Noncompliant and Non-Adherent Patients: When All Else Fails, What Role Do You Play?

In every practice, there are always a few patients who are more difficult to manage. The first question to ask is: why is the patient refusing treatment recommendations? Is the patient’s decision influenced by knowledge deficit (they do not understand what is required of them), low health literacy, cultural/socioeconomic barriers, religious prohibition? Or is it due to the belief that the physician and staff do not care, unreturned phone calls, complaints left unanswered, or fear?

When left unaddressed, all can contribute to a negative impression of patient care. This is not the time to avoid or distance yourself from the patient.

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There is a difference between a noncompliant patient and a non-adherent patient:

  • Noncompliance is generally a term which includes deliberate or intentional refusal by the patient.
  • Non-adherence is generally a term which includes unintentional refusal by the patient.

Having some strategies for managing noncompliant and non-adherent patients could possibly restore the physician-patient relationship and may even prevent a lawsuit.  A competent and caring physician should take reasonable steps to assist their patients in understanding the importance of compliance.  The physician-patient relationship is fiduciary. Physicians have a non-delegable duty to inform patients about the nature of treatment and the importance of their complying with the treatment plan.

Physicians become vulnerable to allegations of breach of duty to the patient if they fail to document their efforts to inform the patient and encourage compliance.  A patient’s sworn testimony at trial that “I was never informed” will resonate with sympathetic jurors.

Despite appearances, the patient is usually not angry at you.  Anger is often a cover for frustration or fear.  It’s easier to be empathetic when you know it’s not personal.

We recommend the following:

  • Ask open-ended questions including asking about possible obstacles.
  • Active listening is crucial to understanding the patient’s dissatisfaction. Using phrases like: “I understand you’re unhappy because… “ or rephrasing or repeating back what the patient has said lets the patient know that you’ve heard him pr her and that what he or she has to say matters.
  • Improve communication by engaging patients as shared decision-makers. Explaining a basic treatment rationale is essential to gaining the patient’s acceptance.
  • Ensure patients who require close monitoring are not lost to follow-up by scheduling return appointments.
  • Track patients referred to other physicians and those sent for diagnostic tests. Recognize that patients who are in denial and who underestimate the importance of treatment are at risk for noncompliance.
  • Help the patient understand the risk of not complying or not adhering to the provider’s treatment plan.
  • Document provider recommendations, patient noncompliance, and specific objections to treatment (if possible in the patient’s words), and risk of not complying or not adhering if the medical issue remains untreated or undertreated. Informed refusal should be treated the same as informed consent.

Whether it is noncompliance or non-adherence, it is essential that the patient has a common understanding of the medical issues.


Authored by Diana Douglas
Vice President, CAP Risk Management and Patient Safety

 

If you have questions about this article, please contact us. This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.