Determinants of Discharge Against Medical Advice Amongst Neonates
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Niger J Paediatr 2019; 46 (1):5 – 8 ORIGINAL Jalo I CC –BY Determinants of discharge against Isaac EW Alkali YS medical advice amongst neonates Nduibisi V admitted at Federal Teaching Hospital Gombe, Nigeria DOI:http://dx.doi.org/10.4314/njp.v46i1.2 Accepted: 16th February 2019 Abstract: Objective: Discharge of the person signing DAMA with Against Medical Advice (DAMA) the patient and the reason (s) for Jalo I ( ) is a major problem in health care signing DAMA were recorded in a Isaac EW, Alkali YS, Nduibisi V delivery in Nigeria. Children, proforma. Department of Paediatrics, especially neonates, who can nei- Results: Out of the 1,110 neonates Federal Teaching Hospital/College ther understand nor contribute to admitted during the study period, of Medical Sciences, Gombe State decision concerning their own 103 were discharged against medi- University, Gombe, Nigeria health, are the most commonly cal advice giving a DAMA rate of Email: [email protected] affected. The objective of this 9.3%: Male 50(48.5%) and Female study was to identify the reasons 53(51.5%). Majority 98(95.1%) of proffered for DAMA in neonates DAMA cases were signed by the and persons involved in making father and the main reason stated such decisions. for DAMA was financial con- Materials and methods: A de- straint 62(60.2%). scriptive study of consecutive Conclusion: Financial constraint neonates who were discharged was the main stated reason for against medical advice from the DAMA and the father was the sig- Special Care Baby Unit at Federal natory to DAMA in majority of Teaching Hospital (FTH), Gombe newborn in FTH, Gombe. from January 2016 to December 2017. Patients’ Biodata, Diagno- Key Word: Determinants, sis, Socio demographic character- DAMA, Neonates istics of both parents, relationship Introduction model of decision making in our community. In Africa and other developing countries, the concept of autonomy Discharge against Medical Advice (DAMA) is a major is still very controversial and not wholly acceptable problem in health care delivery in Nigeria.1-3 The preva- mainly because of the communal way of life in these lence rates of DAMA range between 0.002% to 5.7% communties10. An individual is considered as part of a depending on the population studied and region4. Rates family or clan and important decisions concerning them ranging from 1% to 2% have been reported in the United must be taken by elders of the community or head of the States of America5, while 1.3%, 5.7% and 1.2% were family.10,11 reported from Port Hacourt3, Benin7 and Lagos8 respec- tively. Children, especially neonates, who can neither Discharge against medical advice can be frustrating for understand nor contribute to decision concerning their the physician because it interrupts Patient – Physician own health are the most commonly affected.1,5 relationship often jeopardizing favorable outcome for According to World Health Organization estimates, out the patient5. The objective of this study is to identify the of 130 million babies born each year about 4 million die persons involved in making decisions and reasons prof- during the neonatal period9. Studies have shown that fered for neonates discharged against medical advice in patients discharged against medical advice have high Federal Teaching Hospital Gombe. It is hoped that find- mortality rates therefore, contributing significantly to ings from this study will help in shaping policies that neonatal mortality.5,9 will address this frustrating practice. The conflict between the professional values (beneficence) of the physician and autonomy (self deter- mination) of the patient is the most prominent ethical Subject and Method dilemma in discharge against medical advise10. The issue of discharge against medical advice is more The study was conducted at the Special Care Baby Unit complicated in the case of newborn not only that he (SCBU) of Federal Teaching Hospital (FTH) Gombe, lacks capacity for consent but by the extended family which is a 450-bed capacity tertiary health institution 6 located in Gombe metropolis. The Hospital serves as a Table 1: Demographic characteristics of study subjects referral centre for private hospitals in the state, twelve Characteristic Frequency Percent (12) secondary health institutions within Gombe State Gender and other health care facilities in neighboring states of Male 50 51.5 Bauchi, Yobe, Borno and Adamawa. The SCBU is di- Female 53 48.5 vided into inborn unit with capacity to admit 10 to 15 Place of Delivery babies and out born units with 8 to 10 bed capacity. Inborn 70 68.0 Staff complement includes one consultant, two senior Outborn 33 32.0 registrars, three registrars, interns and 24 hours nursing