Dr. Lateef Olutoyin Oluwole
Department of Psychiatry, College of Medicine, Ekiti State University, Ado-Ekiti, Nigeria.

Dr. Maryam Okorejior
Department of Psychiatry, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria.

DOI: https://doi.org/10.55320/mjz.51.4.577

Keywords: LAMA, healthcare, providers, perceptions, attitudes

Background:

Patients leaving against medical advice (LAMA) is a common issue that presents significant challenges to healthcare providers, leading to worsened health outcomes and increased healthcare costs. This study aimed to investigate the distribution patterns of LAMA across various admission units in a tertiary healthcare facility in southwest Nigeria and to explore healthcare providers’ perceptions and attitudes toward LAMA.

Methods:

A retrospective and cross-sectional study was conducted at Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria, between July and December 2022. LAMA cases were identified from hospital records and case files, and relevant demographic and clinical data were extracted. Additionally, a questionnaire exploring healthcare providers' attitudes toward LAMA was administered to 113 staff members, with a 94.5% response rate.

Results:

Out of 4,547 admissions, 576 patients (12.7%) left against medical advice. The highest LAMA rates of 21.8% in the Adult Emergency and 15.9% in Medical units were observed. Postnatal unit had the lowest rate (0.38%). Healthcare providers identified communication barriers, dissatisfaction with care, financial concerns, and patient autonomy as key reasons for LAMA. Providers also reported frustration and emotional impact when dealing with LAMA cases, and 80% of the healthcare workers emphasized the importance of improved communication as a preventive strategy.

Conclusions:

LAMA is a significant issue across various hospital units. The highest LAMA rates of 21.8% in the Adult Emergency. The study sought to understanding healthcare providers' perspectives and attitudes that are critical to developing targeted interventions to mitigate LAMA and enhance patient care. Recognizing the importance of healthcare providers’ attitudes would help to address the fundamental causes of LAMA with a view to improving patient outcomes, safety, and satisfaction.

The phenomenon of patients who leave against medical advice (LAMA) may be broadly defined as including situations where patients leave the hospital before clinician certification of fitness is granted. LAMA may manifest when a patient is absent without leave, absconds, or elopes while escaping from an involuntary or voluntary healthcare facility. LAMA may occur in both inpatient wards and emergency units. Patients who leave against medical advice (LAMA) are both a concern and a challenge for healthcare workers.^[1] LAMA is a serious decision that can significantly affect a patient’s health and well-being. LAMA, albeit undesirable, is common worldwide with a global incidence of 0.8-2.2%.^[2] LAMA accounts for approximately 1% to 2% of hospital discharges in the United States with similar trends observed in the UK.^[3] This rate may reach up to 25.9% in some centres, especially in developing countries.^[4,5]

LAMA can complicate patient evaluation through the perpetuation of illness as the patient may be inadequately treated, resulting in foregone care. LAMA patients are at a higher risk of adverse outcomes such as readmission or mortality.^[6-13] LAMA may also raise the issue of liability of the managing health care workers. Besides, further care may be more difficult and costly. Thus, curbing LAMA in the long run may benefit patients and healthcare systems.

Systemic issues contributing to LAMA include communication barriers, limitations in access, and deficiencies in cultural competence.^{[14] [15]} Additionally, fragmented care and resource constraints may further intensify these challenges. Addressing these factors is essential to improving patient outcomes effectively. In developing countries, including Nigeria, patients leaving against medical advice is a significant concern in healthcare settings. Healthcare providers’ knowledge and attitudes toward LAMA are crucial in management of patients.

