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Self-discharge needs overhaul to combat 'inherently paternalistic' approach

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Approaches to self-discharge, including forms used to document the process, should be overhauled to explore the reasons behind those wanting to leave hospital early, instead of them being used to persuade patients to stay “as a priority”, a new study has concluded.

Researchers noted that nurses and doctors are currently encouraged to caution against patients discharging themselves when they have not been medically advised to do so, because of “inherently paternalistic” hospital procedures.

“You get why somebody would much rather be at home in their own bed using their own facilities”

Nurse interviewed for the study

But this approach is “out of step with contemporary values of patient-centred health care,” which focus on patient autonomy, said the study authors from Lancaster University and Sheffield Teaching Hospitals NHS Foundation Trust.

Their research, which included interviews with 17 hospital and community-based health care practitioners and 16 patients, found staff were often understanding of the reasons behind patients wanting to leave.

Patients said it was often the “uncomfortable, anxiety-provoking environments” of hospital that made them want to discharge themselves, rather than poor care, suggested the study published in the journal Qualitative Health Research.

Nurses and doctors were often empathetic about this – and on some occasions practitioners revealed they believed the decision to self-discharge was reasonable, highlighted the study paper.

“We are waking them up in the middle of the night to check their observations, we’ve got patients coming and going and monitors going off, you get why somebody would much rather be at home in their own bed using their own facilities,” said one nurse who was interviewed for the study.

“Proposing that a positive view of DAMA is possible does not erase the occasions when lapses in care are experienced”

Study on patient self-discharge

In addition, patients who discharged themselves said they believed they were reducing the workload of hospital staff, noted the researchers.

“These patients… presented the patient-staff relationship as a sympathetic one, constructed around appreciation and understanding,” they said their research paper.

UK patients are legally allowed to leave hospital if they are over the age of 16 and not detained under the Mental Health Act 1983.

The study authors claimed that previous research had framed the process of self-discharge in a largely negative light, in which staff “hold an authoritative, knowledgeable position” and were deemed uncaring, while patients were labelled as difficult and irrational.

The researchers said their study showed the process could be viewed as an opportunity to demonstrate compassion towards patients.

But they said changes were needed in the way that self-discharge was described – often referred to as discharge against medical advice (DAMA), which implied an unauthorised event.

The language used has “failed to keep pace with contemporary medical practice, which values patient centredness, and where patient autonomy is respected and medical paternalism is frowned upon”.

“We suggest… the decision made need not necessarily be read as threatening or critical”

Study on patient self-discharge

Self-discharge forms must also be revised to explore patients’ and relatives’ rationales for leaving hospital earlier than advised, rather than focussing on persuading people to stay “as a priority”, said the researchers.

In addition, they called for healthcare practitioners to receive training on shared decision-making in order to avoid unconsciously adopting the “predominantly disparaging perspective.

“Proposing that a positive view of DAMA is possible does not erase the occasions when lapses in care are experienced, or suggest that DAMA is always appropriate,” they said.

“Instead, we suggest that the reasons for the care delivered and received, and the decision made need not necessarily be read as threatening or critical,” added the authors.

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Readers' comments (1)

  • My brother in law with mild learning difficulties, and aged 82, had a TAVI procedure in a regional hospital. He has poorly controlled diabetes treated with insulin and metformin. He had to stop the metformin because of the dye used. He was on a sliding scale for insulin and couldn't walk around freely for exercise. He was eating puddings, something he wouldn't do at home. It was now 6 days post procedure. The sliding scale was stopped and he and I agreed that he needed to go home so that he could eat more carefully and take exercise again. The doctors wanted him to stay and said he couldn't leave! The charge nurse supported them. With my support he discharged himself. The only way we could leave was to park ourselves by the nurses' station and say we were going having waited four hours and explained without success why he had to leave. Needless to say, his blood sugars returned to better levels and the diabetic specialist nurses at the GP surgery helped with the process. It was very frustrating!

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