Human Rights: Addressing Non-Adherent Patients
For most medical conditions, the correct diagnosis, effective medical management and the prevention of reoccurrence are important components to a patient’s survival and quality of life. However, a barrier to effective treatment may be due to the patient’s failure to follow the recommendations given by their health care providers. This is referred to as “patient non-adherence” and may be presented in various forms such as, the advice given to the patients by health care practitioners to cure and control diseases are too often misunderstood, carried out incorrectly, forgotten , or just ignored (Leslie R Martin, 2005).
The term adherence is defined as, “the degree to which the person’s behaviour corresponds with the agreed recommendations from a health care provider” (Dobbels, Damme-Lombaert, R., Vanhaecke & Geest, 2005). Various factors are thought to contribute to a patient’s adherence to treatment provided by the health care provider. Some of these contributing factors are following advice, attendance to appointments, implementing the recommended exercise program and correct exercise technique usage (Kolt, Brewer, Pizzari, Schoo & Garret, 2007).
I chose this topic due to the fact that I often come across non-adherent patients in clinical practice. During one of my experiencing I had a patient who needed chest physiotherapy but after several attempts the patient refused treatment. I documented the experience in the patient’s folder and spoke to the doctor; who said I should try again the next day. When reporting back to my clinicians at the placement I was asked why the patient refused, however I was not able to give an explanation. I was then reprimanded and told that I should still have treated the patient even after he refused. After several days trying to persuade the patient to receive treatment but being unsuccessful, the patient was taken away from me. The clinician made me feel very incompetent about the situation, however I did not feel it was right to force treatment on a patient who refused several times. This made me interested in understanding more about why patients refuse treatment.
According to the Human Rights Act of 1998 (British Medical Association, 2000) every patient has the human right to refuse treatment. However, research shows that there are strategies that may assist in these cases. Effective adherence strategies may be divided into two components: intrinsic motivators and extrinsic motivators (Smith, 2017). Intrinsic motivators are factors within the patient that would inhibit or enhance the patient to adhere to a treatment program. Intrinsic motivators can include characteristics such as the patient’s attitude toward exercise, chronological age, home environment, feelings or self-efficacy and the willingness to incorporate exercise into their daily routine and the severity and prognosis of the condition.
Extrinsic motivators are factors within the patient’s external environment which affects their willingness to exercise or follow a treatment program. Extrinsic motivators include the health care provider-patient relationship, social relationships, and the prescription format. The prescription format includes goal setting, number of exercises and sessions, presentation/education and follow ups. The presentation of the exercises to the patient can have a large effect on their continuing level of motivation. Whereas the patient’s social relationships can affect their enjoyment of home exercise programs (Smith, 2017).
There are many factors that should be taken into account when a patient refuses physiotherapy treatment. It is the physiotherapist’s responsibility to identify possible causes leading to the patient’s decision to refuse. Should a physiotherapist come across a non-adherent patient, the physiotherapist should try to adjust their approach by perhaps focusing on the patient’s lifestyle. A study by George and Shalansky suggests that health care providers should try and understand the reasoning behind non-adherence patients if they are to provide supportive and effective health care.
References
• Committee on Medical Ethics, British Medical Association. (2000). Human Rights Act 1998. Retrieved 3 October 2018, from http://www.cirp.org/library/legal/BMA-human-rights/
• Dobbels, F., Damme-Lombaert, R., Vanhaecke, J., & Geest, S. (2005). Growing pains: Non-adherence with the immunosuppressive regimen in adolescent transplant recipients. Pediatric Transplantation, 9(3), 381-390. http://dx.doi.org/10.1111/j.1399-3046.2005.00356.x
• George, J., & Shalansky, S. (2007). Predictors of refill non-adherence in patients with heart failure. British Journal Of Clinical Pharmacology, 63(4), 488-493.
• Kolt, G., Brewer, B., Pizzari, T., Schoo, A., & Garrett, N. (2007). The Sport Injury Rehabilitation Adherence Scale: a reliable scale for use in clinical physiotherapy. Physiotherapy, 93(1), 17-22. http://dx.doi.org/10.1016/j.physio.2006.07.002
• Leslie R Martin, M. (2005). The challenge of patient adherence. PubMed Central (PMC). Retrieved 4 October 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1661624/
• Smith, R. (2017). Motivational Strategies for Improving Patient Compliance with Rehabilitation – American Chiropractic Association Rehab Council. American Chiropractic Association Rehab Council. Retrieved 4 October 2018, from http://www.ccptr.org/articles/motivational-strategies-for-improving-patient-compliance-with-rehabilitation/
4 thoughts on “Human Rights”
Thank you for your writing piece. I found it to be a good and interesting read. I like how you decided to rather focus on one human right, that of the right to refuse treatment, in terms of non-adherent patients. I like that you incorporated a personal experience to link up to the topic. I was just wondering, when you say you tried to persuade the patient to participate in treatment, how did you do this? What did you say to them? I feel that it is always good to educate the patient on the treatment you want to perform and the benefits thereof in relation to that specific patient. I am assuming this is what you did but just wanted to confirm. I too have encountered the same scenario of a patient refusing treatment, and your piece made me think of this. I never really thought about it in terms of intrinsic and extrinsic factors and how if you as a physiotherapist are able to determine what factors are at play, then you may be able to influence these and therefore, motivate the patient to participate in treatment.