According to some previous studies, the causes of patients leaving against medical advice are multifactorial. LAMA may be predicted broadly by patient variables and healthcare provider variables.^[3] The patient’s decision to LAMA may include financial concerns, dissatisfaction with care, or cultural beliefs.^[16-19] Previous studies often focused on individual patient factors and not system-related issues or factors. However, understanding why patients might leave the hospital against medical advice should be important. A deep understanding of the reasons for leaving against medical advice (LAMA) will help improve patient care and outcomes for these patients. Consequently, this could help to develop early interventions to prevent increased morbidity, mortality, strain on the healthcare system health and care costs.^[20-22] 20–22

The dynamic interplay of healthcare providers’ perceptions and attitudes may shape how the providers and the healthcare system respond, albeit insightfully, to patients leaving against medical advice. The divergent perceptions of LAMA are a reality providers have to grapple with, and earnestly determine the management approach to intervening in cases of LAMA. A conflict between caregiver and patient has been adduced as one of several reasons a patient may leave against medical advice^[23]

Despite the crucial role that healthcare providers play in shaping patient experiences; extensive research has explored the patient-level factors associated with LAMA. However, the perspectives and attitudes of healthcare providers toward this phenomenon remain understudied.

This study aimed to analyze the distribution of LAMA across specific units and assess the attitudes of healthcare providers toward LAMA in a tertiary health facility in southwest Nigeria.

This study adopted retrospective and cross-sectional approaches at the Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria. This study that spanned six months (July-December 2023) extracted data on LAMA cases from wards’ admission registers. It was considered patients left AMA if they either signed a hospital form acknowledging that they were discharging themselves from admission against the advice of their physician, or patients left the hospital unscheduled. The case files of all identified LAMA cases were retrieved for data extraction of relevant biomedical information. The information extracted included: (i) those that comprised patients’ demographic characteristics such as age, gender, educational attainment, time of muting desire to LAMA by patient or relative, (ii) those related to patients’ management as noted or recorded in the case files by the healthcare providers such as diagnosis, length of admission, hospital setting, staffing, admission and discharge policies, managing team clinical style and experience.

Instrument questionnaire

Using artificial intelligence, through Natural Language Processing (NLP), The existing literature and survey on the topic of health providers’ perceptions and attitudes towards LAMA were analysed to identify patterns and themes relevant to the research questions for this study. The authors developed a prototype tool with question items designed to capture healthcare providers' perceptions and attitudes toward patients leaving against medical advice. The tool was used to conduct a pilot test among a small group of samples of professional healthcare workers—doctors, nurses, psychologists, and social workers—from various audited admission units within the health facility. The question items were further refined following feedback from pilot test. The prototype tool included various question types such as multiple-choice, Likert scales, and open-ended questions that were phrased neutrally to avoid bias. This was done to ensure that a wide range of perspectives was captured and to minimize response bias. It covered a broad spectrum of healthcare providers' attitudes and experiences with LAMA, including demographics, attitudes, experiences, communication, emotional impact, barriers, training, and open-ended questions.

The questionnaire was administered through electronic media to all 113 healthcare staff workers who worked in the admission units of the study center during the period under study. One hundred and seven (94.5%) responded. Only 98 of the responses were considered adequate for analysis. The participants were assured of their anonymity. Anonymity was also adopted to cull the patients’ data records for analysis.

Ethical approval was sought and obtained from the Ethics and Research Committee of the Ekiti State University Teaching Hospital.

During the study period, 4547 patients were admitted to various units of the tertiary healthcare facility. Of these, 576 (12.7%) left against medical advice (LAMA). The distribution of LAMA patients across different admission units is shown in Table 1.

The highest proportion of LAMA patients was observed in the Adult Emergency unit (21.8%, n=423), followed by the medical unit (15.9%, n=64). The postnatal unit had the least proportion (0.38%, n=2). In the medical unit, 64.1% (n=41) of patients who left against medical advice (LAMA) were male. The male patients had an average age of 64.1 years and an average length of stay of 7.9 days. In the Surgical unit, 41.2% (n=14) of LAMA patients were male, with an average age of 50.6 years and an average length of stay of 5.9 days. As for the Paediatrics unit, 83% (n=5) of LAMA patients were male, although the mean age was not reported. The average length of stay for these patients was 3.0 days. Lastly, 41.7% (n=10) of LAMA patients in the Paediatric Emergency unit were male, and the mean age was not reported. The average length of stay for this group was 2.5 days.

