Discontinuation of care in hospitalized children at a tertiary pediatric emergency unit-a mixed-methods study

Leave against medical advice (LAMA), discontinuation of inpatient care, remains a significant yet poorly characterized challenge in pediatric settings in low- and middle-income countries. We estimated its prevalence and identified clinical, social, and financial drivers among children admitted to a tertiary pediatric emergency unit. A prospective mixed-methods study was conducted over nine months (May 2022-January 2023). Quantitative data were collected using a predesigned case record form, and caregiver satisfaction was assessed on a pilot 10-point scale. Semistructured face-to-face interviews were conducted for qualitative analysis. Inductive thematic analysis followed Braun and Clarke's framework. A sequential explanatory design with triangulation was employed. Of 6547 admissions, 835 (12.75%) were unplanned discharges; prevalence was higher among neonates than post-neonatal children. Among 139 eligible children (aged 0-12 years), 80 were enrolled (35 neonates, 45 older children). Most families (86%) were from lower socioeconomic strata; 60% received government financial support. About 47% required invasive ventilation, 42% vasoactive support, and 35% underwent cardiopulmonary resuscitation. Despite high satisfaction with clinical care, 97% reported severe stress (≥8/10) and 91% minimal personal support. Qualitative analysis (n = 50) identified four key themes: perceived unfavorable prognosis (64%), infrastructure limitations, indirect financial constraints, and personal beliefs. Collective family decision-making occurred in 75% of cases. LAMA was primarily driven by perceived clinical futility rather than financial barriers alone. Infrastructure constraints, indirect costs, and personal beliefs contributed meaningfully. Targeted interventions should focus on improved prognostic communication, structured family counseling, psychosocial support, and financial protection extending beyond direct medical costs.