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Aristus

(66,075 posts)
Tue Mar 26, 2013, 07:25 PM Mar 2013

I tell you, patient non-compliance with treatment is one of the worst things about this profession.

Just got a discharge summary from the Emergency Department. One of my patients presented for treatment of his uncontrolled condition (clinical treatment for which he is non-compliant). I could almost hear the ED doc sighing heavily as he wrote the report. The patient was evaluated and offered treatment, which he declined, and left against medical advice.

Which begs the question: why did he present to the ED in the first place?

I have another patient who just flat-out refuses to comply with his treatment plan; yesterday, he brought back all of his medications and stated he was "tired" of managing his chronic complaints.

Providers have the right to discharge their patients for non-compliance. But my clinic is pretty much the last stop for some of my patients. I can't deny them care, even if they deny themselves. If this guy shows up at the clinic again, I'll give him 100%. But it's frustrating to see patients give up like that...

Ugh. Hold me...

30 replies = new reply since forum marked as read
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I tell you, patient non-compliance with treatment is one of the worst things about this profession. (Original Post) Aristus Mar 2013 OP
Oh boy, my dear Aristus... CaliforniaPeggy Mar 2013 #1
100% In_The_Wind Mar 2013 #2
OK, I gotta say this: trof Mar 2013 #3
Sorry sheshe2 Mar 2013 #4
Non-compliance Texasgal Mar 2013 #5
A friend of mine in college was bi-polar and she was treated with some really HEAVY drugs. MiddleFingerMom Mar 2013 #6
Yep. See my note downthread. I wish to God mental health meds were better. nolabear Mar 2013 #19
Do they offer any explanation? sarge43 Mar 2013 #7
It's good to ask questions. AnotherMcIntosh Mar 2013 #16
Thanks, sarge. Aristus Mar 2013 #22
I've been non-compliant re: diabetes for years. LancetChick Mar 2013 #8
I do a pretty good job of explaining treatment protocols to my patients. Aristus Mar 2013 #12
If I were dx'd with cancer, for instance RainDog Mar 2013 #9
Where I live, a diagnosis of cancer automatically qualifies you for state benefits. Aristus Mar 2013 #13
Yes, single payer is the way to go RainDog Mar 2013 #15
I read your reply last night, Aristus Mar 2013 #23
I had a friend who was fired by a doctor for non compliance undeterred Mar 2013 #10
Sometimes, we just need a little help from Mother... Aristus Mar 2013 #14
At first I thought the doctor had crossed the line undeterred Mar 2013 #21
Non-compliance is rampant when dealing with chizophrenia patients. WilliamPitt Mar 2013 #11
You didn't state the condition, but such things are self-inflicted doctor-assisted suicide. talkingmime Mar 2013 #17
I feel ya, Aristus. Me too. nolabear Mar 2013 #18
First, a parable. Then thanks for what you do. UTUSN Mar 2013 #20
Thank you for your kind reply. Aristus Mar 2013 #26
Here is a 'hold' for you libodem Mar 2013 #24
Aw, thanks... Aristus Mar 2013 #25
welcome libodem Mar 2013 #30
Since I worked as a therapy tech in a State Hospital libodem Mar 2013 #27
I learned the hard way to be complient with my asthma meds. hunter Mar 2013 #28
I'm fortunate in one respect: My clinic often has donated medications that I can give to Aristus Mar 2013 #29

CaliforniaPeggy

(149,296 posts)
1. Oh boy, my dear Aristus...
Tue Mar 26, 2013, 07:29 PM
Mar 2013

I understand. You want so much to help them get well.........

And they refuse.

I truly don't understand this. Maybe it's denial?

Maybe they're still looking for the magic wand to cure them?

I'm so sorry...

Texasgal

(17,029 posts)
5. Non-compliance
Tue Mar 26, 2013, 07:54 PM
Mar 2013

is a big problem for us too. I am a surgical nurse for a large Opthalmologic practice. We do it all. I have seen more corneal grafts due to non-compliant contact lens wear than I can shake a stick at. . It's unfortunate, especially since compliance could have prevented such a thing, and they are so young in many cases.

It is very frustrating.

