All 11 pediatric residents joined the focus group discussion. The level of training of the residents consisted of 2 third-year level trainees (most senior), 4 second-year level trainees, and 4 first-year level trainees. The Chief Resident also joined in the discussion. There were 8 female and three male pediatric residents. The ethnicity of the pediatric residents consisted of a mix of Tausug, Visayan, Tagalog, Chavacano, and Samal.
During the discussion, one of them had to step out during the early part because a patient at the ward needed medical attention. She promptly returned in a few minutes and joined in the discussion. There were three prominent themes that arose in the discussion: variability in the definitions of DAMA, factors considered before “allowing” the patient to go on DAMA, and the implications of a DAMA request on their performance as pediatricians.
Definition of DAMA
In cases of DAMA, the pediatric residents have three main classifications or categories for DAMA which they also report in their monthly and annual census of admissions and discharges. Their decision as to the classification of the DAMA status depends on the reason given by the caregiver for the DAMA request, such as financial reasons (DAMA-financial), cultural reasons (DAMA-cultural), or terminal cases (DAMA-terminal). Cases signed out as DAMA-Financial are those cases where parents express the desire to be DAMA because of inability to shoulder expenses for medical treatment, inability to provide in-hospital care to their child because of lost days at work, or situations where the parents give other reasons such as bringing the child to a traditional healer since it is a cheaper form of treatment. However, this last reason overlaps with another common reason for DAMA that is to bring the child for traditional healing, the term of which they use is DAMA-Cultural, since this is based on cultural beliefs (“…we know that the patient will die weeks or months after and they want to bring the patient to the traditional healer, so we label them as DAMA cultural”). The pediatricians believe that even though resorting to traditional healers is a common practice in this part of the country, going to traditional healers is also cheaper. To determine the cause for the DAMA request, much is based on the pediatrician’s own observation. Some of them observed that in cases with families who do not request for DAMA but wanted to consult a traditional healer, they would ask the healer to come over to the hospital to conduct a session of healing at the bedside. In situations like these, the pediatricians often allow the parents to bring traditional healers as respect to their cultural beliefs. The status of DAMA-Terminal, on the other hand, is given to a case where the child has a serious condition that has a poor prognosis of which the residents can’t do much to reverse the situation and out of hopelessness, the parents decide to bring the child home (“As long as they [parents] know that the patient will die right after or immediately on discharge, [we classify as] terminal”). Amongst a subgroup of pediatric residents, a discharge status called Home Per Request or HPR is sometimes used. In this situation, the parent or caregiver still initiates the request to be discharged but the perceived prognosis of that particular case is good in contrast to DAMA where the perceived prognosis is poor (“…the physician cannot trust the caregivers to administer the medications correctly or religiously so that’s when the physician terms it as DAMA. And if it’s like home per request, the physician trusts the parents and he knows that the parents know how to give the drugs so he can let go of the patient…more confidently, although the medications have not been completed and the patient is not completely well”). Differentiating one type of DAMA from the others would give the resident an opportunity to identify situations where they could still do something to help the family or to identify areas of care that need to be improved.
Factors considered before giving the DAMA order
There are four major factors that a pediatric resident considers in deciding to write out a DAMA order: their ability to do something about the reason given for the DAMA request, the condition of the patient when the DAMA request was given, their impression of the kind of care that the parents/guardians provide, and their legal liabilities.
