The Physician's Corner

By Henry Tulgan, MD, FACP

When patients refuse to follow medical advice and adverse outcomes occur, it is not only exasperating for physicians, but devastating if those patients enter into litigation. These actions may be delayed for years and can become protracted in nature.  Therefore, physicians should attempt to ascertain early on why patients are acting in noncompliant fashion.

Challenges

Challenges to compliance may include language and/or cultural barriers, adverse reactions to prescribed medicines, or in some cases, neuropsychiatric issues. Non-compliance may stem from actual or perceived unpleasant interactions with office staff and even the physician him/herself.

Solutions

Solutions to non-compliance may include having translator services available, or in the case of drug intolerance, a change in the prescription, or dosage adjustments. Additionally, instituting a code of conduct in your practice regarding interactions with patients and their families may safeguard you against angry and/or noncompliant patients.

To avoid potential litigation, physicians should thoroughly document all patient interactions. Physicians should attempt to ascertain why their patient is acting in a noncompliant manner. Not only should the action of noncompliance itself be recorded, but the notation should acknowledge that the patient is giving the equivalent of informed consent with respect to refusal of treatment, (which h/she has the right to do). The notation should not be written in a pejorative tone for if litigation is entered into, this negative tenor may be looked upon as being adversarial 

Resolving non-compliance issues also prompts the development of practice strategies for dealing with “no-show” appointments, lack of follow-through for recommended laboratory work or radiological exams, lack of obtaining these reports and/or openly discussing them within the practice setting.

Certain patient groups deserve particular attention.  As an example, if minors are the patients and noncompliance may be the result of parental or guardian disregard, state law may require that the physician reports this as a case of potential child abuse. Similarly, where elder patients are involved and noncompliance is a guardian issues, the physician may be responsible for reporting the potential of elder abuse to authorities.

As a final resort, physicians do have the right to terminate the physician-patient relationship. It is important however to avoid an action that may be construed as patient abandonment. Legal experts suggest that as a first step, the physician have a conversation with the patient about the problem. If  this course of action does not resolve the issue, or if the physician determines that it is not possible to continue the relationship, a letter, with a return receipt requested, should be sent to the patient giving thirty days notice to locate another health care provider. The letter should also include a list of alternative providers along with the offer to transfer records to the new provider with proper authorization.

As difficult as this problem may be, with proper documentation and pre-developed strategies, the termination of care may occur in a workable manner and litigation, avoided.

Risk Management Strategies

• Strive to diagnose and address possible reasons for patient noncompliance;
• Thoroughly document all interactions with the patient, including informed refusal;
• Maintain systems to identify noncompliance early on and act on it sooner than later;
• Be aware of special issues related to elderly and minor patients who may not have ultimate responsibility for their compliance; and,
• If termination of the physician-patient relationship results, conduct this action in a manner that does not constitute abandonment.

Next: CME Exam Instructions