MiddleFingerMom

(25,163 posts)
6. A friend of mine in college was bi-polar and she was treated with some really HEAVY drugs.
Tue Mar 26, 2013, 07:54 PM
Mar 2013

.
.
.
I think amongst them was lithium. Every once in a while, she would intentionally go off her meds, all
the while KNOWING that she would end up in a hospital for inpatient care for a fair amount of time
until they got her meds back up to the right levels again.
.
I had no idea why she would do something so STUPID time-and-time again.
.
Until she told me... her meds kept her on an even keel with which she had no sadness... but no
pleasure whatsoever, either.
.
She told me it was not worth living that way.
.
Sad. Yes. Stupid. No. I got a little glimpse of the hell she lived in even when being "successfully"
treated.
.
.
.

sarge43

(28,939 posts)
7. Do they offer any explanation?
Tue Mar 26, 2013, 07:54 PM
Mar 2013

Even an unreasonable one?

Try not to let it get you down. That job is tough enough.

Aristus

(66,075 posts)
22. Thanks, sarge.
Wed Mar 27, 2013, 10:26 AM
Mar 2013

Nope. No explanation. At least if they offered an objection of some kind, I could try to offer a reasonable explanation to overcome it...

LancetChick

(272 posts)
8. I've been non-compliant re: diabetes for years.
Tue Mar 26, 2013, 08:01 PM
Mar 2013

I've had type 1 diabetes most of my life, and honestly, if I had taken the advice given to me over the years I'd probably be on dialysis by now. Doctors do not understand insulin management, and often give dangerous advice. I know better than they do, and the results prove it.

I broke my ankle a few years ago and was advised to have surgery to reattach the deltoid ligament, which I refused because I didn't have insurance. I was told to remain non-weightbearing for 6 weeks, but I developed a "stinger" on my hand which was excruciatingly painful when barely touching the crutch, but not painful at all otherwise, so at two weeks I started using one crutch. By two and a half weeks I was walking easily and painlessly without crutches because walking with crutches felt like I was faking a broken ankle. Now I do admit, that was pretty risky, since the bones could have shifted without ligament support. They didn't, though, and I healed quickly.

When I had cellulitis I was totally compliant. Basically, if what the doctor is telling me makes sense and they can give me a reason why, other than "because that's the rule", I'll take their advice. But because of my experience with doctors and diabetes, and because of my sister's experience with doctors, I automatically assume they're generally ignorant. If they can't explain why they advise something, forget it. Not all non-compliance is from left field.

Aristus

(66,075 posts)
12. I do a pretty good job of explaining treatment protocols to my patients.
Tue Mar 26, 2013, 08:12 PM
Mar 2013

I'm not a 'because-I-said-so' kind of guy. I have to admit, I've never had an 'I-know-better-than-you' patient, so I'm not sure what I would tell him or her, especially since they ostensibly presented to the clinic for medical advice.

I have had patients who allow chronic conditions to become dangerously uncontrolled, and when I ask them why they waited so long to obtain care and management, they say: "I just don't like doctors."

My response is usually: "Well, you sure showed us, didn't you?"

RainDog

(28,784 posts)
9. If I were dx'd with cancer, for instance
Tue Mar 26, 2013, 08:02 PM
Mar 2013

I cannot afford health insurance - or medical care, for that matter.

If I were dx'd with a life-threatening and/or long term disease, I probably wouldn't bother with medical care - because I can't afford it. This nation lets you know very well if it considers you worth anything.

And what this nation tells its citizens is that it only cares about rich people.

If this nation had a different attitude toward those who have faced issues related to health, etc. you would find more people think it matters if they continue to live.

Aristus

(66,075 posts)
13. Where I live, a diagnosis of cancer automatically qualifies you for state benefits.
Tue Mar 26, 2013, 08:15 PM
Mar 2013

I have a lung cancer patient whose most recent oncological evaluation shows improvement, and his prognosis is getting better. He came to me with no insurance, and when I diagnosed him, he had state insurance by the next day.

I long for the day when we have a single-payer national health insurance program...

RainDog

(28,784 posts)
15. Yes, single payer is the way to go
Tue Mar 26, 2013, 08:22 PM
Mar 2013

I don't know about illness and state benefits. All I know is that I went to a social worker a while back b/c I needed health care. She asked me why I didn't sell my earrings.

