Introduction
Discharge with personal consent before the completion of the treatment course and despite the recommendations of the medical team is considered one of the basic problems of the health care system and can indicate the lack of satisfaction of the patients. The results of the studies show that the discharge by personal consent in most countries accounts for 0.8-4.2% of all discharge cases. In Iran, the percentage of people who leave the hospital voluntarily varies from about 3% in neurology departments and 20% in the emergency department [6, 7]. Discharge by personal consent, in addition to affecting the treatment process, reduces the hospital’s income. As satisfaction in the patients increases their cooperation in the treatment process and contributes to the success of the treatment, the lack of understanding of the patient by the treatment staff and the weakness in establishing proper communication with them reduces the patient’s sense of trust in the treatment staff and subsequently leads to the decision to discharge with personal consent. With the ever-increasing advances in treatment methods and better recognition and understanding of the needs and expectations of patients who leave the hospital against medical advice, it is possible to achieve targeted and practical strategies to minimize the negative effects of these discharges. Finding the solutions to reduce the rate of discharge with personal consent based on the current situation, in addition to promoting public health, is for the benefit of the health system and can reduce the wastage of resources. Due to the fact that the Kosar Hospital in Semnan, Iran, has the highest number of patients in the province, in this study, the reasons for discharge with personal consent from the emergency department of this hospital were investigated.

Methods
This is a descriptive-analytical study with a cross-sectional design that was conducted in 2021 in the emergency department of Kosar Hospital in Semnan. The study population consists of all patients who were discharged from the emergency department of this hospital in 2021. Sampling was done by census method. To collect data, a two-part questionnaire was used measuring the patient’s demographic information (age, sex, educational level, marital status) and the reasons for discharge with personal consent (medical personnel and staff, hospital equipment and facilities, personal reasons, and fear of COVID). Based on the opinion of 11 experts, its face validity and content validity with 23 items were confirmed. The collected data was statistically analyzed in SPSS software, 22 using descriptive and inferential statistics (chi-square test and Student’s t-test), considering a significance level of P<0.05.

Results
During the study period, 16,719 people (8,124 in autumn and 8,595 in winter) admitted to the emergency department of Kosar hospital, among whom 1,869 patients (959 in autumn and 910 in winter) were discharged with personal consent (11.1%). Finally, the data of 140 patients discharged with personal consent were examined, who were 82(58.6%) men and 58(41.4%) women aged 5-87 years (Mean years 33.52±16.17). Among participants, 89(63.6%) were married and 51(36.4%) were single or divorced. Moreover, 30(21.4%) had middle school education or lower, 59(42.1%) had a high school diploma, 41(29.3%) had education higher than a diploma, and 10(7.2%) also did not answer about their educational level. Also, 11 people (11.4%) had a history of taking neuropsychiatric drugs. Among 140 discharged patients, 96(68.6%) were in the surgical emergency ward, 40(28.6%) in the internal emergency ward and 4(2.8%) in the corona emergency ward. Moreover, 28(20%) discharged in the morning shift, 59(42.1%) in the evening shift, and 53(37.9%) in the night shift. 
Among participants, 37(26.4%) reported that the reason for discharge with their personal consent was the fear of getting infected with COVID-19, and 42 people (30%) reported the lack of insurance or problems related to insurance as the reason. Financial issues, family issues such as having a young child, and other reasons were also mentioned by 11(7.9%), 3(2.1%) and 5(3.6%) patients, respectively.
Among the problems related to personnel and medical staff, the most frequent reasons for discharge with personal consent included inappropriate behavior of the doctor and lack of proper response (n=24, 17.1%), dissatisfaction with diagnostic and treatment measures (n=22, 15.7%), improper behavior of the personnel (n=18, 12.9%), long hospitalization time (n=17, 12.1%), lack of accuracy and skill in the treatment staff (n=16, 11.4%), and absence of doctor (n=13, 9.3%).
Among the problems related to environmental issues and hospital equipment, the most frequent reasons for discharge with personal consent were: Dissatisfaction with the inappropriate environment of the emergency room (sanitary condition, peacefulness, etc.) (n=17, 12.1%), absence of empty beds in the emergency room (n=10, 7.1%), dissatisfaction with the available diagnostic and treatment equipment (n=9, 6.4%), and being a teaching hospital (n=8, 5.7%).

Conclusion
According to the findings of the present study, the most common reasons for discharge with personal consent from the Emergency Department of Kosar Hospital are patient-related reasons, staff-related reasons and hospital-related reasons. By intervening in the quality of care in various dimensions, the hospital’s management system can play a significant role in reducing the rate of discharge with personal consent and preventing or minimizing the imposition of additional costs on the patient and the hospital and the aggravation of disease complications due to early discharge. Considering that health insurance coverage and economic issues were among the most important factors affecting discharge with personal consent in the present study, identifying low-income patients and people without insurance coverage from the beginning of the patient’s arrival at the triage unit and deploying health workers in the emergency department and non-administrative shifts to handle patients’ affairs and facilitate the treatment process can be effective in reducing self-discharges in hospitals.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Semnan University of Medical Sciences, Semnan, Iran (Code: IR.SEMUMS.REC.1400.173).

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
Conceptualization, study design, methodology, project administration, financing, review and editing: Mehdi Yarahmadi; Investigation and initial draft preparation: Mohammad Taghi Ghorbanian; Visualization and supervision: Mehri Ayati.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors would like to thank the Development Unit of Kausar Educational and Research Center, Semnan University of Medical Sciences, Semnan, Iran, for
providing the necessary facilities to conduct this research.

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