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  • Comments: 7
  • 19 September 2015 04:29
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  • patients, patient-care, lama, doctors
  • Last Modified: 20 September 2015 02:46
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Learning About a Medical Atrocity

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My guilt would come later. My blood will boil later with my own shame. But first there was happiness. There was relief. A lot of it.

It was 1996 when I first noticed the phenomenon. Ramaiah (name changed because of obvious reasons and the not so obvious fact that I forgot it) was admitted in the Government Hospital where I was doing my internship. He had a non-healing ulcer of the right leg and was suffering with acute infection of the leg up to the knee. He was admitted by the assistant professor himself in the ward and the care was handed over to the lowest order of the caretakers: the interns. As interns, our status was far less than that of the nurses and probably less than that of orderlies who could dress a wound certainly better than us. Above the nurses were the junior postgraduate students, who were supposed to prostrate before their senior colleagues who bowed to the assistant professors, who in turn played an occasional hypocritical sycophantic card with the ward professor and the head of the department. And then there was the Superintendent aka the demigod.


So Ramaiah’s fate, by the quirkiest of fates, fell in to my and a couple of colleagues’ hands. The care involved dressing the wound daily and administering the antibiotics and improving his nutrition. It was understood that the healing would be slow and he would be stuck with us for the next several days. The only problem was that Mr. Ramaiah was not a pleasant man. Not by an incredibly long margin. He used to shout and swear while we were dressing the wound. He added quite generously to our sparse vocabulary of Telugu expletives. Though we didn’t mind his abuse initially, after a week of a continuous barrage, we thought that we were getting more than we had bargained for.


We have investigated him thoroughly in that week. We got the blood tests done, we X-rayed him and we even got the blood and urine cultures done and it was looking like he was indeed getting better. He required at least one more week of inpatient care but suddenly he threw the metaphorical bomb at us. He said he wanted to get discharged.


Naturally we were annoyed. We took all the abuse, worked on him comprehensively for a week and there he was asking me to send him off because he was not happy with the care he received. But that’s when I understood what a LAMA was. LAMA means Leaving Against Medical Advice.

Indeed there was a great relief to the doctors when a patient goes on LAMA. We were being totally absolved of our responsibility towards the patient once the patient declares that he is going on LAMA. But the problem was that the patient would get a very raw deal. He would not be given a proper discharge summary, he would not receive any reports of the investigations done on him, nor would he receive – you wouldn’t believe this – any instructions about the medications he should take or the precautions he has to follow or the diet he should consume. In short, if the patient says LAMA, he is on his own. He would have relinquished all his rights for a proper treatment and follow up.

My guilt would come later. My blood will boil later with my own shame. But first there was happiness. There was relief. A lot of it.

I noticed this practice a lot and it was ubiquitous in government hospitals. But what was worrying was that the same trend is being followed in a lot of private hospitals as well. And surprisingly, the younger doctors are the ones who are particularly insensitive to the treatment meted out to the LAMA patients.


There were a lot of doctors who saw that this age old practice was wrong. But this lot was in the minority. And most of the doctors thought that this was too trifle a thing to bother about. I personally know several doctors who think that this practice is justified. Some even think that it is not only ethical and moral to refuse to give the complete information to a patient leaving against medical advice, but they also think that it is legally mandated!


The simple fact is that doctors take LAMA as an ultimate rejection of their services. They may even forgive a patient going away because of financial reasons, but not the one who wants to choose a different, if not better medical care. Sometimes, may be a lot of times, the doctors’ intentions may be right and the patients may unnecessarily be moving on to a different facility, but what has to be understood is the undeniable fact that it is the patient’s right to seek medical care where ever he wants. And while it is really annoying to have a patient not having confidence in his doctor, the doctor cannot and should not refuse to give a complete account of what transpired when the patient was in his care and a proper discharge advice as well.


There should be a clear statement by the Medical Council of India urging the doctors to give a comprehensive discharge plan to the patients leaving against medial advice. And doctors also should understand that exercise of the right of a patient to seek the treatment elsewhere is not a mandate against his or her skills.


"One who is injured ought not to return the injury, for on no account can it be right to do an injustice; and it is not right to return an injury, or to do evil to any man, however much we have suffered from him” - Socrates


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