How to Handle the Noncompliant Patient

You’ve likely dealt with patients who don’t follow your instructions to achieve a good clinical outcome. Noncompliance includes patients who don’t follow your referral orders or those who refuse to stop smoking or lose weight.

Noncompliance can be especially troubling when it continues over time, despite your repeated efforts. Potential consequences include treatment delays and more extensive, costly, invasive, or aggressive therapy. The ND practice may face liability if a patient suffers as a result of the noncompliance. Consider the following scenario:

Patient Avoids Healthy Lifestyle

Joe Anderson was a 40-year-old grossly obese patient with a family history of early cardiac death among the males in his family. His father and two uncles all died from acute MIs before they were 50. In addition, Joe had hypertension, hypercholesterolemia and pre-diabetes.

Joshua Chang, ND, was trying his best to help Joe improve his health and have a better outcome than his family history would predict. Dr. Chang recommended a Mediterranean diet (and he provided educational materials about the diet), aquatic exercise with a trainer, liposterols, vitamin C, cocoa flavanols and niacin.

Despite Dr. Chang’s repeated counseling and warnings, Joe did nothing to change his sedentary lifestyle or unhealthy diet. His use of supplements was erratic, and he didn’t significantly modify the omega 3 content or the glycemic index of the foods he chose.

Joe bluntly told Dr. Chang that he considered an early death to be inevitable. He couldn’t fight his genes, and felt Dr. Chang’s recommendations were “impossible” to follow and not worth the “suffering.”

Consequently, Dr. Chang referred Joe for psychological evaluation and therapy. After several sessions, the psychologist determined Joe was clinically depressed, and he advised several sessions of therapy.

When Joe returned to naturopathic care two months later, Dr. Chang noticed a marked change in his demeanor, outlook on life and compliance. Joe had been consistently exercising and following Dr. Chang’s diet/supplement regimen, which had a positive effect on blood sugar, cholesterol and weight.

Understand Why Patients Are Noncompliant

In addition to a psychological issue as shown in the scenario above, underlying causes for noncompliance may include the patient’s:

  • Lack of trust or confidence in the physician or the treatment plan
  • Lack of self-confidence or the patient’s own ability to follow advice  
  • Economic hardship
  • Language, religious, education, intellectual and physical barriers

An ND must determine the reason for a patient’s noncompliance, if at all possible. A face-to-face discussion can be extremely productive if you explain:

  • The reason for the course of treatment
  • The potential benefits and risks associated with the treatment
  • The patient’s role and responsibilities to achieve a good outcome
  • What will happen if the patient doesn’t follow advice

Then, ask the patient if the recommendations are achievable. If patient says “no,” ask why not. Once you determine the underlying cause, solutions may be possible.

Lack of understanding about your recommendations can lead to patient noncompliance, so make sure your communications and materials are easy to understand. If language is a barrier, offer to make interpreters and translation services available. If there are financial barriers, check to see what resources may be available.  

Remember, naturopathic medicine is new to many patients. They may have been indoctrinated with the belief that diseases are easily swept away by the taking of a pill. Therefore, improvements with a patient’s behavior or compliance will often be inconsistent.

Patient Has the Right to Refuse Care

Keep in mind that a patient has a right to refuse clinical care for any reason. What you deem to be patient noncompliance may actually be a patient coming to an informed decision to refuse care or to choose another type of care after weighing the treatment options.

In these situations, it is your role to ensure the decision/refusal actually was informed, just as you would with obtaining the patient’s informed consent. Your discussion with the patient should include your rationale behind your proposed treatment or diagnostic study, its potential benefits, complications, risks, consequences of refusal, and possible alternative therapies or procedures.

Sometimes, a little dialogue is all that’s needed to get to the root of the problem and turn a noncompliant patient into a willing, compliant participant. The discussion with the patient, the events leading up to it, the steps taken to resolve the problem and the patient’s response to this information should be documented in the patient’s record.

If the patient still refuses the clinical care you recommended, the patient’s decision should be documented in the records. Some practices will ask the patient to sign a “refusal of treatment” or “against clinical advice” form, and then will place the form in the patient’s clinical record.

Dismissing a Patient

If you believe there is little hope of obtaining compliance, you may have to make the difficult decision to dismiss the patient from your practice. Obviously, dismissing a patient who still needs clinical attention is not to be done hastily or without good cause. What’s more, it should only be done if there are no other viable alternatives.

Be aware that the dismissal itself could become grounds for an allegation of abandonment if not handled carefully. Take the necessary steps to arrange for ongoing care options for this patient, and be thoughtful in how you communicate what you are doing.

Overcoming the Challenges

Not only is noncompliance potentially harmful to the patient, it can be frustrating for NDs. Fortunately, effective patient communication can minimize noncompliance and thorough documentation can assist in the defense of any malpractice allegation. 

Noncompliance can be especially troubling when it continues over time.

ND Insights is published for NCMIC policyholders. Articles may not be reprinted, in part or in whole, without the prior, express consent of NCMIC. Information provided in ND Insights is offered solely for general information and educational purposes. Names and events are created for illustrative purposes only. It is not offered as, nor does it constitute, legal advice or opinion. You should not act or rely upon this information without seeking the advice of an attorney.