I was wearing a pair of earrings from Claire's Boutique that I had owned for about ten years - three pair for 5 bucks. I'm sure I could finance health care from that...

I left and didn't go back.

Aristus

(66,075 posts)
23. I read your reply last night,
Wed Mar 27, 2013, 10:29 AM
Mar 2013

and I'm still shaking my head over it. I can't believe that person wanted to be a social worker. I expect better from someone whose job is to help people, other than an attitude of "Well, if you can afford earrings, why can't you afford health insurance?"

undeterred

(34,658 posts)
10. I had a friend who was fired by a doctor for non compliance
Tue Mar 26, 2013, 08:02 PM
Mar 2013

and he was quite surprised by it. He didn't think he was so bad. He would be truthful with the doctor and tell him his excuses for not taking the medication. The doc tried to work with him regarding side effects and he still didn't cooperate. So the doc wrote him a referral to another doctor. He didn't like it but he realized it was time to grow up.

Another person I'm thinking of had a major heart event/bypass operation and was told he HAD to stop smoking and drinking. So the guy said yeah yeah and pretty soon he starts smoking again anyway and the doctor can smell it. Well this doctor calls up the guys elderly mother and says your son is going to die because he won't stop smoking. And she calls him up sobbing and begged him to stop smoking. Strong medicine. It worked.

undeterred

(34,658 posts)
21. At first I thought the doctor had crossed the line
Wed Mar 27, 2013, 01:29 AM
Mar 2013

but after thinking longer I realized, that's a doctor who really cares about keeping his patient alive, whatever it takes.

 

WilliamPitt

(58,179 posts)
11. Non-compliance is rampant when dealing with chizophrenia patients.
Tue Mar 26, 2013, 08:05 PM
Mar 2013

The curse of the newer, better medicines: patients believe they are cured, and decline the meds.

 

talkingmime

(2,173 posts)
17. You didn't state the condition, but such things are self-inflicted doctor-assisted suicide.
Tue Mar 26, 2013, 10:21 PM
Mar 2013

I've got about a half-million in death benefits (more than that actually). If I was diagnosed with a terminal disease, it would be tempting to avoid treaatment as a way of "assisting suicide", but that's not what the coronor would say. It would be ruled "natural causes" and thus the insurance would be valid.

It's a tough call. Should I leave my family with 100's of thousands in debt or just let time take its toll and give them the resources to unwind it?

Either way, it is NOT your fault. It isn't your life. The best you can do is offer suggestions.

And for the record, I do have a life-threatening disease and I'm not afraid of death anymore, not since the last few comas. Death isn't a problem for the deceased. It hurts the survivors.

nolabear

(41,915 posts)
18. I feel ya, Aristus. Me too.
Tue Mar 26, 2013, 10:56 PM
Mar 2013

People don't like the side effects, or like a portion of the syndrome (bipolar folk sometimes struggle with the loss of the wonderful feeling part of the swing so try to manipulate to keep it. Understandable but never successful). Or the problem itself gets in the way, like delusions or paranoia. It's awful, and I have yet to find a way out. Usually a part of the patient and I are battling mightily to get another part of them to comply. It makes it all the more important to enjoy every little success, eh?

UTUSN

(70,494 posts)
20. First, a parable. Then thanks for what you do.
Wed Mar 27, 2013, 12:29 AM
Mar 2013

I believe you know what's going on with non-compliance very well, as do all the posters:

Post #6 MiddleFingerMom: “She told me it was not worth living that way.”

Post #8 LancetChick: “Not all non-compliance is from left field.”

Post #17 talkingmime: “it is NOT your fault. It isn't your life. The best you can do is offer suggestions.”


I understand the frustration, which is experienced by all (who really care) in the helping professions. And I'm not excusing the non-compliance. I'm sure you know the legal side, too, that adults who are not declared mentally incompetent through the court are technically mentally capable and able to make their own decisions. Some of the ones described here don't seem to be making the decision, wasting resources with "Help-me-I-refuse" thing. In a way they are ACTING their decisions based on some of the "reasons" from the quotes above.

