Treatment Ignored: Non-Compliant Patients and the Standard of Care

This newsletter often discusses standard of care, but what happens when a physician sees a non-compliant patient who does not follow medical advice or treatment instructions.

Consider this scenario:

A 72-year-old male patient was suffering from decubitus wounds on his foot and leg. The patient was a smoker and a diabetic. During his first visit to the physician, the wounds were debrided and a topical antibiotic ointment applied. The patient was also prescribed a special shoe to help with offloading the wounded foot. He was advised to quit smoking and schedule an appointment with a diabetic nutritionist to help him better treat his diabetes.

However, the patient continued to smoke against medical advice and failed to schedule the recommended nutritionist appointment. The physician scheduled an appointment with an orthotic company to begin the process of manufacturing a shoe insert for the patient. The physician also ordered an arterial ultrasound and the results came back normal.

The patient’s lack of progress and non-compliance with physician orders were documented in the chart along with wound photos.

The patient continued to see the physician on an almost weekly basis. A total contact cast (TCC) was placed on the patient to reduce pressure on the foot wound and promote healing. The TCC is often used on diabetic patients to help offload a foot with decubitus wounds.

The patient’s condition eventually worsened and he had to undergo a below-the-knee amputation. The patient filed a PCF complaint against the physician, who claimed he treated the patient’s condition according to the standard of care for a foot wound in a diabetic patient. According to his statement, the two biggest factors in the wounds not healing were the patient’s continued non-compliance through smoking and poorly controlled diabetes. These issues were mentioned to the patient during each visit and, equally important from a professional liability standpoint, the chart was regularly documented to reflect this.

The Medical Review Panel found no deviation from the standard of care. The panel noted that the doctor “followed all of the evidence-based recommendations for treatment of this condition. A proper workup was performed with appropriate therapy, surveillance and follow-up appointments.”

When it comes to treating non-compliant patients, documenting non-compliance and physician suggestions in the chart at the time of an appointment can be the difference between a favorable or non-favorable legal outcome.

Dealing with non-compliant patients is a day-to-day challenge for healthcare providers who have limited control of what their patients do in their daily lives. In the above case, the standard of care was found to be met. There are several approaches that may help a patient become more compliant. Healthcare providers should consider these additional factors in an attempt to identify barriers to compliance.

• Has the patient been properly educated on the underlying medical condition and risks involved? Provide the patient with as many educational resources as possible regarding their condition and risks such as handouts, websites and other resources.
• Does the patient have a hearing disability or a mental barrier? Does the patient have adequate insurance and/or financial resources to pay for the recommended treatment? Have a social worker or case manager meet with the patient to discuss discharge needs, current living environment and any special needs the patient may have that are contributing to the non-compliance. If any opportunities are identified, the social worker/case manager can possibly provide external resources for the patient.
• Is the patient uncomfortable or embarrassed by their current health conditions and/or lifestyle choices? Is the patient forgetful? Schedule appointments for the patient with recommended services. Even if the patient does not attend the scheduled appointment, an attempt was made to help the patient become more compliant. In this particular case, the physician could have scheduled the patient an appointment with a diabetic nutritionist and a smoking cessation program. Both appointments would have provided more resources for the patient.

Going above and beyond the standard of care might be the key to getting a patient to become more compliant with the physician’s recommendations for treatment.