all the study trails are consistent with: low socioeconomic status, male sex, young age, no insurance coverage and substance abuse [3,4,5,6].

There have been various strategies used at various medical centres all over the world for preventing the rate of LAMA [7] including the following:

Addressing substance abuse – failure of assessing the critical elements of the social history can lead to deficiencies in care and prevent the timely evaluation and intervention.

Recognizing psychological factors – various series of case studies emphasized the need for early recognition of emotional elements like their feelings, often anger, anxiety, or depression [8]. Another consistency in the literature on AMA discharges is the recommendation for proactive physician-patient communication. Indeed, many problems like these originate in incomplete physician-patient communication.

Motivational interviewing – This basically relies on the principle of patient-centred interviews which help the physicians to examine and make decisions through patient perspective. It has also attempted to improve chronic disease outcomes by focusing on patient behaviour [9,10].


This is a prospective study using the data stored over the network system of the hospital.


During the study, the number of in-patient admissions through our Emergency Department were around 900 patients (approximately) out of which 62 went LAMA from the ED. The bar graph below clearly shows the ratio of admission and patient taking LAMA from the ER department (Figure 1). The peak admission session was during the months of March and April 2021 due the second wave of Covid-19 infection which was witnessed by the capital.

SNI-JCEMR-21-10-fig 1

Figure 1: Ratio of admission and patient taking LAMA from the ER department

 Out of the total number of LAMA taken, most of the people had financial problems (n=27) followed by second opinion seekers (n=16) and OPD follow-up seekers (n=12) and others (n=7) (Figure 2).

SNI-JCEMR-21-10-fig 2

Figure 2: Pie chart showing numbers of LAMA taken

During the follow-up of all these patients, it was seen that of patients who took LAMA for:

  • Financial reasons (n=27), 16 were admitted in government institutes, 6 patients died and the rest 5 didn’t want to respond to the call.
  • Second opinion (n=16), 8 went to another hospital and got admitted there, 5 did not seek any medical attention and rest were lost during the follow up.
  • Very few patients who took LAMA for personal reasons / feeling better and OPD follow-up went for hospital check-up or admission later on.
  • A few of the patients (n=15) went onto home remedy or alternate path of healthcare practices.


Leaving against medical advice is a prevalent and frustrating issue for both patients and their healthcare providers. There is minimum literature available which is limited primarily to review of medical records and retrospective analysis for the associations with LAMA. LAMA is a major healthcare challenge which not only leads to a series of negative health consequences but also puts a great burden on healthcare costs. Literature studies show that there is not only failure of admissions for care seeking in these patients but also increases the rate of readmission in such patients [4].  Thus, there is an increased risk of morbidity and mortality among such patients [11]. Most of the studies in literature suggest that LAMA is commonly taken by the middle age group (between 30-50 years) patients [12]. The results of our study also suggest that very few patients who leave AMA have health insurance. India being a medium income country, our social security services are poorly organised, healthcare policies of the country are not adequately enforced and rate of unemployment and poverty is high. In such conditions, patients as well as the healthcare providers have to sustain the endless rising cost of medical care by themselves. Our study from most of the respondents suggests that financial burden is an important reason to leave against medical advice.

Some remedial methods for reducing LAMA suggests:

  • A good national health policy by the state, proper implementation and core team to look after the functioning and governing of institutes in accordance to the policy.
  • Awareness among the masses about various health policies and its role.
  • Proper channel of communication between the patient, caregivers and the healthcare team.

Adoption of national health insurance plan policy by the country does not cover all the costs but it surely reduces the burden and makes healthcare including critical care more feasible for more people. Relatives are the primary caregivers and are involved in decision-making at the expense of patients’ consent. Literature reveals that relatives constituted up to 77.3% cases of signatories in LAMA patients [13,14]. Lastly, having proper care planning is an important part for all the patients leaving against medical advice. Care planning includes – the process of discussing, planning and communicating one’s health care treatment and goals within the framework of a person’s values.


The study helped us to realise that financial burden remains the main reason for patients leaving against the medical advice in a tertiary care hospital in New Delhi. This study was conducted during the peak months of Covid-19 (second wave) in India in 2021. Covid-19 in 2020-21 has hit the common people financially badly during this period. Stronger and more practical healthcare policies are required to overcome the financial burden faced by the middle class and lower-class population of the country. Leaving for obtaining a second opinion is also seen to be a good reason for people leaving against medical advice. Choosing the alternative systems of healthcare practice and home remedies is also prevalent in Indian community. Proper education through mass media, school education and various other means can reduce the stigma and help people by letting the modern medicine and other systems of medicine (AYUSH – Ayurveda, yoga and naturopathy, unani, siddha, homeopathy) work hand-in-hand. This study has its own limitations and we need more studies in future to have better understanding in this topic.

Source(s) of Support

 Tintinalli’s textbook of Emergency Medicine, Google search engine, Institute’s Library. 

Conflicting Interest

There is no conflict of interest to declare. This article was written without any sponsorship and so the authors have no financial disclosures. 


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  1. Dubow D, Propp D, Narasimhan K. Emergency department discharges against medical advice. The Journal of emergency medicine. 1992 Jul 1;10(4):513-6. 
  2. Wong TW, Lee KM, Chan R, Lau CC. A Study of patients who leave an accident & emergency department against medical advice. Hong Kong Journal of Emergency Medicine. 2000 Jan;7(1):22-6. 
  3. Ibrahim SA, Kwoh CK, Krishnan E. Factors associated with patients who leave acute-care hospitals against medical advice. American journal of public health. 2007 Dec;97(12):2204-8. 
  4. Hwang SW, Li J, Gupta R, Chien V, Martin RE. What happens to patients who leave hospital against medical advice? Cmaj. 2003 Feb 18;168(4):417-20.
  5. Aliyu ZY. Discharge against medical advice: sociodemographic, clinical and financial perspectives. International journal of clinical practice. 2002 Jun 1;56(5):325-7. 
  6. Jones AA, Himmelstein DU. Leaving a county hospital against medical advice. JAMA. 1979 Dec 21;242(25):2758-.
  7. Alfandre DJ. “I’m going home”: discharges against medical advice. InMayo Clinic Proceedings 2009 Mar 1 (Vol. 84, No. 3, pp. 255-260). Elsevier.
  8. ALBERT HD, KORNFELD DS. The threat to sign out against medical advice. Annals of internal medicine. 1973 Dec 1;79(6):888-91.
  9. Post LF, Blustein J. Handbook for health care ethics committees. JHU Press; 2015 Jun 30. 
  10. Miller WR, Rollnick S. Motivational interviewing: Helping people change. Guilford press; 2012 Sep 1. 
  11. Southern WN, Nahvi S, Arnsten JH. Increased risk of mortality and readmission among patients discharged against medical advice. The American journal of medicine. 2012 Jun 1;125(6):594-602. 
  12. Muftau Jimoh B, Anthonia OC, Chinwe I, Oluwafemi A, Ganiyu A, Haroun A, Chinwe E, Joshua A. Prospective evaluation of cases of discharge against medical advice in Abuja, Nigeria. The Scientific World Journal. 2015 Mar 2;2015. 
  13. Nasir AA, Babalola OM. Clinical spectrum of discharges against medical advice in a developing country. Indian Journal of Surgery. 2008 Apr;70(2):68-72. 
  14. Gursahani R. Palliative care and the Indian neurologist. Annals of Indian Academy of Neurology. 2016 Oct;19(Suppl 1): S40.




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