Patient Noncompliance in Patients Advanced

Patient Noncompliance

Noncompliance in Patients

Advanced Practice Nursing represents a partnership between the patient and service provider. Many times the success of the treatment plan depends on the patient taking responsibility for compliance with certain prescribed actions. Examples of these actions include taking prescribed medication as directed, following a certain diet, or following an exercise regimen. If a patient does not follow the treatment plan, it can jeopardize the outcome of the treatment. Many physicians and other medical practitioners now view patient noncompliance as a breach of the relationship.

The practice of "firing" patients that do not follow recommended advice is becoming more common. This research will explore the practice of terminating patients for lack of compliance to prescribed medical treatments. It will explore the ramifications of this practice for the patient and for the medical practice. It will explore alternatives to firing a patient and steps that can be taken by the nurse practitioner to help avoid this unfortunate event.

Factors Affecting Patient Noncompliance

The American Medical Association supports the practice of firing a patient for failure to follow prescribed medical procedures. The American Academy of Nurse Practitioners defines the relationship as that of helping clients to make wise health and lifestyle choices. They recognize the relationship as a partnership, rather than a service. This research explores the ethics involved in terminating the patient/client relationship when the patient fails to follow sound medical advice.

When a patient chooses not to follow prescribed treatment regimens, it can have serious affects on their health. It may reduce their quality of life, or may lead to increased morbidity or death in some cases (Rosner, 2006). These issues make the topic of patient noncompliance an important issue for medical professionals. Noncompliance with treatment plans can lead to increased costs due to worsening conditions, or the development of new conditions or complications. Noncompliance has medical and financial implications.

Often nurse practitioners and other medical personnel are at a loss to understand the reasons for patient noncompliance. However, there are often reasons for a patients actions or lack of action during the treatment plan. Understanding these reasons will help nurse practitioners to be able to predict those patients that are at risk for noncompliance and develop ways to help them follow their treatment regime. Recently, a considerable amount of academic research concerning the prevalence and reasons for patient noncompliance has been produced. The following summarizes the latest findings regarding patient noncompliance among various health disciplines. Many of these studies are targeted towards doctors, but they still apply to nurse practitioners, or any other health professional that must interact with patients on a regular basis.

Often information regarding medication history relies on self-reporting by the patient. Among heart patients, compliance with the treatment regime can be important to preventing future heart related incidents. In a recent study, blood samples were taken from patients upon admission to the hospital. The purpose of the study was to determine if information regarding medication use by patients matched medication levels found in the blood system (Glintborg, Hillestrom, & Olsen et al., 2007). Results indicated that only 2% of the patients reported use of drugs that were not found in their system. However, six percent of the patients had drugs in their system that was not reported prior to the blood draw (Glintborg, Hillestrom, & Olsen et al., 2007). The study concluded that a majority of the patients provided accurate information to health care professionals and that only a small percentage misrepresented their medication history. However, those patients that did not report other medications that they were taking are of particular concern due to the possibility of a harmful drug interaction.

In a similar study, noncompliance with heart medication regimes was defined as failure to comply at least 75% of the time (Gehi, Ali, & Na et al., 2007). Noncompliance was found to lead to a significant increase in coronary events as compared to patients that complied with the prescribed regime (Gehi, Ali, & Na et al., 2007). The reasons for patient noncompliance are not well understood and a number of factors contribute to noncompliance in patients.

Ho, Spertus, Masoudi & associates (2006) found several demographic factors that correlated with patient discontinuation of medication after myocardial infarction. Those that did not graduate from high school were more likely to discontinue at least one of three medications prescribed. Increasing age was also associated with medicine discontinuation. Females were more likely than males to discontinue at least one medication (Ho, Spertus, & Masoudi et al., 2006). This study also corresponded with Gehi, Ali & Na et al. (2007) in that patients who discontinued their medication had a significantly lower one-year survival than patients that followed the prescribed medication regime. Therefore, it is important to stress the need to follow prescribed treatments.

Patients prescribed thienopyridine therapy after placement of a heart stent were likely to discontinue treatment after only 30 days or less (Spertus, Kettelkamp, & Vance et al., 2006). Discontinuation of this therapy was associated with death within 11 months, due to complications (Spertus, Kettelkamp, & Vance et al., 2006). This study found similar demographic risk factors to Spertus, Kettelkamp, & Vance et al., (2006) in noncompliant patients. They found that those with lower educational levels, older patients, and married patients were less likely to comply with prescribed medication regimes. Another fact found in this study was that cost, preexisting cardiovascular disease, and anemia were factors in noncompliant patients. One of the key concerns raised in this study was that many patients that discontinued their medication had not received discharge instructions prior to leaving the hospital. They also had not received referral for cardiovascular rehabilitation (Spertus, Kettelkamp, & Vance et al., 2006).

Many studies address rates of noncompliance, but little attention has been directed towards discovering the reasons for noncompliance. Chatterjee, (2006) found that the quality of the doctor/patient relationship plays a significant role in outcomes regarding noncompliance. In the past, the doctor may have viewed the patient as less knowledgeable and therefore, the less knowledgeable of the two in terms of treatment decisions. Patients felt as if they were being dictated or given orders by the doctor.

It is now recognized that the patient has the right to make decisions about their own health and treatment. This developed into the idea of "concordance" (Chatterjee, 2006). Under this relationship model, the patient is viewed as an equal and has the right to make informed decisions. Patients with concordance in the doctor/patient relationship were more likely to follow prescribed diabetes management routines than those that lacked concordance in their doctor/patient relationships (Chatterjee, 2006).

