Discharge against medical advice in children: Key guidance for clinicians

22 Jun 2026 Estimated read time: 6 min read

Sr Letmore Chigudu, Case Manager at Medical Protection, discusses the delicate balance between parental autonomy and a child’s best interests, and outlines practical steps to help reduce medicolegal risk.

Discharge against medical advice (DAMA) in paediatric care presents a particularly complex ethical and clinical dilemma for healthcare professionals. It occurs when a parent or guardian decides to remove their child from hospital care before the treating doctor deems it medically appropriate. This decision can range in urgency and risk. In low-risk situations, such as when a child on intravenous antibiotics can reasonably continue treatment as an outpatient, early discharge may be manageable. In moderate-risk cases, such as when a child developing complications and requires continued monitoring, premature discharge can cause harm. At the high-risk end of the spectrum are scenarios requiring immediate interventions, such as emergency surgery or blood transfusions – where refusal or early discharge could be life-threatening.

While clinicians may perceive DAMA as irrational or negligent, parents rarely refuse care without reason. Their decisions are often rooted in fear, frustration, or competing pressures. Understanding these motivations is key to effective communication and conflict resolution.

Exploring parental motivations

One of the most common reasons for discharge against advice is perceived improvement. Parents may see visible recovery - a settled fever or improved appetite - and conclude that hospital care is no longer necessary. Without appreciating the risks of incomplete treatment, they may believe it is safe to take their child home. Financial constraints also play a significant role. Hospitalisation often carries indirect costs such as transport, meals, lost wages, and uncovered medication expenses, which can force families to withdraw their child prematurely.

The inconvenience of prolonged hospitalisation is another major factor. Many parents, especially single caregivers or those with limited support, struggle to balance hospital stays with other responsibilities. Dissatisfaction with care – whether due to long waiting times, lack of communication, or perceived indifference from staff – can erode trust and prompt parents to seek care elsewhere. Cultural misunderstandings or experiences of discrimination may further deepen mistrust.

In some cases, parents turn to traditional or alternative medicine, guided by cultural beliefs or prior experiences. Religious convictions can also influence decisions, such as the refusal of blood transfusions or preference for spiritual healing. For some families, the hospital setting may conflict with cultural norms surrounding illness and death, prompting them to remove a critically ill child to allow care or passing to occur within a traditional context.

Acting in the child’s best interests

At the heart of paediatric ethics lies a guiding principle - every decision must serve the best interests of the child. In South Africa, this concept is not merely ethical but constitutional. Section 28(2) of the Constitution states that a child’s best interests are of “paramount importance in every matter concerning the child.” This means that in all clinical decisions, the child’s welfare takes precedence over all other considerations, including parental preferences or cultural norms.

Healthcare providers have a duty to promote the child’s health and development beyond immediate survival. They must consider the long-term effects of decisions on the child’s growth, dignity, and potential. While parents have the right to guide medical decisions, that right is not absolute. When parental choices endanger the child, clinicians have a legal and ethical duty to intervene.

Legal and ethical considerations

South Africa’s legal structure strongly supports the protection of children’s health rights. The Constitution provides the overarching foundation, while the Children’s Act 38 of 2005(Children’s Act) operationalises these protections in clinical settings. Section 129 of the Act outlines how consent applies to minors. Children over 12 years may consent to medical treatment if sufficiently mature, and to surgical procedures with parental assistance. However, when parents refuse essential care that could prevent serious harm or death, the law allows clinicians to act without consent.

Section 129(10) of the Children’s Act states that no parent, guardian or caregiver of a child may refuse to assist a child by reason only of religious or other beliefs, unless that parent or guardian can show that there is a medically accepted alternative to the medical treatment or surgical operation concerned. Courts can also issue care and protection orders to ensure the child receives necessary treatment. Refusal of life-saving care, such as antibiotics, transfusions, or surgery, may legally constitute medical neglect.

South Africa’s child protection laws are further reinforced by international agreements such as Article 3 of the United Nations Convention on the Rights of the Child and Article 4 of the African Charter on the Rights and Welfare of the Child, both affirming that a child’s best interests must always guide decision-making.

Managing conflict and ensuring protection

When faced with parental refusal or DAMA, confrontation should never be the first response. The table below shows a step-by-step approach to addressing the situation.

Step	What it involves	Key actions
1.Re-engage and clarify	Shift from confrontation to collaboration; understand the parent’s concerns.	Explore their reasoning (fear, misinformation, past trauma). • Clarify medical facts using plain language. • Address misinformation with balanced, evidence-based information. • Respect cultural or religious beliefs; accommodate where possible. • Use empathy to reduce defensiveness and rebuild trust.
2.Assess risk	Evaluate the clinical consequences of delaying or refusing the recommended care.	Low risk: Delay unlikely to cause harm; consider alternatives (discharge with safety-netting, outpatient follow-up). Moderate risk: Delay may worsen condition; continue negotiation, reinforce risks/benefits, document thoroughly. High risk: Delay or refusal threatens life or wellbeing; immediate action required.
3. Involve a multidisciplinary team (MDT)	Bring in additional expertise when discussions stall or uncertainty remains.	MDT may include senior clinicians, nurses, social workers, psychologists, cultural/religious advisors, ethics committee members. The MDT can: • Provide diverse perspectives • Support both family and staff emotionally • Resolve misunderstandings • Strengthen rationale for care • Reduce perception of bias
4.Escalate if necessary – legal pathways	When engagement fails and the child remains at risk, legal intervention may be required.	• Contact hospital legal or medicolegal team. • Notify child protection services if appropriate. • Approach Children’s Court for urgent intervention under Children’s Act 38 of 2005. • Apply for emergency order to proceed without parental consent if lifesaving.

The role of documentation

Comprehensive documentation remains one of the strongest safeguards for clinicians and patients alike.

What to document

Category	What to document
Clinical assessment	Diagnosis, current condition of the child and prognosis. Justification for proposed treatment or hospitalisation. Risks of not proceeding with recommended care.
Communication with parent/guardian	Date, time, setting of discussion. Who was present (interpreter, social worker, senior doctor). Summary of information provided: treatment options, risks/benefits, consequences of refusal or delay. Questions raised by the parent and responses given. Parent’s position (refusing, requesting discharge, uncertain). Efforts to correct misunderstandings or fears. Cultural/religious considerations and how these were managed.
Risk categorisation	Whether the situation is low, moderate, or high risk. Rationale for the risk classification.
Multidisciplinary involvement	Team members consulted (senior clinicians, nurses, social workers, ethics team). Summary of MDT discussions and agreed plan.
Final outcome	Whether treatment was accepted or refused. Whether child was discharged or retained. Safety-netting advice given (warning signs, when to return). Follow-up arrangements (appointments, referrals). DAMA form signed, if applicable.
Escalation/legal steps	Legal justification for proceeding without consent (e.g. Children’s Act Section 129(10)). Any legal interventions initiated: steps taken, by whom, and when (child protection referral, court application).

Conclusion

Always remember – If it’s not written down, it didn’t happen.

Discharge against medical advice in children requires delicate navigation between respecting parental autonomy and upholding the child’s right to health and safety. By prioritising open communication, ethical reflection, and adherence to legal frameworks, healthcare professionals can manage these difficult situations with compassion and integrity. Ultimately, every decision must align with one unchanging principle - the best interests of the child remain paramount.

The author would like to thank Dr Volker Hitzeroth, medicolegal consultant at Medical Protection, for his valuable contribution to this article. 