Patient's Who Don't Help Themselves

[deleted862527]

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In clinical practice, it is not uncommon for practitioners and healthcare providers to encounter patients who refuse or neglect following treatment plans devised by the healthcare team. In one example, a morbidly obese patient was released from a Hospital for violating his care plan by ordering pizza: (800-pound man: Hospital kicked me out over pizza). Other situations encountered include family members withholding important preventive care (vaccinations, etc).

Doesn't this anger anyone? I find this extremely frustrating.

Lastly, what if a patient who has a psychological disorder (who may not be able to understand the pathophysiology of his/her illness or its severity) is of adult age and decides not to pursue treatment. As a consequence, the illness worsens. In a desperate plea for help, family members and siblings of the individual affected pressure him/her to pursue medical treatment but the person decides not to take his/her family members advice. In this scenario, what can family members due to help the person receive medical treatment---if anything? Does the law say anything about this?

 

[CloverBale]

You can lead a horse to water, but you can't make it drink.

It's frustrating, but there's nothing else you can do.

If they have a psychological disorder, it gets tricky. They need to figure out of this person has 'significantly impaired decision making abilities'. Depending on if this is a yes/no, certain actions can be made to prevent this person from harming themselves, e.t.c

 

[mcdocky]

Unfortunately, physician compliance is even more of an issue in socioeconomically disadvantaged communities. Poor education, poor access to resources, etc = more likely to ignore a physician.

All the more reason why we need more targeted, preventative measures that include rigorous education for the disadvantaged.

 

[Lucca]

A lot of people won’t continue treatment because it’s too expensive and that’s lumped into “non compliance”. Can’t make your chemo appointments on time if you can’t get off work and/or find a ride because you live far away from the hospital and don’t own a car. Etc. Sure there are lots of people that won’t listen no matter what you do, but this is a much bigger issue in the US than it is anywhere else for structural reasons, not because Americans are uniquely wary of listening to their docs, although they certainly trust docs less than in other countries too.

 

[TypeADissection]

You can be angry or jaded, or just come to the acceptance that you're dealing with people, and we are all flawed. Some hurt themselves by omission and others by commission, but I've just come to the point early in my career that all I can do is the best I can do and that's it. That's really all I can control. If I provide a therapy and they come back for one reason or another, I could get mad but at that point, what does that accomplish? I have a healthy enough amount of "not giving a ****" to actually be very effective at my job.

 

[Anti-PD1]

There are a lot of personal and life reasons patients do not comply. I'm not particularly fond of the national conversation of this issue. Somehow, 'compliance' has taken a negative connotation in the era of patient self-determination.

You do what you can. It is frustrating. No one will tell you this now, but when you're deciding which specialty to pursue, the mean behavior of the patients you treat will be a great factor. God bless nephrologists, endocrinologists, cardiologists, vascular surgeons, family physicians, and on and on... They're constantly fighting patient choices and lifestyles.

It was a major factor in my specialty choice, but even then, impossible to escape.

 

[Goro]

In clinical practice, it is not uncommon for practitioners and healthcare providers to encounter patients who refuse or neglect following treatment plans devised by the healthcare team. In one example, a morbidly obese patient was released from a Hospital for violating his care plan by ordering pizza: (800-pound man: Hospital kicked me out over pizza). Other situations encountered include family members withholding important preventive care (vaccinations, etc).

Doesn't this anger anyone? I find this extremely frustrating.

Lastly, what if a patient who has a psychological disorder (who may not be able to understand the pathophysiology of his/her illness or its severity) is of adult age and decides not to pursue treatment. As a consequence, the illness worsens. In a desperate plea for help, family members and siblings of the individual affected pressure him/her to pursue medical treatment but the person decides not to take his/her family members advice. In this scenario, what can family members due to help the person receive medical treatment---if anything? Does the law say anything about this?

Get used to it now.

The term is "non-compliant patient". My students get a lecture in their Clinical Medicine course on how to deal with these.

Start with diabetics and the obese who don't follow thier diets.

Then to the addicted who have trouble with their illnesses

And then all the other people who don't take their meds when you tell them too, and that's not counting the anti-vaxxers and devotes of nostrums and other pseudoscientific beliefs.

 

[aldol16]

Compliance is always an issue in most fields of medicine. Patients just don't necessarily want to do what's best for their health. We're all encouraged to exercise every day but it's very easy not to exercise and very hard to get up and exercise. We all know it's healthy to eat our greens but greens don't taste that great, especially when compared to potato chips. Food insecurity may also be an issue. All of these are factors in care.

With the psychiatric patient, there are ethical guidelines on what to do and when somebody can be declared legally incapacitated (quite stringent guidelines, actually). If you do not have capacity, then your care decisions are transferred to someone else. But this is a fine line - patients who have severe neurodegenerative diseases can still have capacity to make their own decisions. This is why things like living wills and advance directives are so important.

 

[Lannister]

People have to make their own choices. All we can do is make sure they're informed and have access to the resources they need. Otherwise... You can't help someone who doesn't want to be helped.

 

[workaholic181]

This is rampant in all fields of medicine, especially PC.. I have a few pre med friends who chose other paths after encountering this in scribing or shadowing etc and just found it infuriating. It is absolutely part of the equation when you’re deciding if this is the career you want to pursue.

Personally, while frustrating at times I think it’s an interesting challenge in being a provider but it is sobering when you first experience it.