In the Psychiatry unit, 56.4% (n=44) of patients were male, with a mean age not reported. The average length of stay in this unit was 11.3 days. No LAMA patients were reported in the Gynaecology, Antenatal, and Postnatal units.

There was a 94.5% response rate to the questionnaire exploring perceptions and attitudes of healthcare providers towards patients leaving against medical advice. Most respondents were between 41 and 60 years old, with an average of 44.4 years (±6.7). Five main themes and concerns emerged from the responses of the professional clinical workers.

Theme 1: Healthcare Providers' Attitudes towards LAMA

"Three-quarters (76.5%) of providers considered LAMA a significant concern affecting patient outcomes and healthcare resource utilization. Additionally, 8 out of 10 respondents reported experiencing frustration when patients leave against medical advice.

Theme 2: Reasons for LAMA

Regarding reasons for LAMA, patient autonomy and decision-making were cited as primary reasons for LAMA. Communication barriers, lack of trust, and dissatisfaction with care were also mentioned.

Theme 3: Impact of LAMA on healthcare providers

Two out of three of the providers reported feeling emotionally affected, including feelings of guilt and failure.

Theme 4: Strategies for Addressing LAMA

Most (80%) of the respondents acknowledged that improving communication is a key strategy for reducing LAMA. Other suggested strategies included building trust with patients and addressing systemic issues, such as staffing and resource constraints.

Theme 5: Support and Resources

"More than two-thirds of the providers indicated a need for additional support and resources to manage LAMA situations, including training, guidelines, and interdisciplinary collaboration. The statistical proportions of the respondents' various responses are detailed in Table 2."

The study examined the distribution patterns of patients who left against medical advice (LAMA) in the various units admitting patients in a tertiary healthcare facility. The results showed that the highest proportion of LAMA patients was in the Adult Emergency unit (21.8%), followed by the medical unit (15.9%). This observation aligned with earlier studies that found the Adult Emergency unit among the top two units with a recorded high rate of patients LAMA.^[24-26] The elevated prevalence of "Leave Against Medical Advice" (LAMA) cases in the Adult Emergency unit may stem from possible extended stay which is likely to incur a high financial obligation.^[27] Unlike adult emergency, the incidence of LAMA in paediatric emergency unit is low. The low incidence of leaving against medical advice (LAMA) in paediatric emergency settings may be due to several interrelated factors, including socioeconomic status, parental involvement, and healthcare policies.^[28,29] Additionally, legal and ethical considerations, family-centered care, perceived severity of the condition, support systems, and shorter lengths of stay in paediatric emergency departments also contribute to a lower likelihood of LAMA.^[30-32]

The relative occurrence of patients leaving against medical advice from psychiatric admission within the period of this study was atypical of what had been reported in some previous studies. The incidence of psychiatric patients LAMA was very low (0.04%) in this study; this is far from some estimates ranged 3% - 36% from the literature.^[33,34] 33,34

The postnatal unit also had a low incidence of LAMA (Leave Against Medical Advice) patients at 0.38%. This could be because of the shorter length of stay and the emphasis on routine postnatal care in this unit. The fragile and unstable physiological nature of postnatal patients, similar to neonatal patients, might influence them to abide by the advice of the treating physicians until conditions are satisfactory for discharge.35 While the incidence of LAMA is low in postnatal units, it is essential to recognize that systemic issues, such as healthcare accessibility and socioeconomic disparities, can still influence patient decisions. Addressing these factors holistically can further enhance care quality and patient satisfaction. The demographics of LAMA patients varied across units, with males dominating in the Medical and Surgical units. This finding is in line with previous research.^{[4 ,36-38]} 4,36–38

The average length of stay for LAMA patients was highest in the Psychiatry unit (11.3 days). This may suggest that patients in the psychiatric unit have more complex care needs for safety, considering the risk of leaving against medical advice. Research has shown diverse findings regarding the average length of stay (LOS) in psychiatric units before discharge against medical advice (LAMA), with some studies reporting a significantly extended LOS.^[39]

