These studies demonstrate that there are several factors associated with patient noncompliance, regardless of the disease being treated. Medication side effects represent only one of these issues. Nurse practitioners could help to resolve many of these issues by being proactive and asking questions about side effects in patients at risk for becoming noncompliant. They may also be able to predict noncompliance in patients that are prescribed medications with known side effects. By informing the patient of the side effects and giving them practical ways to cope with them, the nurse practitioner can play an active role in helping to eliminate patient noncompliance.
Education was found to play an important role in patient noncompliance. The overall educational level of the patient was found to be important. The nurse practitioner can take positive action by being aware of the patient's overall educational background. Extra care must be taken with those of low educational status. The nurse practitioner must make certain that these patients understand the medication, any side effects, and the importance of taking their medication or following other treatment regimes. The nurse practitioner must make certain that the patient has all of the information that they need and that they understand this information.
This group of studies highlights the role that the nurse practitioner can take in preventing noncompliance in patients. Being sensitive to those patients that fall into risk categories for noncompliance will help the nurse practitioner in taking appropriate action to make certain that the most common reasons for noncompliance are eliminated, or at least lessened in at-risk patient populations. The nurse practitioner must be willing to educate the patient in all aspects of the treatment plan. They must also be willing to listen to patient concerns and to help them devise ways to alleviate fears and problems with their medication regime. Academic research supports the idea that the nurse practitioner can have a positive impact on the willingness and ability of the patient to follow their treatment program.
Legal Ramifications of Discontinuation of Treatment
There is little information available on the topic of the legalities of dismissing patients. This is a relatively grey area of the law that has not been addressed by legislature or academic research. However, in the dismissal of patients, the practitioner can open themselves to lawsuits. From a legal standpoint, the patient is considered a customer. There are few other professions where it would be beneficial to "dismiss" a customer. This makes the topic of dismissing the noncompliant patient unique from a legal perspective.
There are currently no statutory laws that specifically deal wit patient dismissal (Eastern, 2006). Many of the lawsuits stemming from patient dismissal are based on antidiscrimination and abandonment laws (Eastern, 2006). From a legal perspective, the danger is not in leaving oneself open to criminal actions, but in leaving oneself open to civil litigation. However, there are steps that one can take to protect themselves from civil suits, if the occasion should arise that requires the dismissal of a patient.
Just as there are no hard rules concerning the legalities of dismissal, there are also no hard rules concerning when a patient should be dismissed. Nonpayment of legitimate and reasonable charges is the most common reason for patient dismissal (Eastern, 2006). This reason would appear clear-cut, but it often involves problems, such as changes in health plans and the various rules that dictate those changes. Some plans force the doctor to terminate treatment of all participating patients, if the doctor drops out of the plan and the patients were given an option to pay out of pocket but declined (Eastern, 2006). Theft of insurance checks also falls under this same category (Eastern, 2006).
According to Eastern (2006), these are the most common legitimate reasons to dismiss a patient, but most cases involve interpersonal conflicts between the patient and physician. In many cases, this involves noncompliance with medical treatment, but it can involve unruly or uncooperative behavior, particularly in the presence of other patients. Eastern based this analysis on his own opinion, citing no studies to support his opinion. However, this analysis is reasonable, considering what we know about the noncompliant patient.
Professionals agree that when a patient insists on treatment outside of the doctor's area of expertise, or on treatment in a location other than the private office, it is reasonable to refuse to comply with their wishes (Eastern, 2006). Every physician must establish their own tolerances and norms regarding patient compliance and dismissal of patients from their practice. In doing so, one must be careful not to step over reasonable boundaries that are perfectly within a patient's rights, such as seeking a second opinion or consultation with a specialist.
In the dismissal of patients, the practice manual is an important tool in making certain to avoid lawsuits stemming from patient dismissal. Most agree that dismissal of a patient should be a last resort and that other corrective actions need to be pursued first. Reconciling differences is always the better option when one wishes to continue to build their practice. Sometimes an honest and open discussion is all that is needed to resolve any issues that arise.
Reasons for dismissal should be clearly defined in the practice manual. Once they are defined, they should be followed in every circumstance (Eastern, 2006). Granting exceptions to the rules weakens their impact in a court of law. The patient may be able to establish a discrimination suit based on the ability to prove that the rules are only applied with certain patients, but not with others. Rules of practice only have an impact when they are closely followed and exceptions to the rules are rare.
The practice manual outlines procedures to help resolve conflict in a peaceable manner. Dismissal should be the last resort (Eastern, 2006). The first step when a conflict arises should be an attempt at reconciliation. However, in order to protect oneself legally, this conversation and the outcome of the conversation should be documented (Eastern, 2006). This conversation should be recorded in the patient's chart and a follow up letter should be sent that confirms what was discussed and the outcomes (Eastern, 2006). Many times, this step is all that will be needed to address the concerns of both the physician and the patient. Communication failures are easily resolved, but represent major issues between the medical practitioner and the patient.
Many times patients are not aware or will not admit that they are not in compliance with office policies (Eastern, 2006). Communication is the key to resolving conflicts such as these. Open and honest communication is the first step in resolving conflicts and in building the foundations of a productive, positive relationship in the future. Honest communication can turn a noncompliant patient into a model patient in the future. This is certain a better outcome for the patient and the practice than dismissal. Reconciliation and building relationships should be the first priority in resolving patient-practitioner issues.
While, communication is the magic pill that can cure many poor relationships, it will not work in every case. In some cases, the patient may continue to be problematic after these initial steps. The patient should be aware that further violation of principals will lead to dismissal, if that becomes necessary (Eastern, 2006). This should be clearly stated and it should not be assumed that the patient automatically understands this potential consequence. This conversation should be clearly documented in the patient's chart and should be contained in a follow-up letter (Eastern, 2006).
The practice manual should have clear steps leading up to potential dismissal of a noncompliant patient. These steps can include up to two or three warning letters and attempt at reconciliation before termination of the patient is carried out. These letters should clearly document how the patient has violated office policy and what steps are to be taken if this violation continues in the future. These steps will help to reduce the chances of a lawsuit, and will increase changes that the practitioner will prevail, should one occur (Eastern, 2006). Diligence in these steps is the key to successful termination of patient relationships. This is particularly important if the patient has a physical or mental disability (Eastern, 2006).
Ultimate dismissal of the patient is not the best option for anyone involved. The patient loses access to medical treatment and must go through the process of finding another physician. The medical practitioner suffers loss of income from that patient. In addition, it is not likely that this patient will give them positive referrals. They may even have the affect of creating negative publicity. For these reasons, reconciliation should be the goal of procedures to resolve issues between the medical practitioner and the client. However, if in the end, the issues cannot be resolved and the decision is made to terminate the patient, there are certain steps that can be taken to help avoid a potential lawsuit.