Working with patients who refuse your recommendations

[Smashing]

Hi everyone,

Hypothetical situation I'm sure all of us has been in - A patient with SMI, several suicide attempts and repeated hospitalizations becomes stabilized on medications then stops taking them and decompensates into an acute mood or psychotic episode several months after coming off of them.

They adamantly demand to be taken off medications because they do not believe they have mental illness when they have recovered. There is no absolute indication to stop the medication. The patient generally recovers to a point where they have a capacity to understand the condition they likely have and the standard treatments for that condition, although are still in denial regarding the diagnosis.

Do you:
#1) Ally with the patient and engage in doing the experiment of seeing if they decompensate off medications continue supportive care and taper the medication gradually - The cons being knowing that this will increase the patients risk of decompensation/suicide before they develop insight into their condition. The potential benefit being however, maybe this time if (though more likely when) they decompensate they will accept their diagnosis.

#2) Or do you give them the ultimatum that if they wish to continue seeing you they need to continue taking the medication as prescribed and if they wish to be off all medications you can refer them to another provider for a second opinion. The pro to this being taking a firm stance with the patient about their diagnosis and (*Edit: con being that this destroys the provider patient relationship and patient either dies or continues in the cycle of repeated hospitalizations after making a good amount of progress)

Lets also say for arguments sake that this is a standard of care medication for the given condition with proven benefits in suicide prevention in mental illness such as lithium or clozapine. Additionally lets say you can know with certainty that the patient is taking their medication consistently as prescribed.

---

Members don't see this ad.

 

[Celexa]

Neither. I would kindly but firmly communicate to the patient that my recommendation is to take the medications and it is not going to change. I would also discuss with them my belief that they will end up hospitalized again without the meds. I would then let them choose if they want to keep seeing me. I would not discharge them if they are currently well enough to engage in voluntary outpatient care nor would I put a stamp of approval on a plan I believe is not in their best interest.

I actually have been in the analogous situation far more often where the pt is asking for med increases or additions that are not indicated (sometimes controlled, sometimes not). I just keep saying no and reiterating why. I make it clear I am trying my best to get or keep them healthy. Most of them keep coming anyway and as the rapport builds they are more inclined to follow all of the recs you make.

 

[Candidate2017]

Hypothetical situation I'm sure all of us has been in - A patient with SMI, several suicide attempts and repeated hospitalizations becomes stabilized on medications then stops taking them and decompensates into an acute mood or psychotic episode several months after coming off of them.

They adamantly demand to be taken off medications because they do not believe they have mental illness when they have recovered.

How far along are you in terms of training? How did your attendings handle this? I ask because this situation pops up everyday in residency, if not every hour.

The unique part of psychiatry is that any choice you choose, will usually (but not always) be valid and defensible if you have considered the rationale for choosing choice A over choice B. Of course, any choice in medicine can lead to the ultimate adverse outcome, which in psychiatry is suicide/death.

At some point, we need to radically accept that many things in psychiatry are literally out of our hands due to the nature of human autonomy, and that the spectre of death is ever present. But, unlike many other specialties, psychiatry is actually far removed from death. Our colleagues in fields like IM or surgery are less anxious about adverse outcomes because they are exposed to death regularly, up close and personal. The surgeon's confidence comes from knowing he or she laid hands on the patient and did everything they could to a human made of flesh and bone. Whereas we learn of patient deaths in the form of hearsay and we are often left wondering if there was something more that could be done with a human made of hopes and dreams, some of which we may have projected.

 

[clozareal]

Why don't they just stop their medication and stop coming to see you?

 

[Fan_of_Meehl]

Hi everyone,

Hypothetical situation I'm sure all of us has been in - A patient with SMI, several suicide attempts and repeated hospitalizations becomes stabilized on medications then stops taking them and decompensates into an acute mood or psychotic episode several months after coming off of them.

They adamantly demand to be taken off medications because they do not believe they have mental illness when they have recovered. There is no absolute indication to stop the medication. The patient generally recovers to a point where they have a capacity to understand the condition they likely have and the standard treatments for that condition, although are still in denial regarding the diagnosis.

Do you:
#1) Ally with the patient and engage in doing the experiment of seeing if they decompensate off medications continue supportive care and taper the medication gradually - The cons being knowing that this will increase the patients risk of decompensation/suicide before they develop insight into their condition. The potential benefit being however, maybe this time if (though more likely when) they decompensate they will accept their diagnosis.

