Dr. MC Gupta, a doctor turned lawyer, guides with practical answers and insights for queries posted by Indian doctors. Here he explains the difference between DOR, DAMA, LAMA, and absconding, and the appropriate actions that need to be taken for each.

A— DOR means “Discharged on request”

It would mean that the patient requested to be discharged and the doctor discharged him. Here the doctor does not commit any illegality. As a matter of fact, very often patients are routinely discharged on request and, mostly, such discharges are not against medical advice. Hence DOR is not really a good term to use.

The use of the term DOR may potentially lead to complications later:

a—If the condition deteriorates or the patient dies later, the relatives may say that they never made any request for discharge but the doctor wrote DOR on his own for ulterior motives. A common ulterior motive alleged may be that the doctor wanted to make a bed available for his own relative or for somebody from whom he had received illegal gratification. This is more likely to happen in government hospitals. The opposite counsel would argue that there was no request at all.

b—If the condition deteriorates or the patient dies later, the relatives may say that they made the request because, as laymen, they thought that the patient’s condition had sufficiently improved, but, the doctor being an expert, should have known that the patient was not fit for discharge and should have explained the gravity and the risks involved in discharge. They can allege that their request was natural and understandable but the doctor’s behaviour was not; he should have informed them about the adverse possibilities.

The opposite counsel would argue that even though there was a request, it was not an informed request. He would plead that the doctor acted mechanically and did not apply his mind. He would say that just as an informed consent is of extreme importance in law, similarly there must be an informed discharge. He would allege that the doctor failed in his duty.

c—If there are unpaid dues and the hospital asks for the dues later, the patient/relatives are likely to say that they had paid all dues in cash and the hospital did not give a receipt.

---

Practical advice

1. The doctor should ask the patient or the relatives to submit a written request for discharge.
2. Such a request should contain two declarations as follows:

• ONE, that it has been explained to them that the discharge at this stage is not advisable and is risky and that they have understood the risk
• TWO, that they have paid or promise to pay all dues before leaving the hospital

3. It is better that the DOR certificate should be signed by two doctors and countersigned by the patient/relative and should contain, if applicable, a statement that reads: “Dues not paid. The patient promises to pay within a week”.

---

B—DAMA means “Discharged against medical advice”

It would mean that the patient requested to be discharged and the doctor told him that it was such discharge was not medically advisable. The 'Practical advice' given above applies here also.

---

C—LAMA means “Left against medical advice”

It would mean that the patient wanted to be discharged from the hospital but was advised against it, but still decided to go. In such a situation, it is a common practice in hospitals not to give a detailed discharge slip to the patient which may contain necessary clinical details.

This is a wrong practice. No patient can be forcibly kept in a hospital, even for his own benefit. He must be discharged when he makes such a request. In that case, proper discharge slip should be given on which it may be written that he was discharged on request. It would then be a case of DOR.

Ideally, there should be very few LAMA cases in a hospital. Most of the so-called LAMA cases should have been DOR cases. The term LAMA should apply to only those cases who decide to leave in a hurry or huff or in bad temper and leave at once at very short notice, without giving time to the staff to explain the risks involved and to prepare a detailed proper discharge slip. In such cases, it is better to take the following steps:

1. It should be clearly written in the case sheet, under signatures of two doctors, that the patient took a sudden and precipitate decision to leave and even did not give time to the staff to prepare a detailed discharge slip and hence the patient was declared LAMA.
2. After the patient has thus left in a hurry, the doctors should still prepare a proper discharge slip and keep it in the case sheet and give a copy to the patient if he turns up later and wants the same. Treating a patient and not giving, even when requested later, a proper discharge slip containing a summary of the hospital stay and diagnosis etc. would be an illegal act on the part of the hospital.

---

D—“ABSCONDED”

This is a serious event calling for urgent steps

a—“Absconded” means that the patient has left the hospital without permission or information and is not traceable within the hospital premises. This is a very serious situation and calls for immediate reporting to the police and the relatives. The duty of the treating doctor is to inform the medical superintendent/hospital administration urgently. The administration should, without delay, inform the police after necessary inquiry.

b—If the police are not immediately informed, complications can occur, such as the following:

1. The patient is in the custody of the hospital. If anything in custody is found to be missing from the custody of the custodian, the latter is liable. Thus the relatives would be fully justified in suing the hospital for deficiency of service if the patient is missing from their custody. This would imply lax custody.
2. If a sick person in hospital custody is missing from custody and the hospital takes no action and the person is traced later in a serious condition, the hospital would be liable for negligence because it is the duty of the hospital to take all necessary steps to treat disease and to prevent its deterioration.
3. If the absconding patient commits suicide, the hospital/doctors can be sued for abetment to suicide. Though, in practice, the courts may let them off lightly.
4. If the absconding patient meets with an accident and dies, there may be insurance claims (life insurance policy claim; health insurance policy claim; accident insurance policy claim); compensation claims (compensation awarded by the Motor Accidents Claims Tribunal, MACT), consumer claims or claims awarded through other legal mechanisms. All these would usually necessitate an FIR and may even have the hospital as a party.
5. If the absconding patient commits some crime, and the police have not been informed, the police may like to implicate the hospital/doctor also. I think the police would be justified in doing so.

---

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

Content from the writer has been directly replicated on the website. No edits have been made.

The writer, Dr. MC Gupta is a practising lawyer specialising in medical negligence cases. He also has an MD Medicine from AIIMS, Delhi where he also worked as a faculty member for 18 years, later working another 10 years as a Professor and Dean at National Institute of Health and Family Welfare, New Delhi, before pursuing law.