In asthma patients, low rates of adherence to asthma self-management regimes were linked to the patient feeling that treatment was unnecessary (Horne, 2006). Asthma patients were also concerned about the long-term adverse affects of corticosteroids (Horne, 2006). Local symptoms that were considered intolerable also affected patient noncompliance with asthmas self-maintenance regimes (Horne, 2006). These reasons for noncompliance represent legitimate concerns and remind us that the noncompliance issue is not one-sided. Medical professionals need to address legitimate concerns such as these in order to increase patient compliance with prescribed medication regimes.

Depression was found to be a factor in discontinuation of medication adherence in patients with coronary heart disease (Gehi, Haas, & Pipkin et al., 2005). Renal transplant patients were found to comply with immunosuppressant therapy after transplant surgery (Chisholm, Lance, & Mulloy, 2005). Sex of the patient was not found to be a factor in noncompliance within this group. However, patient age, income, and time since the implant procedure were found to affect compliance rates in this group of patients (Chisholm, Lance, & Mulloy, 2005).

Pharmacist instruction did not increase patient compliance in patients with uncontrolled diabetes (Odegard, Goo, & Hummel et al., 2005). A significant number of patients beginning medication for a number chronic conditions including stroke, coronary heart disease, asthma, diabetes, and rheumatoid arthritis, quickly became noncompliant with their medication regimes (Barber, Parsons, & Clifford et al., 2004). Noncompliance in this group occurred in as little as ten days after prescription. Patients cited medication problems and a lack of information as key factors in their decision to discontinue medication as prescribed (Barber, Parsons, & Clifford et al., 2004). Some of the patients that reported no problems and were compliant in the beginning later developed problems and had discontinued medication by the four-week mark. These studies highlight the need for support for patients beginning a new medication regime.

Noncompliance in women with fibromyalgia was predicted by several factors. Those not under a rheumatologist's care were less likely to continue therapy, as were those with less disease activity (Sewitch, Dobkin, & Bernatsky et al., 2004). Instrumental coping mechanisms increased the likelihood of compliance in patients (Sewitch, Dobkin, & Bernatsky et al., 2004). Problems with the doctor/patient relationship were found to be at the heart of many noncompliant women in the study. These patients were divided into compliant, intentionally noncompliant, and unintentionally noncompliant. Those that were unintentionally noncompliant often cited costs or inability to access the treatment as reasons for noncompliance.

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.

The first step in protecting oneself legally is to clearly state the reasons for dismissal in a certified letter to the patient. The letter should state that these problems have been discussed in the past, that warnings were given, and that the problems continued despite these efforts (Eastern, 2008). The letter should be sent certified, even though there is an assumption that a letter sent by first class mail is received by the client (Eastern, 2008). Sending the letter by certified mail is just an extra precaution to make certain that the client receives it. The return receipt and all correspondence should be placed in the patient's chart.

In the case that the patient has a third-party health insurance provider, the medical practitioner must make certain that they are acting within the regulations that govern that plan (Eastern, 2008). It is common courtesy to given the patient 30 days to find another provider and to agree to treat the patient for any emergencies that should occur within that time (Eastern, 2008). Eastern suggests that the physician provide the patient with a list of physicians that may take over care of the patient. However, this could be dangerous and open the potential for lawsuits in the future, as this could be seen as a personal endorsement of services. From a legal standpoint, it is best to let the patient make their own choices in medical practitioners once they leave your practice.

Providing assistance and allowing the patient 30 days to find a replacement medical practitioner is standard practice and can help to avoid abandonment lawsuits (Eastern, 2006). However, providing a list of local physicians as Eastern suggests can help to eliminate abandonment lawsuits. However, this can also set one up for future legal liability. As an alternative, one can help provide numbers to referral services, or other organizations the patient find a new medical practitioner. This is a courteous way of helping the patient, without leaving them the ability to construe endorsement of a particular practice.

Cooperating with the transition to a new medical practitioner also demonstrates good will and makes it appear that you are acting in the best interests of the patient. For instance, one should offer to transfer medical records to the new medical provider promptly upon receipt of written request by the patient to do so (Eastern, 2006). Cooperation with the new physician will help to establish that your intentions are in the best interest of the patient. Eastern also suggests not dismissing a patient in the course of treatment, if it can be avoided. Consultation with a malpractice carrier is also suggested before dismissal of a patient.

There is little written regarding the legalities of dismissing a patient. However, it is clear that this is not an issue to be taken lightly. Dismissing a patient is not only an emotional event, but can lead to unwanted legal ramifications, if not handled with caution. It should be clear from this discussion that dismissing a patient should only be a last resort. There are many steps that should be taken before resorting to dismissal. Often problems can be resolved without resorting to dismissal. The nurse practitioner can play an important role in preventing the need to terminate patients.

Conclusion

Patient noncompliance can have a negative impact on the patient in terms of future reoccurrence of the condition or possibly even death. In the time that a physician spends with a noncompliant patient, they could have been helping a patient that was willing to comply with the treatment plan. The noncompliant patient is not acting in their own best interest and are preventing others from receiving medical treatment. The noncompliant patient is not likely to resolve their medical issues, particularly when they are severe or life threatening. To dismiss a patient without having first made every effort to resolve the issues of noncompliance could be seen as a violation of medical ethics. The physician or nurse practitioner knows that to abandon the patient may pose a threat to their health and life. Therefore, in the best interest of the patient it is better to attempt to continue treatment. However, this can be difficult when the patient is uncooperative.

The research revealed that many factors are associated with noncompliance in patients. In some cases, the patient had perfectly logical reasons for noncompliance, such as side effects, or lack of access due to cost. The topic of patient noncompliance is not black and white. In many cases patients would be compliant if they had access to needed medication or transportation to pick it up. In other cases, issues regarding information or side effects need to be addressed. Rather than simply dropping the patient for noncompliance, doctors, and nurse practitioners must open the channels of communication and find out the reasons for patient noncompliance.