 

[HomeSkool]

Of course it's frustrating, but you deal with it and move on. People are free to make their own decisions, even when those decisions are poor. Just as @TypeADissection said, there's a certain amount of detachment that's necessary to function optimally as a physician. You need to care about your patients...but not too much. You have to be able to counsel them on smoking cessation; then when they come back with COPD, you treat it; then when they come back with cancer, you treat that, too. Ultimately, you can't have your self-worth wrapped up in your patients' health because that's a losing game. You have to know you're doing the best you can even when it feels like you're screaming into the void.

As for those with psychiatric disorders, they also have their autonomy. It's difficult to get someone involuntarily admitted to the hospital, and even harder to get legal approval to give them medication by force. The key phrase to remember there is "a danger to self and others."

 

[Matthew9Thirtyfive]

In the OR, we had some frequent fliers who were non-compliant. I will never forget this guy who was very young, but we had him in the OR half a dozen times, progressively taking more and more of his left leg (first time I met him, we took some toes--last time I saw him, it was an AKA). Dude would NOT stop smoking despite his diabetes and other health problems. As a primary care provider, I have also experienced non-compliance. It is very frustrating, but what I've learned is that these people are the ones who are suffering because of their poor decisions. They don't also need us judging them for it, they need us to treat what's wrong with them the best we can.

 

[bioboy23]

You have to look at it from both sides. I am involved with an internship with family med residents and they frequently have to let patients go because they will no-show for a looooong stretch of time, so it becomes a liability issue for the PCP. You can't keep prescribing meds without at least semi-regular check ups and labs, etc. Usually the resident is not the one who wants to get rid of the patient--its usually the preceptor. The residents are afraid to let them go because they are their patients' only hope for healthcare. It's just a liability thing sometimes. This isn't exactly the same thing as the pizza-ordering guy, but it is something I learned just recently that I would have never thought about.

 

[calivianya]

It's actually a lot less sad in some ways when the patients are noncompliant. Not a physician yet, but I work a high acuity MICU and I deal with a lot of death. The "good" news is it's mostly older people who have killed themselves through their noncompliance. I feel sorry for them (sucks to suffer, whether you've done something to deserve it or not), but it doesn't tear me up nearly as much as when we get that healthy, nonsmoker, marathon-runner guy with five kids who's never touched an alcoholic drink in his life and then ends up with stage 4 cancer of some sort.

God bless anyone who wants to go into oncology. There are so many people that haven't done a dang thing to deserve what's happening to them. I couldn't do it.

 

[Freeinfinity]

To receive effective care, the patient needs to trust their doctor. It's practically impossible to take care of someone if they don't want to be in your office in the first place. Then it becomes a question of if they have a good understanding of the consequences for their decisions. Sometimes, I get straight to the point and explain to them the most extreme complication that can happen if they don't take their meds (which is usually increased risk of death at an earlier age). This usually "wakes them up". I wouldn't advise this in every single patient, but after repeated hospitalizations simply due to refusal to receive care, sometimes these patients need that kind of wake-up call.

For patient's who don't have medical decision capacity (the official term), once that's determined you follow the rules laid out for you which is the patient's spouse unless they have a designated power of attorney. Next would be children, etc. If it's not clear, usually there's a representative in ethics at your institution that can assist.

I've come to accept that every clinician will encounter patients like these throughout their practice. It definitely sucks, but if you're constantly bothered by it, then it places a great mental burden on you and certainly can make your work even more stressful. First priority is always to keep yourself happy and healthy. THEN you can start taking care of your patient.

 

[Blanky]

The patient who is non compliant with medication, treatment or behavior
The patient who waits to see you until they are so sick they need the ER
The patient who is so healthy but want to see you every week
The patient whose spouse/parent brings them every week
The patient who wont tell you the truth
The patient whose family wont tells you the truth
And the patient who needs as much emotional and psychological support as they do medical

The actual administering of medical treatment is smallest aspect of being a physician. Even dealing with patient records, insurance claims, and other administrative task, which can be frustrated pales in comparison of what will be your main duty and service as physician. That is dealing with the people who come to your for help. It isnt the medicine but the patients as humans,with all the flaws, foibles, and fears that they carry into your exam room. You all may be the best and the brightest but you will need all that intellect to learn to deal with the most vulnerable, least educated and least trusting people in a sensitive, caring and, above all, human manner.

Well written. Id add a dash of honesty and a touch of backbone.

 

[stickgirl390]

Unfortunately, physician compliance is even more of an issue in socioeconomically disadvantaged communities. Poor education, poor access to resources, etc = more likely to ignore a physician.

All the more reason why we need more targeted, preventative measures that include rigorous education for the disadvantaged.

This 1000000 times

 

[arcus]

If you are frustrated with patient non-compliance, you will enjoy this hard hitting article recently published in JAMA.

“The US way of life is the problem.....Individuals must take more responsibility for their own health behaviors.”

Cardiovascular Guideline Skepticism vs Lifestyle Realism?

Philip Greenland. Cardiovascular Guideline Skepticism vs Lifestyle Realism?. JAMA. Published online December 14, 2017. doi:10.1001/jama.2017.19675

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[A_Garrr]

Everyone here has pretty much nailed it on the head. Non-compliance is a complex issue with an incredible amount of contributing factors. Yes, navigating the barriers that lead to these issues is one of the biggest challenges of being a health care provider. But, it should just as well be recognized as a vital part of any healthcare profession imo.