#2) Or do you give them the ultimatum that if they wish to continue seeing you they need to continue taking the medication as prescribed and if they wish to be off all medications you can refer them to another provider for a second opinion. The pro to this being taking a firm stance with the patient about their diagnosis and (*Edit: con being that this destroys the provider patient relationship and patient either dies or continues in the cycle of repeated hospitalizations after making a good amount of progress)

Lets also say for arguments sake that this is a standard of care medication for the given condition with proven benefits in suicide prevention in mental illness such as lithium or clozapine. Additionally lets say you can know with certainty that the patient is taking their medication consistently as prescribed.

Some solid advice in this thread.

I'd say,

(a) realize that your obligation is to (repeatedly, if necessary) offer the patient standard of care/ practice in your field and

(b) document this clearly in the record

(c) realize that you cannot *make* them do anything

(d) [as a subroutine], of course, always monitor whether they meet criteria for involuntary hospital admission

(e) *** [super important]*** with psychiatric patients (or anyone else in life, for that matter) you NEVER articulate a boundary that you are unable or unwilling to behaviorally enforce; dodge the frequent 'invitation' they are giving you to engage in a knock-down-drag-out game of 'you-can't-make-me' with stoic resolve every time and you've won all those battles by default by never engaging in them

 

[FlowRate]

If the patient is otherwise capable of forming an alliance then I keep seeing them. This has actually led to patients reconsidering their decision. Granted, the patients that immediately come to mind were not quite as severe as the case you're referring to. But they were psychotic and saw significant improvement from taking medications. Similar deal with less dramatic examples for patients with hypomania or anxiety/depression issues.

I saw a woman yesterday who had pretty severe life disruption from a late-life onset manic episode who is in denial, wanting to insist it's only anxiety. I focused more on building an alliance than on pushing any specific medication and by the end she committed to trying a med if X or Y milestones did/didn't happen shortly (they were reasonable indicators of things not heading in the right direction.)

 

[clausewitz2]

(e) *** [super important]*** with psychiatric patients (or anyone else in life, for that matter) you NEVER articulate a boundary that you are unable or unwilling to behaviorally enforce; dodge the frequent 'invitation' they are giving you to engage in a knock-down-drag-out game of 'you-can't-make-me' with stoic resolve every time and you've won all those battles by default by never engaging in them

Write this on a sticky note and put it in your desk drawer if you have to, absolutely one of the most critical principles of outpatient work. If you are arguing with your patient for any reason, just stop. You lose. Game over. Laying out your rationale and making your best persuasive effort is good, but make like MI and roll with the resistance. I work with a lot of patients with psychotic disorders and so have a lot of versions of the conversation about heavy cannabis use not being the best idea, but I emphasize that my job is not to come to their house and smack the blunt out of their hand, so at the end of the day it is up to them to decide whether or not it's worth it.

This mindset, incidentally, will also serve you well in dealing with children of all ages in the parental role.

 

[randomdoc1]

It can be very interesting to explore with the patient why do they keep coming if they do not follow through with the plans. In residency, I had a patient that literally did not follow up with a single recommendation, even the non-pharmacologic ones. My attending asked me to broach the subject and the patient's response was "because you're hot and I like seeing you."

 

[randomdoc1]

This mindset, incidentally, will also serve you well in dealing with children of all ages in the parental role.

This hit home. Very nice additional effect of psychiatric training. My son sometimes says things like "I don't HAVE to do it." My response was, you don't have to do anything theoretically. There's just different outcomes and you need to decide if you're ok with the consequences. Indeed, do not fight the resistance. Find ways to roll with it, build the rapport, yaddy yaddy ya.

 

[comp1]

Such great responses! The dichotomy of choices the OP created is not the greatest, as others stated. They shouldn't work with the patient on stopping the meds or kick them out of their clinic. Another provider of any competency is going to have the same issue and probably be a lot less introspective about this than they are. In my experience, the patient is very likely to stop coming, but if they don't, the OP at least gets a chance to explore the reasoning behind them continuing to come. Psychiatrists aren't just a person pushing pills. The OP can ally with the patient even actively opposing the patient's plan. I see some others above are focused on the medicolegal aspect of this and that's really not the big part. Even the barest documentation stating the OP told the patient to stay on meds should be sufficient. The psychodynamic part of the OP coping with a patient's chronic help rejection is a lot more complicated.

 

[FrustratedFamDoc]

Don't go down the rabbit hole. This doesn't have to be confrontational.

I never fire unless they threaten staff.

I say that I 'will not' rather than I can not, because I can not is usually not accurate. Also why I want to do XYZ, because of this reason. I could do pdq but here's why that is not a good idea. Here's why what you're suggesting is not a good idea. This is what you can expect if you don't take XYZ, and none of it will be good. I've been seeing you for a long time, I care about you, and I don't want to see that happen.