As patients leave against medical advice (LAMA), it continues to pose significant challenges to healthcare providers. Understanding their perceptions and attitudes towards this issue is germane. While LAMA can have serious consequences for patient outcomes and healthcare resource utilization, the perspectives of healthcare providers should be of immense importance. Understanding these patterns and the context can inform strategies to reduce LAMA rates and improve patient care.^[40]

This study found that one out of three respondents frequently experienced patients leaving against medical advice, with the majority (80%) of providers expressing great concern about their encounters. The key findings from previous studies indicate that providers are significantly concerned about the problems associated with patients leaving AMA. They understand that such discharges can lead to negative health outcomes.^[23]

Interestingly, the respondents in this study identified financial constraints, patients’ desire to seek alternative treatments and a lack of understanding about the treatment as the main reasons why patients leave against medical advice. This perception might indeed find a place as in some previous studies.11,23,41 However, healthcare providers often downplay the provider’s attitude as a factor contributing to patient LAMA. Healthcare providers' attitudes towards communication, respect, quality of care, systemic issues, ethical considerations, and cultural sensitivity have been reported to significantly contribute to the problem of patients leaving against medical advice.^[11,23,42]

Among the communication strategies, such as active listening, predominantly adopted by the respondents in this study are in tandem with the approaches reported in previous studies. The adopted strategy of active listening to show empathy while addressing patient’s concerns communicates effectively to enhance understanding, and ultimately reduce the likelihood of patient LAMA.^{[11,27,38,41,42]}

About two-thirds of the respondents who felt they could justify a patient’s decision to LAMA were of the consideration that the patient may have the right to refuse treatment. They are also of the opinion that a patient may be justified to LAMA lest there are financial constraints. Financial constraints are a significant and commonly cited reason for such decisions. Numerous studies emphasize the prevalence and impact of financial factors on patients' decisions to discharge themselves prematurely. It is of note that respondents who opined that patients would not be justified to LAMA believed patients who LAMA lack understanding regarding their treatments and the potential harm or risk to the patients.^[2,27,42] 2,27,42

Nine out of ten respondents perceived patients’ resistance as one of the major barriers to addressing the issue of LAMA in the study center. Healthcare providers often identify patients' resistance as a significant barrier to addressing the issue of patients LAMA). Such resistance can be attributed to a range of factors, including communication challenges, cultural beliefs, and systemic concerns within healthcare environments. Patients’ resistance is a complex issue that may stem from communication breakdowns, external influence, dissatisfaction with care, and limited health literacy.^[23,43,44] Endeavouring to overcome these challenges through better communication strategies, prompt care delivery, and increased patient engagement may help to reduce LAMA incidents and enhance overall patient outcomes.

The large sample size and multidisciplinary perspective of perceptions and attitudes provide a comprehensive understanding of patients leaving against medical advice. The practical implications of this study can be used to develop strategies to reduce LAMA incidents and improve patient outcomes. The study has laid the groundwork for future research and potential interventions to address LAMA. However, the study’s findings may not be generalized because of the bias towards a specific healthcare setting. Furthermore, the retrospective data collection method may be prone to errors or inaccuracies. Furthermore, the reliance on healthcare providers' self-reported attitudes and perspectives may introduce bias and limit the exploration of reasons for patients leaving against medical advice.

This study observed different patterns of patients leaving against medical advice (LAMA) across hospital units. Concerning the findings derived from our research, we advocate for the implementation of strategies aimed at enhancing communication and fostering trust through active engagement in listening, the resolution of patient concerns, and the inclusion of patients in the decision-making processes about their care, to diminish the incidence of patients departing against medical advice. Furthermore, it is essential to address financial and social issues, as well as to provide educational resources and support, because these measures will help alleviate the challenges faced by patients who leave against medical advice.

Competing interest

The authors maintain that there was no conflicting interest in the development of this article.

Author's contribution

Both authors played a crucial role in the successful accomplishment of this project. The preliminary manuscript of the article was prepared by L. O. O. The conceptualization and planning of our research was carried out by L. O. O and M. O. The ultimate rendition of the text underwent a comprehensive evaluation and obtained the endorsement of both authors

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Medical Journal of Zambia, Vol 51, 4

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