In general, the pediatricians’ ability to modify the situation that prompted the request for DAMA is one of the strongest factors that they consider when they sign out a case as DAMA. For example, when confronted with a request from a parent or guardian to DAMA, the participants in this study stated that the first thing they think about is the reason behind such a request. Their main motive for this is to determine whether they can still do something to help with the situation and allow the child to receive complete treatment (“So we can find ways to stop them, for example, if the reason is financial, you can give options on how to solve the problem”). For this aim, they sometimes are required to interpret a possible “hidden” reason for the parents asking for DAMA because in their view the child is already well. This occurs when the child shows early favorable responses to the treatment regimen such as in very severe pneumonia cases. Children with this problem come into the hospital with fever, rapid and difficult breathing, cyanosis, and sometimes with decreased level of sensorium. After starting antibiotics, when the child’s fever lyses and is more awake, parents feel that their child has improved and opt to be DAMA rather than to complete the full course of antibiotics (“It is their perception, Doc, that when they see that the patient is well clinically, the situation is okay. They rely on their own judgement that the patient is okay). However, the pediatricians believe that this is because of financial difficulties of having to buy the entire course of antibiotics, missed days of work (because laborers are paid according to a completed day of work), and additional costs of staying in the hospital like food and transportation expenses (“…even though we tell the parents that we will shoulder the cost of the medicines and the hospital bill, they still want to go home because the parents claim that they don’t have money for food and other expenses like transportation during the hospital stay” or “the other parents can’t go to work because they had to stand watch in the hospital…”). Moreover, it was noted in the discussion that since the billing system changed in the hospital from 2005 up to 2010, it was harder for the patients to pay for their bills, especially among the poorest who used to get free medical care but are now required to shoulder a portion of the bill (“…the patients are always surprised that medical services are not free anymore in this hospital”). There was no perception that there was a lack of comprehension on the part of the parents about the need for complete treatment, as the pediatricians reported to speak a variety of local dialects and are diligent with explaining the situation to the parents (“....everybody explains to the parents, Doc, or maybe, we can have a longer explanation or have a family conference for better understanding.....” and “You cannot insist that they follow what you want so you’ll just need to explain very well”). There was unanimous agreement among the participants that if they perceive financial difficulty as the main reason for DAMA, they try to dissuade the family and instead try to look for ways to help them such as referring to the social services department, to the Philippine Charity Sweepstakes Office for grants, other private non-governmental organizations, or the pediatricians themselves shell out money for medications. If the reason for DAMA is modifiable by the pediatricians, their first recourse is to fix the situation in favor of the parents to alleviate the difficulties in continuing treatment. When the pediatricians feel like they can’t do much to help their patient’s family, then they sign out the case as DAMA.
In some instances, the pediatricians believe that one of the reasons for asking for DAMA is the “nurse factor”. This factor, which pediatricians believe can be modified, affects DAMA rates in two ways. Firstly, all the pediatricians believe that there are some nurses who encourage parents to bring home their children because this would mean less work for them. When the pediatricians were asked if they adapt the same attitude as the nurses, none agreed. Instead, one pediatrician explained that they view this situation of patient overload as a part of their job therefore, they shouldn’t be sending patients away. They also tried to share this attitude with the nurses who have been identified by the parents to have encouraged them to DAMA, to influence them not to encourage parents to DAMA (“We tell the nurses not to think that way because we are basically being paid by the patient to do our work here”). The second way the “nurse factor” causes DAMA is dissatisfaction with nursing care. This is perceived by the pediatricians through such comments from parents that a few of the nurses are nasty, short-tempered, and procrastinate especially with IV catheter reinsertions (“the parents don’t like the nurse-on-duty because she is nasty”, “the nurses scold the parents”, or “iv catheters are often dislodged and it takes a long time for the nurses to re-insert…..”). Again, if these are the reasons for DAMA, the pediatricians dissuade the parents from bringing their children out of the hospital and instead try to talk to the nurses to provide better service. None of the pediatricians mentioned that DAMA could be due to dissatisfaction with physician care, although one mentioned that she did wonder at one time if such a reason has been given about her services but was not fed back to her (“I don’t know whether families under other pediatricians who were DAMA during my duty mentioned that they didn’t like me but among my patients who were DAMA, no one told me that they were dissatisfied.”). Another narrated that one of her patients requested to DAMA because the mother wanted to be under the service of a certain private pediatrician. She told the resident that their decision is not because of the pediatric resident’s fault, except that the child is “more accustomed” to the preferred private pediatrician (“Because my child gets well all the time under Dr......., he is accustomed to that doctor”). Some interpreted this as a better way of telling the pediatric resident that they don’t like her management of the case but most believed that there was no reason for parents to be dissatisfied with their care.
The second major factor that influences the residents’ decision-making to sign out the case as DAMA is the medical condition of the child on the day of DAMA. When they see that the child is medically unstable such as those admitted in the intensive care unit or they feel that the chances of recovery is very slim if brought out of the hospital, the pediatricians sign out as DAMA. If the child is medically stable and is eating enough and is simply completing treatment in the hospital, they do not sign out as DAMA but sign out the case as HPR. What eventually came out from the discussion was an apparent gray area of what the order of HPR versus DAMA implies (“the department should make an operational definition so that there is only one definition among the residents”). All the pediatricians mentioned that the status of either DAMA or HPR eventually is used for their own purposes, indicating how medically serious the patient is at that time, especially during presentations in the monthly mortality and morbidity conference (“It gives a sense of personal satisfaction on the part of the physician in that he was able to send the patient home with a chance to survive....”). Nevertheless, there was one who expressed that in essence, HPR is still a form of DAMA since it’s the parents or guardians who requested to be discharged under a situation where the attending physician is not ready to discharge the patient yet. There was also conflict in terms of the appropriate situations to “use” the term HPR versus the term DAMA. For example, for a terminal case of cancer where the parent requests discharge, some would sign out as HPR apparently because the resident feels that there is not much that they can do to help but the patient is stable. However, if the diagnosis is something like pneumonia where much can still be done, they sign out as DAMA but some residents again base their decisions on the status and prognosis of the case.
