In the course of a single day, we often see frustrating patients who do not follow the seemingly simple instructions that we give to them. Treating non-compliant diabetic patients, specifically those who are dealing with issues of wound care, infections and even amputations, can be particularly challenging.
When I use the term non-compliant, I am sure that everyone immediately visualizes his or her most memorable patient. You may refer to this patient as a problem patient, a troublemaker or any other choice word, but are these negative judgments of patients making the challenging cases even more frustrating? After all, non-compliance ultimately causes delays in the resolution of problems and often leads to more aggressive and costly treatments.
It’s important to strive for a better understanding of non-compliant patients. Indeed, non-compliance is defined as the lack of follow through with your advice. However, non-compliance can be the intentional result of a rational decision based on personal beliefs related to the disease and its treatment. In other words, does the patient own his or her diabetes-related complications or is he or she in a stage of denial?
The term compliance itself has a negative connotation. It conjures images of submission to authority, coercion and a unidirectional flow of care from doctor to patient instead of a partnership. Others who have researched this topic generally prefer the term adherence.
There may also be a tendency to assume the profile of a non-compliant patient is that of a young, poor, illiterate or indigent person. However, the literature does not substantiate this. According to the literature, several key factors are linked to non-compliance, including social and family relationships, experiences with the health care system and patient perceptions about illness and medication.
The barriers to compliance generally fall into one of three categories: patient factors, physician factors and factors associated with the health care system.
Understanding Patient Non-Compliance Factors
Patients themselves may be the true source of non-compliance. In order to get to the bottom of the behavior, there are several key questions you must ask.
• Does the patient assume control over diabetes?
• Has the patient accepted diabetes as a chronic illness requiring lifestyle changes?
• Has the patient been educated about outcomes?
• What is the patient’s attitude toward diabetes?
The answers to these difficult questions may reveal the reasons your problem patient is not following instructions. Of course, obtaining the answers is a difficult process given the number of patients one may see in a given day. For a patient to feel comfortable revealing these answers truthfully, he or she must also perceive the clinician as having a genuine interest in positive outcomes.
Other patient factors influencing compliance are mechanical difficulties (i.e., swallowing pills), impaired mobility, cost (i.e., medications, dressing supplies), fear, pride, religious beliefs, and the patient’s perception of whether he or she is feeling better, worse or feels there is a lack of progress.
There are also factors associated with the health care system that may lead to patient non-compliance. Prolonged waiting times, impersonal service, lack of continuity of care and issues associated with transportation are just some of the issues.