Leaving hospital against medical advice.

Early post-discharge deaths were identified in a recent study based at St Vincent's Hospital, Melbourne, over a two and a half year period. As a result of linking patient records with the Victorian Minimum Database (VIMD) those who had discharged themselves against medical advice (ama) were identified. In this study information relating to all patients who discharged themselves ama from St Vincent's Hospital was obtained from the VIMD. We found that 1.5% of separations over the study period were discharges ama. Nearly half were over the age of 60 years. Injuries and poisoning, circulatory disorders and mental disorders were the most common diagnostic categories associated with discharge ama. The specific conditions contained within these included fractured neck of femur, cerebral occlusion and subarachnoid haemorhage. The study raises the important question of how discharge ama affects the clinical outcome in patients with such serious conditions. A follow up of such patients, which includes interviews with clinicians and families is suggested. The patients who died within 28 days were in the main elderly, suffering from malignancy. Even in these cases a knowledge of the attitudes and experiences of clinicians would be useful in order to manage optimally requests by critically ill patients for discharge.