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Discharge against medical advice: ‘deviant’ behaviour or a health system quality gap?
  1. Anshula Ambasta1,
  2. Maria Santana2,
  3. William A Ghali3,
  4. Karen Tang1
  1. 1Medicine, University of Calgary Cumming School of Medicine and the O'Brien Institute for Public Health, Calgary, Alberta, Canada
  2. 2Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
  3. 3Departments of Community Health Sciences & Medicine, and the O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
  1. Correspondence to Dr Anshula Ambasta, Medicine, University of Calgary Cumming School of Medicine, Calgary, AB T2N 4N1, Canada; aambasta{at}

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Discharge against medical advice (DAMA) remains a persistent problem in healthcare where a patient decides to leave the hospital before the treating physician recommends discharge. Irregular discharges are high-risk events with such patients having a higher adjusted risk of readmission and mortality. Existing research in this area has focused heavily on describing patient characteristics associated with DAMA. This has unfortunately served to perpetuate the current notion that leaving against medical advice is deviant behaviour observed in certain groups of predisposed patients, that is, young, male, socially isolated and economically disadvantaged individuals often with concurrent stigmatising medical comorbidities like substance use and/or mental health disorders. This article challenges the reader to instead view DAMA as a failure of the healthcare system to help the patient achieve his or her medical goals. We examine DAMA from a quality lens and describe how it represents a more systemic issue with current healthcare delivery models leading to significant quality gaps in all six dimensions of quality. DAMA could be seen as a product of ineffective and non–patient-centred care that disproportionately impacts vulnerable groups and itself leads to inefficient, untimely, inequitable and unsafe care. We conclude by advocating for a shared patient–healthcare system responsibility model where we replace the term DAMA with ‘premature discharge’ and critically analyse each event to help allow our healthcare systems to better serve our patients.


Discharge against medical advice (DAMA) occurs when a hospitalised patient chooses to leave the hospital before the medical care team recommends discharge.1 Other forms of irregular discharges include ‘absconding’ or ‘elopement’ where patients leave the hospital without telling staff,2 and ‘left without being seen’, where patients in the emergency department (ED) leave prior to being seen by a doctor.3 The DAMA rate in the USA between 1993 and 2015 ranged between 0.8% …

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  • Contributors This article was conceived by AA and KT. Valuable content information was provided by WAG and MS. The article was drafted by AA and all authors reviewed and critiqued it for important intellectual context.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement There are no data in this work.