Understanding patients' decision to leave hospital care in Ghana: clinical cases and underlying determinants

The quality of patient discharge teaching and information influences most patients' readiness for discharge and perceptions of care. Planned patient discharge positively impacts patient health outcomes and post-discharge care management. However, some patients withdraw from care before being formally discharged, often termed discharge against medical advice (DAMA), among other labels. Patient withdrawal from care occurs in some Ghanaian hospitals, yet this phenomenon is understudied. We present clinical cases of this phenomenon in a Ghanaian hospital to understand why patients and their families leave hospital care before formal discharge.

Data was obtained through interviews, a focus group, and participant observations from nurses, patients, and caregivers. Thematic analysis and ethnographic case mapping helped us to identify patient discharge types and five DAMA cases.

The underlying factors for discharge in these cases were identified and interpreted. These included health beliefs and cultural norms, costs of care, low health literacy, length of hospital stay and recovery outcomes. Others were social responsibility demands and lack of medical specialists and equipment. A detailed interrogation of the clinical cases and underlying factors revealed the need to reconceptualize discharge against medical advice.

We recommend that providers embrace dialogue, cultural competency, and person-centered care and communication in managing patients' decisions respecting discharge. We reason that discharge against medical advice is a quality gap requiring both patient rights and ethical lense to address.