Antenatal care Booked 82 79.6 coverage. Unbooked 21 20.4 Mode of Delivery Consecutive neonates who were discharged against SVD 71 68.9 medical advice while on admission and receiving treated Emergency C/S 27 26.2 at both inborn and out born units of the SCBU from Elective C/S 5 4.9 January 2016 to December 2017(two years) were re- Counseled before Admission cruited for the study. Patients’ Biodata, Anthropometry, Yes 86 83.5 Diagnosis, Socio demographic characteristics of both No 17 16.5 parents, relationship of the person signing DAMA with the patient and the reason (s) for signing DAMA were Table 2: Diagnoses of Subjects that were DAMA in FTH, recorded in a proforma. Gombe Data was analyzed using SPSS version 23. Results were Diagnosis Frequency Percent presented in tables of simple percentages, graphs and Severe perinatal asphyxia 32 31.1 Chi square was used to compare means of variables. Respiratory distress syndrome 24 23.3 Relation was significant if the P – Value is less than Sepsis 21 20.4 0.05 Congenital malformation 18 17.5 Ethical clearance was obtained from the Research and Meconium aspirationsyndrome 5 4.9 Ethics Committee of Federal Teaching Hospital Gombe. Others 3 2.9 Total 103 100 Fig 1: Reason for DAMA Result 70 Out of the 1,110 neonates admitted during the study 60 period, 103 were discharged against medical advice (DAMA) giving a DAMA rate of 9.3%. Those dis- 50 charged against medical advice consisted of 53(51.5%) male and 50 (48.5%) female with M: F ratio of 1.1:1. 40 Most 82(79.6%) of the mothers had antenatal and 70 (68.0%) delivered in the hospital. Pre admission coun- 30 seling was given to 83.5% of mothers. Table 1. Patients with severe birth asphyxia constituted the high- 20 est 32(31.1%) number of cases that were discharged against medical advice. Other cases include Respiratory 10 distress syndrome 24(23.3%) and sepsis 21(20.4%) Ta- ble 2. The father was the signatory in 89% of DAMA. 0 Out of the parents that signed and were discharged Financial No reason Advised by Adivised by No Others against medical advice, 37(35.9%) were civil servants heealth worker other mothers improvement and 42(40.7%) of them had tertiary education Table 3. Table 3: Education and occupation of father The main stated reason for DAMA in this study was Educational Status Frequency Percent financial constraint Fig 1. Fig. II Reasons for DAMA The mean age at admission was 2.36 ± 3.96 days and the No formal Education 30 29.1 Primary School 8 7.8 average duration of hospitalization was 5.54 ±3.42 days. Secondary School 23 22.3 At the time of signing discharge against medical advice Tertiary (below university) 26 25.2 by parents 36% of patients were assessed be improving University 16 15.5 clinically, 32% deteriorating while the remaining 32% Total 103 100 had no change in their clinical condition. Occupation Civil Servants 37 35.9 Businessmen 33 32.0 Farmer 21 20.4 Artisans 5 4.9 Unemployed 2 1.9 Others 5 4.9 Total 103 100 7 Discussion The common morbidities for which babies were DAMA were sepsis, severe birth asphyxia, respiratory distress The DAMA rate of 9.3% in this study is higher than syndrome and congenital malformation, this is similar to previous reports which range from 1.3% to 5.7% from earlier reports.3,7and reflect the common neonatal mor- Abakaliki1, Port Harcourt 3 and Binin7. The high preva- bidities in the subregion8,11,14. The clinical status of the lence in this study may be due to poverty which is en- patient at the time of DAMA might not be a critical fac- demic in the North east sub region and made worse by tor in taking the decision as the number of those improv- the current insurgency. This may be supported by the ing, deteriorating and those whose condition has not finding that 58.3% of the parents cited financial con- changed at the time of DAMA are not significantly dif- straint as the main reason for DAMA. There were more ferent. The child’s father was the signatory in 89%, males than females which is in agreement with previous similar to the report by Abdullahi13from Birnin Kebbi, reports from Nigeria.1,3,7Most parents that signed for this could be explained by the practice in the north their neonates to be discharged against medical advice where women are not allowed to take major decision did so within the first 7 days of admission with mean due to cultural/religious factors. Majority of the parents hospital stay of 5.5 ±3.2 days ,this is similar to report by who signed DAMA have either secondary or tertiary Opara8 from Port Harcourt and Onankpa11 from Sokoto, level education. This finding is similar to report by- the period coincides with the time of naming ceremony Woldehanna14 and is not consistent with the popular link which raises concerns about the role of cultural factors of such action and decisions with illiteracy.