PARABLE: Somebody talking to a heavy drinker did some color commentary on a news item about an A-List celebrity who had been arrested for DUI, saying, "I don't understand why X, who has all that money, can't hire somebody to drive her to her good times." And the drinker said, with visible anger, "Because sometimes you just want to GO, not have somebody hanging all over you, TELLING YOU WHAT TO DO!1"

********Now that these probably stoopid 2-cents are over, I'll just add this from the O.P., "If this guy shows up at the clinic again, I'll give him 100%” and send a profoundly heartfelt thanks your way.


Aristus

(66,075 posts)
26. Thank you for your kind reply.
Wed Mar 27, 2013, 11:23 AM
Mar 2013

It isn't the refusers and decliners alone who bother me. There was a reply above which stated basically: "You guys just don't know what you're doing, that's all."



I guess I'll have to tell the guarantor of my student loans that I wasted two years and $75,000 on PA School...

libodem

(19,288 posts)
27. Since I worked as a therapy tech in a State Hospital
Wed Mar 27, 2013, 11:38 AM
Mar 2013

I used to watch the rotation of patients back in after they decided to quit their meds once they felt normal.

Almost never failed. Once they were "well", why bother?

And I have a 62 year old friend who is debating taking a new prescription for her hypothyroid. Why? Because she is already on one for high b/p and one for high cholesterol and another, one more pill, is too many. God, she doesn't get it. I tried to explain how important a functioning thyroid is.

hunter

(38,263 posts)
28. I learned the hard way to be complient with my asthma meds.
Wed Mar 27, 2013, 01:49 PM
Mar 2013

I haven't been hospitalized for asthma since the mid 'eighties.

But the crazy meds have unpleasant side effects and it's always a balancing act.

Whenever I fall into the black hole I get paranoid and avoid doctors until bad shit happens. My ability to judge my own mental state is the very first thing that flies out the window when my meds are not right.

I've become very skilled at faking some sort of functionality when I'm messed up. It used to be I'd lose weight and whither away whenever I was in the dark place, but now I can remember to eat, continue to take my asthma meds, and other things like that.

My grandmother was a crazy bag lady with a house and a pension. The only way she'd see a doctor was by police force or if she was unconscious. When she finally had to be removed from her home because she was a danger to herself and others it took the police and paramedics four hours to drag her out, and when they did she was kicking, clawing, cussing, screaming and biting all the way. I'm glad she didn't like guns. I'm certain the police would have shot her if she'd had a gun in her hand.

My grandma's bad example scares me into some kind of compliance, but I still have my moments.

In my most recent misadventure I smiled and joked with my own doctor that I was probably one of his more non-compliant patients. He did not even pretend to be amused.

From your perspective as a health provider it may look like a patient is "giving up." From my perspective it's something else. I can come up with rational explanations for my bouts of non-compliance, but the basic truth is it's just plain crazy. Something is not right in my head, the chemistry is off. Meds help quite a bit, but they all seem to have side effects I grow weary of. Some medicines I've tried have been absurdly expensive. In the past I've sometimes changed meds for the simple reason I couldn't afford better ones because I had crappy or no insurance. I know which meds from the "$4.00" pharmacy will keep me somewhat functional, but they are not the best.

I'm fearful my "natural" unmedicated state is to be a dumpster diving street person and in that state I wouldn't feel like I was "giving up" anything.

If we were truly a first world society we'd have a national health plan, and we'd make some effort to keep guys like me from becoming decrepit street people. But it seems the people who control the money in this society would rather spend it on other things; things like prisons or the war machine.




Aristus

(66,075 posts)
29. I'm fortunate in one respect: My clinic often has donated medications that I can give to
Wed Mar 27, 2013, 02:13 PM
Mar 2013

my patients for free. Even then, there's is still some non-compliance. Every medication comes with at least some side effects. The more serious the condition, the stronger the potential side effects can be. I try always to explain to my patients about risk-vs-benefit of the side effects. And of course, I monitor my patients clinically and with lab testing when necessary, to gauge the potential side effects.

As I said above, I pray for the day we have single-payer national health insurance in this country. No one should have to go without health care in this country, or be forced to choose between food, rent, and clothing, or health care.

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