Death of the DAMA

“Hi Dave, could you just sign this for me?”

I am standing at one of our clinical computer screens in the One Patient Pathway area of the Emergency Department at around 7pm on a Thursday evening, and one of the triage team has just approached me with a form in hand.  It happens to be a DAMA (Discharge Against Medical Advice) form.

“Who’s it for?” I ask.

“For the gent in C5 – he wants to go home.”

“Tell me the story.”

There is a slight pause and a barely perceptible deeper intake of breath as my more junior medical colleague realises that this is not turning out to be the simple request he had envisaged, and because we have worked together for a few months now, he also suspects that I may be about to embark on more thorough examination of his cognitive processes and motives.  He is correct on both counts – hopefully in a good way.

“Mr Bryant is a 67yr old man, normally fit and well, who fell after tripping on a step in his garden at 4pm this afternoon.  There was possibly a loss of consciousness for less than a minute, and he has an abrasion to his forehead.”

“OK,” I say, “any high risk features or story of collapse? Any anticoagulants?  Any other injuries?”

“No, but he lives alone, and the protocol says that he should stay for 6 hours.”

This is the bread and butter of modern medicine – identify problem, follow protocol for said problem (often based in best evidence though rarely based in “real world” populations and laced with risk aversion and “safety”), carry through and repeat as necessary.

Or rather, this used to be modern medicine.  It is still deeply engrained in our practice, not least because it gives us – clinicians and patients – the feeling of decision support and reassurance that we are doing the “right thing”. 

But what is the “right thing” – is it the same for us as clinicians as it is for patients?  How would we know?  Current, realistic, medicine now asks us to have a different approach to understanding what is the “right thing” to do, and challenges us to embark on achieving this in partnership with our patients.

“What does Mr Bryant want to do?” I ask.

The “What matters to the patient” question is so important that we have it printed in bold on all of our ED sheets.

“He wants to go home now.”

“Does he have capacity to make this decision?” I ask, and we talk through the various strands required to complete this assessment, all of which my colleague has already undertaken.  We also recognise that coming to a different conclusion to the one recommended by a protocol does not mean you do not have capacity!  It turns out that he does.

Deviating from a recognised protocol and acting contrary to medical advice therefore earns you a DAMA form.  In times gone by, it also occasionally earned you the barely concealed scorn of people who were there to care for you, and precluded you from any treatment that may be on offer for whatever condition you were refusing to stay in hospital for.  The DAMA form acted as the paper permission to punish patients who were bucking against medical expectations.

“Why did they come in the first place if they were just going to leave...?”

I believe that DAMA is a symptom of an era that is on the ebb.  We should be equal partners in making decisions with patients and their families and carers about their next steps, without our inherent bias and assumptions that make us closed to understanding their perspective.  We should be actively seeking what matters to them, give open and honest assessments of what the likely course of their condition is, give our best advice on how our investigations and treatments may add value to their care, and act with integrity to help them find the best course through our system to be healthier and happier.  We may have expert knowledge, but that does not make us experts in what our patients want.

The DAMA form speaks of a worrying mismatch in our approach as professionals to the needs of our patients.  We need to cede the power we hold over patients within the system.

We go and speak to Mr Bryant. We ask what he would like out of his visit, and he is clear that he was concerned his wound may need some treatment, but otherwise was just after some reassurance.  He doesn’t want to burden what he knows is a busy system and is adamant that he wants to go home.  We discuss the likelihoods of intracranial haemorrhage and post-head injury complications, what symptoms to look out for, and what analgesia may be helpful.  He clearly has capacity, and who are we to discourage him from taking responsibility for his own management. 

This, of course, needs to be concisely and accurately documented in his notes, as with any other clinical decision, but it does not need a punitive attitude and additional paperwork “for our records”.

Shouldn’t we all be asking

“What matters to you?” and “How can I help you achieve this as safely as possible?”

And let’s start shredding DAMA forms.