DAMA: Discharged Against Medical Advice

DAMA (Discharged Against Medical Advice) refers to a situation in which a patient, or the patient’s family or legal guardian, chooses to leave a healthcare facility despite clear medical advice recommending continued hospitalisation or treatment. This decision is made after the healthcare team has explained that leaving may significantly endanger the patient’s health or life.

DAMA cases present complex clinical, ethical, legal, and emotional challenges for nurses and other healthcare professionals. Nurses play a crucial role in communication, documentation, patient advocacy, and safeguarding both patient rights and institutional responsibilities.

DAMA: Discharged Against Medical Advice

When Does DAMA Occur?

A DAMA situation commonly arises when:

• The doctor has clearly explained that removing the patient from hospital care may lead to serious complications or death.
• The patient or their relatives insist on transferring the patient to another hospital or returning home.
• Financial concerns, cultural beliefs, fear, dissatisfaction with care, long waiting times, or misunderstanding of the illness influence the decision.
• The patient refuses further investigation, procedures, or treatment.

In such cases, the patient or their representative is asked to sign a DAMA/AMA declaration, confirming that:

• The risks of leaving were fully explained.
• They understand that leaving may endanger life.
• The hospital and healthcare providers are released from legal responsibility for adverse outcomes after discharge.

The hospital then provides a discharge summary, detailing the patient’s condition, advice given, and any treatment or medications accepted.

Nursing Responsibilities During DAMA

Occasionally, a patient or family may demand discharge against medical advice. When this occurs, the nurse must immediately inform the treating physician.

If the Physician Is Available

• The physician will attempt to counsel the patient and family.
• If the patient still insists on leaving, the physician will request the patient to sign an AMA/DAMA form.

If the Physician Is Not Immediately Available

• The nurse should calmly explain the DAMA form to the patient.
• Obtain the patient’s or legal guardian’s signature.
• Never detain the patient forcibly—this would violate legal and human rights.

If the patient refuses to sign the DAMA form:

• Do not restrain or delay discharge.
• Allow the patient to leave.
• Thoroughly document the incident and inform the physician as soon as possible.

Ethical and Legal Considerations

Patients have the legal right to refuse treatment, even if that refusal may result in harm or death—provided they have decision-making capacity. The nurse’s duty is to ensure:

• The patient understands the risks.
• The refusal is informed.
• Documentation is accurate, objective, and complete.

Failure to follow proper DAMA procedures may expose healthcare professionals and institutions to legal liability.

A Practical Guide to DAMA: Do’s and Don’ts

✅ DOs

• Do take the request seriously
  Never ignore a patient who wishes to leave AMA. Pause other tasks if possible and address the situation immediately.
• Do assess decision-making capacity
  Ensure the patient can:
  • Understand the information provided
  • Appreciate the consequences
  • Weigh risks and benefits
  • Communicate their decision clearly
• Do explain risks and benefits clearly
  Use simple, non-technical language and confirm understanding.
• Do involve family members or trusted companions
  They may help persuade the patient to stay or support informed decision-making.
• Do apologise when appropriate
  If delays or system issues have contributed to frustration, apologise sincerely. Apologies cost nothing; litigation costs millions.
• Do document “informed refusal” in detail
  This includes refusal of:
  • Investigations (e.g. blood tests, X-rays)
  • Procedures (e.g. lumbar puncture)
  • Treatments (e.g. medications, transfusions)
• Do provide ongoing care
  Offer any treatment, prescriptions, follow-up advice, and discharge instructions the patient is willing to accept.
• Do document thoroughly
  Record:
  • Mental capacity assessment
  • Risks explained
  • Benefits of staying
  • Efforts made to persuade the patient
  • Patient’s final decision
  • Compassionate encouragement to return if needed

• Do have the DAMA form witnessed
  Preferably by a family member and/or staff member.

❌ DON’Ts

• Don’t ignore or dismiss the patient
• Don’t blame, scold, or shame the patient or relatives
• Don’t express anger or frustration
• Don’t ask a nurse to simply “get a signature and send the patient away”
  – this offers minimal legal protection
• Don’t withhold care
  – refusal to provide reasonable treatment may be considered patient abandonment
• Don’t worry about insurance denial
  – insurance issues are not your responsibility; legal risk is

The Nurse’s Role: Compassion Above All

Even when a patient leaves against medical advice, compassion, respect, and professionalism must never be withdrawn. Patients should leave knowing:

• They were heard
• Their dignity was respected
• The healthcare team acted in their best interest
• They are welcome to return at any time

A calm, empathetic approach can preserve trust and may even encourage the patient to seek care again before serious harm occurs.

DAMA is not merely a discharge process—it is a critical clinical event that tests nursing judgement, communication skills, ethical integrity, and legal awareness. By following structured protocols, maintaining empathy, and documenting meticulously, nurses protect:

• Patient autonomy
• Patient safety
• Professional integrity
• Institutional accountability

In nursing practice, how a patient leaves is just as important as how they are admitted.