What to do When Patients Won’t Follow Doctor’s Orders?

By Nancy Wurtzel

Patient noncompliance is a huge source of frustration for health care professionals.  After all, clinicians spend time and energy creating a care plan, only to be thwarted because patients won’t adhere to the prescribed treatment.  This patient behavior often leaves physicians feeling baffled and even downright angry.

Consumer Reports published a survey of 660 primary care physicians, “What Doctors Wish Their Patients Knew.”  The most common complaint was patients not following the doctors’ advice or otherwise adhering to treatment plans, including taking medications.

In fact, medications are well-documented as a top source of patient noncompliance.

Clinicians write upwards of 3.8 billion prescriptions annually in the U.S.  A study published by the FDA and the National Council on Patient Information concluded 14-21 percent of patients never even fill their original prescription, and 60 percent cannot name all the medications they are taking.  Equally disturbing is that 30-50 percent of patients consistently fail to follow medication regimens.

Failure to take medications as prescribed can translate into real health and financial consequences.  Poor medication compliance accounts for 33%-69% of hospitalizations due to drug-related adverse events.  Up to 40 percent of nursing home admissions are linked to poor compliance to medicine regimens.

Even more disturbing is that medication noncompliance is implicated in over 125,000 US deaths per year.

“Non-adherence with medications and treatment plans is a significant problem for patients, particularly those with multiple chronic illnesses, many of which require lifelong treatment to improve health outcomes,” said Dr. Peter Gonzales, an internist and primary care doctor at Beth Israel Deaconess Medical Center in Boston.

With so much at stake regarding health and money, this noncompliance has become an enormous challenge for physicians.

The reasons behind patient noncompliance are sometimes straightforward, such as a lack of funds to obtain a prescription.  Or those reasons could be as complicated as a patient being averse to taking any prescription medications.

Other patients may have good intentions, but taking various meds three or four times a day is too complicated, and they simply forget. The elderly or disabled may experience trouble administering medications. Many patients report side effects are an obstacle to completing a course of medication, so they cease taking them.

Those who have chronic diseases and are taking meds on a long-term basis may feel the drugs have done their job or have lost their potency.  Consequently, this belief might lead them to discontinue their med use.  Another issue lies with patients who self-medicate by adding contraindicated meds or supplements to their treatment plan.

Physicians also report a lack of follow through from patients when a course of treatment involves lifestyle changes, such as diet and exercise. Since immediate results may not be apparent; they don’t see the need to persevere.

Adherence to a treatment plan doesn’t seem to fail for one reason; rather it is more often a cluster of reasons, beliefs, and decisions that vary greatly among patients.

There is no methodology to predict which patients will comply with a treatment plan.  Physicians are left to trust patients, follow their instincts, or gauge from testing whether or not the patient is following their care plan.  These avenues can be haphazard at best.

Doctors do have some tactics that may improve compliance.

For instance, talk plainly in terms the patient can understand, and outline the benefits and the risks of not following their treatment plan.  Emphasize a team approach and that you have their wellbeing in mind.  Explain to the patient that he or she may not get better, and could even get a lot worse. Talk about outcomes and provide “real life” examples.  Ask family members or caregivers to participate in the treatment plan.

If appropriate, address the urgency of their situation.

Ask questions, such as:

• What barriers do you see in your treatment plan?
• What are your concerns about this medication or therapy?
• What do you think this medication will do for you?
• What do you see as the consequences of not following this course of treatment?

Over time, physicians may find they have exhausted all avenues with a patient, but compliance is still not reached.

Risk management specialist Barbara Worsley, advises clinicians to document patient noncompliance following these five steps. A notation about the information the provider gave to the patient concerning the condition and treatment, including reasons for treatment or a referral to a specialist ƒ

1. A notation about the information the provider gave to the patient concerning the condition and treatment, including reasons for treatment or a referral to a specialist
2. A notation that the patient was advised of the risks and consequences of failing to undergo tests or to see a specialist
3. A notation about the patient’s refusal to follow the treatment plan or advice and/or the patient’s signature on a refusal of treatment form
4. A notation about the provider’s referral of the patient to a specialist
5. Verification that the patient did or did not keep his or her appointment with the specialist