Guilt or a show of force NEVER works on defensive people. Show/tell them that you care, you have boundaries and you will usually go much further with people.

As always, they can take it or leave it. You will never be able to save people from themselves.

 

[Old&InTheWay]

I will typically explain my recommendations and rationale while attempting to convey that my thoughts are founded in my care for their well being. That said, I always acknowledge that patients are the ones who have to choose whether to put medication in their bodies and that ultimately it is their choice. If they are adamantly opposed to my recommendations, I try to develop goals with the patient that I can align with. I'll work with them to taper a medication they don't want to take in a cautious and safe manner while developing a plan for what we will do with their symptoms worsen.

I have a patient who I recently started working with who I believe has schizophrenia. We discussed what his life goals are and I recommended an antipsychotic as I believe it will help him get there. He was skeptical and stated that he wanted to try without medication. Together we agreed to continue meeting regularly, and he agreed to reconsider medication if in six months he's not making satisfactory progress towards those goals.

I would argue that the standard of care is not simply offering whatever the best first line treatment is, but working with a patient collaboratively to find a treatment that they can live with.

 

[Smashing]

Appreciate all of the feedback, really helps me think about these cases.

How far along are you in terms of training? How did your attendings handle this? I ask because this situation pops up everyday in residency, if not every hour.

The unique part of psychiatry is that any choice you choose, will usually (but not always) be valid and defensible if you have considered the rationale for choosing choice A over choice B. Of course, any choice in medicine can lead to the ultimate adverse outcome, which in psychiatry is suicide/death.

At some point, we need to radically accept that many things in psychiatry are literally out of our hands due to the nature of human autonomy, and that the spectre of death is ever present. But, unlike many other specialties, psychiatry is actually far removed from death. Our colleagues in fields like IM or surgery are less anxious about adverse outcomes because they are exposed to death regularly, up close and personal. The surgeon's confidence comes from knowing he or she laid hands on the patient and did everything they could to a human made of flesh and bone. Whereas we learn of patient deaths in the form of hearsay and we are often left wondering if there was something more that could be done with a human made of hopes and dreams, some of which we may have projected.

Currently in my 3rd year. Supervisors have split stances on it - usually they both go with option 1 depending on the case/risks in most individuals. However, with the severity of pathology in question (i.e. someone who was boarding for long term state hospitalization for >6 months at one point in recent times), my supervisor who knows the patients very well have told me to go w/ option 2. (To clarify the patients would be firing me for not doing what they ask, not me firing the patients). Whereas the another one who knows these patients more peripherally has told me to go with option 1.

 

[FrustratedFamDoc]

It can be very interesting to explore with the patient why do they keep coming if they do not follow through with the plans. In residency, I had a patient that literally did not follow up with a single recommendation, even the non-pharmacologic ones. My attending asked me to broach the subject and the patient's response was "because you're hot and I like seeing you."

The longer you do this, the more you will realize that you ARE the drug. Where else in their lives can they go for positivity and encouragement?

 

[randomdoc1]

The longer you do this, the more you will realize that you ARE the drug. Where else in their lives can they go for positivity and encouragement?

There's so much psychodynamic stuff that goes into our work, even if we want nothing to do with it and you can even see some in your schizophrenic patients. But I've found that angle to really be helpful in providing therapeutic interventions and a great way to avoid piling on benzos and the patient is more willing to listen. I have a couple patients where I'm terrified for when the day comes that their cat passes away. It'll be doomsday as that is the only positivity in their life.

 

[Stagg737]

Great responses in this thread, and can say as someone at the end of residency that this was probably the most important takeaway from 3rd year for me along with the statement "you shouldn't be working harder than your patient". I don't get into arguments with them or debate about their treatment. I always listen to my patients and their input about why they do or don't want certain treatment plans and often give them 2-3 options. Sometimes the patient will provide new info that will shift the plan, and I try an acknowledge their concerns. But at the end of the day I always give them my recommendations and inform them that if they feel they aren't receiving the appropriate care they are welcome to seek a second opinion.

Write this on a sticky note and put it in your desk drawer if you have to, absolutely one of the most critical principles of outpatient work. If you are arguing with your patient for any reason, just stop. You lose. Game over. Laying out your rationale and making your best persuasive effort is good, but make like MI and roll with the resistance. I work with a lot of patients with psychotic disorders and so have a lot of versions of the conversation about heavy cannabis use not being the best idea, but I emphasize that my job is not to come to their house and smack the blunt out of their hand, so at the end of the day it is up to them to decide whether or not it's worth it.

This mindset, incidentally, will also serve you well in dealing with children of all ages in the parental role.

I love the bolded, but will add the caveat that one may occasionally have to smack something out of their children's hands, lol.