Useful Notes on “Left Against Medical Advice” (LAMA)

3. His disease may be incurable.

4. He may have pressing personal/family problems demanding his attention.

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Whatever the reasons, the decision is generally not appreciated by the staff, partly because they would be losing a patient and partly because the patient was not satisfied with their efforts. It may also be because the patient failed to understand the doctor’s view point.

Many hospitals go to the extent of refusing to issue even discharge summary which has no justification at all. Often the hospital refuses to provide the ambulance for transporting the patient to the next hospital. This goes against the patient’s right to make his own (informed) decisions.

The hospital staff has to respect the wishes of the patient. The correct course in these situations is to:

1. Fully and frankly inform the patient about the facts of the case and advise him/her about the options available and then leave the decision to the patient. It is always better to do so in writing.

2. In case the patient/his next of kin, still decide to leave the hospital, then get the decision in writing and confirming that the facts of the case, the options available, the risks involved to life of the patient because of his refusal to accept the advice of the doctor, have been fully explained to the patient/his next of kin, and they would be fully responsible for the consequences of their decision.

3. Issue a discharge summary (as in case of a normal discharge) endorsing on it the fact that patient is leaving the hospital against medical advice. The discharge summary should include all the investigation reports, films, images, etc. and if the patient so demands, even a copy of the case record has to be issued, may be on payment of a reasonable fee as decided by the hospital.

4. The hospital should extend full cooperation, as expected in case of a normal discharge such as providing ambulance facility and doctor/nurse to escort the patient (on the usual payment), if available. Otherwise, the hospital may help in arranging the same from the next hospital where the patient chooses to go.

There may be situations where, because of the technical problems the hospital may not be able to comply with the wishes of the patient’s attendants. In case of a patient, comatose and on ventilatory support, discharging the patient may involve many technical/legal issues.

It may mean disconnecting the ventilator and letting the patient die in transit. The hospital may not like to be held responsible for pulling the plug and violating the law. In these situations the right course would be:

i. To advise the next of kin to get the critical care transport and the doctor/nurse from the next (receiving) hospital to come and take charge of the patient

ii. Extend all possible help, including briefing of the treating consultant in the receiving hospital about the case

iii. Issue all documents including the discharge summary, the investigation reports in original (copies of reports in case of an MLC) and a copy of the case record if so desired.