When ‘Discharge Against Medical Advice’ (DAMA) rhymes with potential child neglect: a 10-year analysis in a tertiary care center

Abstract

Introduction Taking into account parents’ privileged knowledge of their children, clinicians trust them to make the best decisions for their care. However, sometimes, their choices may appear misaligned with the child’s best interest, such as when “Discharge Against Medical Advice” (DAMA) occurs. In some instances, a DAMA will rhyme with a form of child maltreatment. Method This retrospective study analyzes all pediatric cases of DAMA presenting red flags for medical neglect from a tertiary care center in Saudi Arabia over 10 years (January 1, 2012, and December 31, 2022). The red flags were: 1) being an infant, 2) being vitally or clinically unstable, 3) refusing potential life-saving treatments, 4) presenting signs of physical, sexual, emotional abuse, or neglect, or 5) anticipating long-term consequences to forgo treatments. Data were retrieved from medical records. Results A total of 159 cases were identified with 47.2% females and a median age of 3.6 years. 57.9% were under 5 years. At baseline, 26.4% were medically free, and 73.6% had a significant or chronic illness. The most frequent reason for the encounter was an elective admission (44%). The most frequent red flag for neglect identified during DAMA was being “vitally or clinically unstable” (72.2%). Conclusion Clinicians may feel hesitant to disagree with parental care decisions which may make them worry as it may affect the trust between them. However, children are vulnerable, and all efforts should be made to ensure they get the required care. At times, this involves contacting Child Protection Services.