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JUST WHAT THE
DOCTOR ORDERED:
DEALING WITH
NON-COMPLIANT
PATIENTS
by Catherine E. Miller, RN, JD
CAP Risk Management
Representative
and
Dan Groszkruger, Esq.
Consulting Editor
Do You Recognize Any of These Patients
in Your Practice?
- The gentleman with uncontrolled
diabetes who is openly noncompliant
with diet, blood sugar
monitoring, and medication.
- The teenager treating for Chlamydia
who completed his first course of
antibiotics but failed to return for his
follow-up culture.
- The 60-year old woman with syncope
and shortness of breath whom you
referred to a cardiologist. She failed
to keep her appointment
with the cardiologist and
is now lost to follow-up.
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Ask your patient:
“How is your
medication
(or diet, or therapy)
working for you?”
This simple question
is crucial
to uncovering the
lifestyle barriers
to compliance.
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Physicians are incredulous
that they might be held liable
for bad outcomes that occur
when their patients fail to
follow their instructions.
How can this be? Why
should a physician be held
responsible for an outcome
that seems to be a direct
result of a patient’s poor judgment or lack
of diligence?
Non-Compliant Patients Raise Liability
Concerns
The physician-patient relationship is
fiduciary: Physicians have a nondelegable
duty to inform patients about
the nature of treatment and the
importance of their complying with the
treatment plan. If physicians fail to
document their efforts to inform the
patient and to encourage compliance,
those physicians become vulnerable to
allegations of breach of duty to the
patient. At trial, the patient’s sworn
testimony that, “I didn’t know,” and “I
was never informed,” resonate with
sympathetic jurors who are, after all,
patients themselves.
What Does the Standard of Care
Require? Realistically, the
standard of care does not
require that physicians offer
to drive their patients to
appointments or call them
nightly to remind them to
take their medication.
Nevertheless, juries expect
physicians to take reasonable
steps to assist their patients in
understanding the importance
of compliance. In the final
analysis, one simple question
must be answered: What would a
competent and caring physician have
done?
Preventing Compliance Problems by
Laying a Foundation
Sometimes, patients don’t comply simply
because they do not understand what is
required of them.
Patients who are tired, anxious, preoccupied, or even fearful are less likely to hear their
doctor’s instructions. Physicians who respond to their patents’ needs as learners are
better able to enroll the patient in the treatment plan. Although patients readily defer to
their physician’s judgment and expertise, adopting and maintaining a health regimen
requires that they understand both the purpose of compliance and the steps involved. We
recommend the following:
- Provide patients with a basic rationale for whatever treatment you prescribe.
Explaining the purpose of treatment is essential to gaining the patient’s acceptance;
- Simplify instructions to accommodate diverse learning styles and backgrounds;
- Supplement discussions with written materials and videos for patients to review later,
when they may be calmer. Document that supplemental information was provided;
- Employ translators for non-English-speaking patients;
- Ensure that patients requiring close monitoring are not lost to follow up by scheduling
return appointments before they leave the office. Keep a tracking log of patients
referred to other physicians and those sent for diagnostic tests. Recognize that patients
who are in denial and who underestimate the importance of treatment are at increased
risk for non-compliance;
- At each visit, ask your patient: “How is your medication (or diet, or therapy)
working for you?” This simple question is crucial to uncovering the lifestyle
barriers to compliance;
- Document patient non-compliance and specific objections to therapy, if any;
- Finally, recognize that patients are likely to abandon any treatment regimen that does
not fit their lifestyle.
When all Else Fails . . .
Neither professional diligence nor scientific and technological advances will ensure a
good outcome if the patient refuses to cooperate. If, despite your efforts, the patient
continues to ignore your treatment recommendations, it may be necessary to discharge
the patient to reduce your liability.
Prior to discharge, be sure to document the following elements in the patient’s medical
record and in a certified/return-receipt-requested letter to the patient.
- The patient’s treatment plan, goals and objectives;
- Specific instructions regarding follow-up appointments, medication regimen, therapy
visits, specialist referrals, and the like;
- The nature of the proposed treatment as well as the risks, benefits, alternative therapies
and complications;
- The specific risks associated with refusal or delay in receiving treatment.
For additional assistance on the process of discharging a patient, contact the CAP-MPT
Hotline.
The above recommendation may help to reduce physician liability when an unsatisfactory
outcome results from a patient’s poor judgement or lack of diligence.
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