Original Research

Discharge against medical advice in rural and remote emergency departments: views of healthcare providers


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Jacky Oribin
1,2 M Hlth Ldr, Research Officer

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Yaqoot Fatima
1 PhD, Adjunct Research Fellow ORCID logo

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Catherine Seaton
1 MPH, Research Officer ORCID logo

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Shaun Solomon
1 (Ewamain & Birri) Grad Dip in Indigenous Health Promotion, Head of Indigenous Health

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Maureen Khan
3,4,5 FACEM, FACRRM, MBBS, SMO, Emergency Medicine Staff Specialist

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Alice Cairns
1,6 PhD, Senior Research Fellow * ORCID logo


1 Murtupuni Centre for Rural and Remote Health, James Cook University, PO Box 2572, Mount Isa, Qld 4825, Australia

2 Weipa Integrated Health Services, 407 John Evans Dr, Qld 4874, Australia

3 Emergency Department, North West Hospital and Health Service, Qld, Australia

4 Sunshine Coast Hospital and Health Service, Qld, Australia

5 Sunshine Coast School of Medicine, Griffith University, Qld, Australia

6 Australian Institute of Tropical Health and Medicine, James Cook University, Qld, Australia

ACCEPTED: 23 March 2024

early abstract:

Introduction: The aim of the study was to explore in one remote hospital, emergency department healthcare providers’ experience and perceptions of the factors surrounding a patient’s decision to discharge against medical advice (DAMA). The secondary objective was to gain insight into staff experiences of the current protocols for managing DAMA cases and explore their recommendations for reducing DAMA incidence.
Methods: Cross-sectional study involving a survey and semi-structured interviews exploring healthcare providers (n=19) perceptions of factors perceived to be influencing DAMA, current practice for managing DAMA and recommendations for practice improvements. Health professionals (doctors, nurses, Aboriginal health workers) all worked in the emergency department of a remote community hospital, Queensland, Australia. Responses relating to influencing factors for DAMA were provided on a 3-point rating scale from ‘No influence/little influence’ to ‘very strong influence’. DAMA management protocol responses were a 3-point rating scale from ‘rarely/never’ to ‘Always’. Semi-structured interviews were conducted after the survey and explored participants’ perceptions in greater detail and current DAMA management protocol.
Results: Feedback from the total 19 participants across the professions presented four prominent yet interconnected themes of patient, culture, health service and health provider, and health literacy and education-related factors.. Factors that were perceived to have a strong influence on DAMA events included alcohol and drug abuse (100%), a lack of culturally sensitive healthcare services (94.7%), and family commitments or obligations (89.5%). Healthcare providers recommendations for preventing DAMA presented themes of right communication, culturally safe care (right place, right time) and the right staff to support DAMA prevention. The healthcare providers described the pivotal role the Indigenous Liaison Officer (ILO) plays and the importance of this position being filled.
Conclusions: DAMA is a multifaceted issue, influenced by both personal and hospital system-related factors. Participants agreed that the presence of ILO and/or Aboriginal health workers in the emergency department may reduce DAMA occurrences for Indigenous Australians who are disproportionately represented in DAMA rates, particularly in rural and remote regions of Australia.
Keywords: Aboriginal, cultural competency, cultural safety, discharge planning, First Nations, health equity, Indigenous, patient discharge, self-discharge, racism, remote, rural.