What is non-compliance?

1. CD Week 22: Patient compliance“An action in obedience to another request”COMPLIANCE IS A MAJOR HEALTH PROBLEM!

2. What is non-compliance? • Failure to take recommended dose and at recommended times, failure to complete course of treatment, taking drugs for wrong person, taking other medications that are otherwise contraindicated • Studies show about 1/3 to ½ patients are non-compliant in one way or another!

3. Discussion prompts: Consider reasons why patients may not comply, and appropriate strategies the doctor may use to improve compliance (or adherence). Consider potential divergence between the doctor’s desired outcomes, and the patient’s.

4. Identify factors influencing compliance and non-compliance (1) • Patient characteristics (Age, Gender, Race, Personality, attitude to illness, doctor or their life, socioeconomic status, ability to communicate and comprehend/understand) social supervision, preference for complementary medicine) • Treatment Setting (Inpatients vs. our patients) 80% supervised compared <50% with minimal supervision/follow-up

5. Identify factors influencing compliance and non-compliance (2) • Medication characteristics (Amount of total medications, similar appearance of medication, number of doses per day, taste of medication, side effects caused) • Clinical features of the illness (Chronic illness, mild/asymptomatic illness, delay in consequence of stopping treatment) • Clinician expertise (Ability of prescriber, relationship with patient, confidence in treatment, information to patient).

6. Identify strategies to increase compliance(1) • First is to identify “at risk” patients Some of these include: • Chronic illness • Long term treatment • Prevention treatment • Elderly & children • Hostile patients • Multiple medications • Frequent dosing

7. Identify strategies to increase compliance(2) • Now need to plan an appropriate treatment regime which MUST provide suitable explanation. What needs to be explained? • nature of illness • goal of treatment • target symptoms • disclose likely side effects • reassure • establish therapeutic alliance • positive approach • engender hope

8. Identify strategies to increase compliance(3) NOTE: Vital to complement verbal information with written. • Verbal has 10% recall • Visual 20% recall • Combined shows up to 65% recall after 3 days!

9. Identify strategies to increase compliance(4) • REMEMBER!!! • Only prescribe drugs that are needed • Try use medications that can be given once daily • Continually review medication and progress of patient • Try match a simple regime to daily routine • Try to involve family/friends • Stress necessity of compliance always!!

10. Consider the potential impact on the therapeutic relationship when apatient is non-compliant with recommendations. • Poor/futile treatment outcome could threaten relationship • Frustration (both patient and doctor) • Loss of trust and confidence

11. Discussion prompts: How would you feel if the patient didn’t follow your advice & allowed their disease?to get out of control, so suffering serious health complications?Is it ethical to frighten a patient into complying with medical care or advice?

12. Ethical principles in patient care Discussion prompts: This is an opportunity to reflect on the issue of how the way you feel about someone or something can affect how you provide medical care. Consider experiences in clinical attachments. Do you really look after everyone the same, or are there patients that you will do more for? Is that reasonable? Yes if you recognise what you are doing, but beware the seductive needy patient.

13. Reading: Ethical principles in patient care Impartiality • Doctors must not be swayed by demands of others such as relatives, insurers, administrators or compromise patient care for other reasons (such as financial gain).

14. Reading: The three Ethical principles in patient care Commitment & continuity • Grows with training and experience and straightforward in most cases. But in the difficult cases with undesired outcomes it becomes much harder and this tests the Doctor. • Doctor may need to sacrifice a lot of their ‘self’ in order to meet the best interests of the patient in need. • After a major medical incident that has left a patient with serious complications, It is not an ethical or a legal defence to claim that the doctor was unable to be there because they were too tired, had plane to catch or had a long day etc. This is the reality and demands of being a doctor! Can’t claim responsibility on ‘team work’ as despite teamwork being vital-the key player is the doctor! • This has often been used to avoid responsibility

15. Reading: The three Ethical principles in patient care Abandonment • Doctors should never abandon their patients - whether those patients are terminally and incurably ill. Even if they can offer no treatment! • Whether to assist in palliation or giving of yourself as a human being-even if it means just sitting at the bedside, talking with them in their final stages. • Respects their inherent human dignity • Doctor who leave destroy that patients trust and morale they held in them and nor will the family forget that abandonment-leaves them hurt and tarnished reputation of the doctor.