I 100% agree with you when you say that you didn’t feel it was right to force treatment on a patient who constantly refuses and I am shocked to read that your clinicians reacted in such a way saying that you should have treated the patient regardless of their choice. That is shocking because they do have the right to refuse treatment as long as that right does not infringe upon someone else’s right. I’m sorry that you had that experience with your clinicians, but I am glad that it allowed you to then further research the topic and broaden your knowledge on the patient’s right to refuse treatment.
A suggestion would be to always read through your final piece to ensure that all the grammar is correct and make use of spell check. For example, in the third paragraph you wrote “During one of my experiencing…” which I assume you meant to say “experiences”. This is a simple mistake that happens too many, but just try to be more aware of it when writing other pieces in the future. Another bit of advice I can provide is regarding references. You made use of a good amount of references; however the first few were from 2005 and 2007. This is quite outdated, so my advice would be to try to find more recent research that is still relevant to your topic.
Thank you for sharing your writing piece.
Hi, Abigail.
I thoroughly enjoyed this short, but sweet piece. It put into perspective what most of us, as students, go through on a block. I do believe that patients of sound mind should never be forced to do anything they do not want to in a clinical setting. I definitely would have felt the way you did when you got reprimanded.
However, I would have loved to see you go a bit more in-depth on when it is acceptable to treat a patient even without their consent. Would you treat a patient with a severe TBI even if they do refuse? And if so, what does the law say about that? Should you phone his family first, or just treat him? Ethically, what would be the right thing to do for the patient?
Or, if the abovementioned patient had dementia, would you do what the patient wanted, or what you know would improve his quality of life?
I think it is always a good idea to bring certain scenarios into play when discussing refusal of treatment, because it is not always black and white.
However, thank you for a good, easy to follow and well referenced piece!
Kind regards
Suné
Hi Abigail
Thank you for sharing your writing piece.
I think this is something that many students face (including me) – patients refusing treatment without a valid reason. However, I also agree that even after you have explained your role in treatment and the consequences of not doing treatment, and the patient still refuses treatment, we cannot force to do treatment on them – this is their right. The only time when this right is not honoured is when the patient is 1) a child, 2) mental status is altered and 3) threat to the community (Torrey, 2018).
However, having said that, patients have responsibilities that they need to adhere to and they should be reminded that it is their responsibility to comply with the physician providing the treatment.
Last year, I did a case study on management approaches to motivate patients to comply with treatment, which I think can be helpful to your writing piece. The strategies used were namely;
1. Understanding the patient’s perspective: meaning you want to find out WHY they are refusing treatment, so that you can maybe address that problem and then continue with treatment. The most important aspect for this strategy to work is good communication.
2. Negotiation: this can help make the patient feel as if they are in control of their decisions. However, whatever is being negotiated, the options should be equally beneficial. For instance, to help improve endurance you can give the patient the option to do a brisk walk around in the ward or they can go to the gym and exercise.
3. Using visual aids: so showing the patient consequences through the use of visual aids, if they do not comply.
4. Good cop, bad cop routine: as physicians, we cannot always be the good cop, we have to be the bad cop. Inflicting fear can also motivate or influence patients to comply with treatment. For example, if ICD patients refuse to do arm range of movement exercises due to pain, then you can tell the patient that if they do not get adequate arm range, the doctor won’t be able to remove the ICD.
I found that the good cop/bad cop routine was the most efficient. However, it may differ with you. I am more than happy to email my case study to you if you would like to read through it.
Also, some other pointers that can also help make your writing piece better is checking your grammar and spelling. For example: “During one of my experiencing I had a patient…”, I think you were meant to say “during one of my experiences, I had a patient …”.
The first 2 paragraphs can be summarised into 1 paragraph to make it more concise and straight to the point.
Overall, your writing piece easy to follow.
Thank you.
References:
Torrey, T. (2018, April 8). Do patients have the right to refuse medical treatment? Retrieved from Very Well Health: https://www.verywellhealth.com/do-patients-have-the-right-to-refuse-treatment-2614982