The third major factor affecting the decision to sign out a case as DAMA is the pediatrician’s perception of the kind of care that the patient receives from the parents or the guardians. The discussion of this particular issue brought forth a lot of emotions. Most have indicated that when they see that the parents try their best in looking for resources to have the child taken cared of or that they show genuine compassion towards the patient, they try as much as possible to help them and try to defer a DAMA order. However, if they perceive that the parents “couldn’t care less”, even if they ask only once to be discharged, the pediatricians tend to give a DAMA order right away as they feel that their efforts are of no use since after treatment, the parents probably won’t take care of the patient again at home (“there are cases of DAMA that you’d feel guilty about and wonder what happened to the child after being sent home and there were those cases that you couldn’t care less” and “There were cases that I experienced where I pitied the child so much that I thought he would’ve been better off dead than to suffer under the care of his parents”). This topic caused a division among the residents during the discussion because when one mentioned a situation as an example, wherein she felt that the family did not really care whether the child gets well or not, another pediatrician begged to disagree and thought that the parents just did not express themselves properly.
The fourth major factor that residents consider is the legal aspect of discharging the patient. When they think that the family might come back with an accusatory tone or file a complaint or malpractice suit because the child’s medical condition deteriorated after discharge, then it is best to have them sign out as DAMA. When they think that the family is more amiable and less prone to complain, they sign out as HPR (“it’s more for the security of the physicians because they know that if they let the patient go and the patient will die, and they do not let the caregivers sign it, if something happens, the watchers can always go back on their word and say we were discharged and our patient died.”). In their setting, many relatives can complain and threaten to harm the resident of which two cases were cited in the discussion. In one case, some relatives came back and requested for “blood money” (money paid by the physician or hospital to the family in exchange for the death of the child largely blamed on the physician) and threatened to physically harm the resident or a member of her family if not given. Another pediatrician described how the family approached the district congresswoman to ask for money to help with funeral costs after the death of their child. They claimed that they were sent home thinking that the child was well but eventually died within 24 hours, implying some form of mismanagement. When the congresswoman’s staff investigated the case, the attending pediatrician presented to them the signed DAMA request of the parents, thus absolving them from the case. The residents then concluded that to be able to protect themselves from matters like these, especially when they move on to private practice, it is best to sign out the case as DAMA and even for cases such as HPR, it might be best that they consider it as DAMA as well.
Implications of a DAMA request on their performance as a pediatrician
From all the discussion, pediatric residents see that DAMA has a negative connotation wherein there is dissatisfaction of treatment outcome from the point of view of the parents (i.e. the effort that was put in does not equate to the improvement of the patient). From the point of view of the pediatricians, it is an expression of a sense of hopelessness in the management of the patient. All of the pediatric residents did not take the DAMA request personally and maintain an open and amiable attitude when faced with readmission of their patient. Given a case of readmission of a DAMA patient, the pediatricians unamimously said that they don’t mind treating the patient again (“I will accept the patient again because the child is at the mercy of the caregivers and they cannot decide for themselves. If, for example, you had a misunderstanding with the grandparents or uncles or aunts, which was why they decided to DAMA and then they come back, I still have to put the patient’s best interest in mind.”). They also mentioned that they don’t feel that the previous DAMA status would affect their management of the case, although many have given side remarks of “I told you so….”. This attitude was explained by the pediatricians that in a government hospital, no patient is refused admission so they don’t have a choice who to take care of. Moreover, there is much emphasis on respecting tribal beliefs as well ([pertaining to the tribal group Badjao] “It’s like, [the Badjaos] let fate dictate what happens.... whatever will be, will be, if it’s time to go....they easily accept their fate”) so they still accept the patient after being brought to a traditional healer and then returned back to the hospital. Nevertheless, most of them try to understand the situation that the family was put in and then try to approach them differently from before.