Threshold for "firing" patients

[jb5158]

Question that I've been struggling with...when do you pull the trigger on firing a noncompliant patient? We terminate after 3 no shows, if they are threatening, if there is a lawsuit (haven't seen that happen but obviously policy). I know many also terminate for failure to comply with recommendations. Almost all patients are noncompliant in some way, whether it's not making dietary changes, taking meds as prescribed, etc, and we don't terminate them. 

 

What about extreme cases? What is the breaking point? I work in neurology and we have a patient with epilepsy secondary to craniotomy for aneurysm many years ago. She has been in status epilepticus many times. She continues to have seizures but refuses further testing (EEG or neuroimaging), labs, or even adjustments in medication. She does seem to be compliant with the medicine she takes, but obviously the dose is not adequate and she won't increase it, so basically a moot point. She continues to be admitted for breakthrough seizures, refuses EEG, and leaves AMA. 

 

She refuses to see my SP due to personality conflicts I guess, so I'm her main neurology provider, which is fine. I'm getting more and more nervous however about possible legal ramifications if she goes into status and doesn't wake up. I know I have tried everything I can and I document at length that we discussed the various risks associated with her not complying with our recommendations, that she is aware of the risks and continues to refuse, etc. 

 

I am getting very anxious about the eventual disaster that will happen with her and me being the main person treating her epilepsy. I feel like my documentation is thorough enough that if a lawsuit would happen, it wouldn't go anywhere. Obviously I don't want it to even get to that point however. We have other neurologists here so I wouldn't be abandoning her per se, I just feel very guilty about giving up on her. 

 

As I type this I'm seeing exactly how bad her situation is and I think I know my answer. I know there are practices that terminate for less, even if patients don't get vaccinations.  I would however like to get other people's opinions and see what other PA's breaking points are for when they just don't feel they're getting anywhere with a patient or if a patient blatantly ignores their medical advice. 

 

Thanks!

 

Edit for additional details I forgot, which don't help her case at all, has had hemiparesis, thought to possibly be Todd's paralysis, but has been recommended to start daily aspirin which she also refuses.....

[BruceBanner]

As long as you document the hell out of your (evidence-based and appropriate) recommendations and her non-compliance, you'll be fine.

 

As far as discharging her, you could always say "if you're not going to respect our medical expertise and wisdom, then this cant be a productive provider-patient relationship and I think you should see someone else. If you return you have to be willing to do what we ask, because it's in your best interest."

[Reality Check 2]

Aside - 

 

Family involved? anyone who comes in with her or she has signed as a right to discuss?

Can you call Adult Protective Services about someone who can't make sound decisions for themselves?

Has the hospital ever remanded her to a SNF after hospital or placement in a nursing home?

 

This patient is a danger to themselves and it sounds as though you have tried all rationale.

 

Do you send in the Rx's for the correct meds at elevated doses? 

I wouldn't keep giving the wrong dose. I would send in the right med at the right dose and then compliance is more on her.

 

Just my quick thoughts.

[GetMeOuttaThisMess]

Does she DRIVE?

[probasestealer]

I would recommend discharging her for not following medical advise, I can see your level of discomfort.

[Reality Check 2]

I would exercise caution before discharging her and determine her mental capacity for making sound decisions.

 

You cannot really ethically discharge someone who should be under guardianship. 

 

See post above.

[jb5158]

She does not drive, thank god. Her husband is somewhat involved, will call office if she has a seizure but does not come to appointments. Other than refusing medical recommendations, she seems to be capable of making decisions. Memory is okay, problem solving is okay, judgment otherwise seems fine. I feel she is competent to make her own (horrible) decisions. She just flat out does not want testing or more medicine. Social work has been involved in all of her hospitalizations. Also of note, she has long history of ETOH and drug abuse, but has been clean for the last couple years (confirmed with level and UDS). When I discuss the risks with her, she is able to repeat everything back to me and seems to understand the risks, she just doesn't seem to care. We've tried talking to her husband about the noncompliance when he calls and tried getting him to come to appointments, but he just does not seem worried either. I've tried asking her WHY she doesn't want any of it and she doesn't give a straight answer other than she doesn't want to deal with it........I'd rather "deal" with taking a little more medicine than be intubated in the ICU for several days, but what do I know....

[south]

 

Do you send in the Rx's for the correct meds at elevated doses? 

I wouldn't keep giving the wrong dose. I would send in the right med at the right dose and then compliance is more on her.

 

A good point.  You might get her to go somewhere else if you show a little toughness.  It's on her if she doesn't take them correctly or doesn't pick them up, and you're covered even better.  

 

Who's paying for all these ICU stays due to noncompliance?  "You know, the insurance company usually calls me on difficult refractory cases like this and I will have to discuss with them the plan that isn't being..."

 

We had a married pair of frequent flyers (Medicare o' course) in the ER where I worked, both raging uncontrolled obesity/DM/HTN/COPD, in their wheelchairs from multiple bilateral revised amputations...you always knew they were there from the sound of their chairs, the hiss of the high flow O2, or the smell...anyway, one of the docs got on the horn to Medicare about them once , but I never knew the outcome of that.

[Reality Check 2]

You have gone above and beyond, in my opinion.

 

Somewhat of a futile process with the unfortunate potential for the family to still blame you and your crew when the bad outcome happens - and it will.

 

My letter of dismissal would be somewhat terse and very disclaimer laden....

 

"You have a serious illness with potential for death and further disability. There are standards for caring for this condition and you are not willing to participate to meet those standards. We have outlined a treatment plan and monitoring and you are unwilling to follow that plan. That means we do not have a meaningful patient-provider relationship where we both participate in your health and I cannot provide any further care for you. Again, your epilepsy is very serious and carries a high risk of death and complete physical incapacity and you need medical attention. Failure to seek care or participate in your own health will bring dire consequences. I will provide 30 days of medication and you will need to find a new medical provider immediately."

 

Just my thoughts. I am in an oratory mood today.

[moestown1016]

I think it's cool that you have kept seeing her this long. I doubt she would try hard to seek help elsewhere which probably makes you feel even worse about dismissing. Would it help if you delivered her the letter at her next appointment and tell her it's coming via certified mail in a few days if she doesn't start some changes? Sorry. Tough situation.

 

 

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[SedRate]

She does not drive, thank god. Her husband is somewhat involved, will call office if she has a seizure but does not come to appointments. Other than refusing medical recommendations, she seems to be capable of making decisions. Memory is okay, problem solving is okay, judgment otherwise seems fine. I feel she is competent to make her own (horrible) decisions. She just flat out does not want testing or more medicine. Social work has been involved in all of her hospitalizations. Also of note, she has long history of ETOH and drug abuse, but has been clean for the last couple years (confirmed with level and UDS). When I discuss the risks with her, she is able to repeat everything back to me and seems to understand the risks, she just doesn't seem to care. We've tried talking to her husband about the noncompliance when he calls and tried getting him to come to appointments, but he just does not seem worried either. I've tried asking her WHY she doesn't want any of it and she doesn't give a straight answer other than she doesn't want to deal with it........I'd rather "deal" with taking a little more medicine than be intubated in the ICU for several days, but what do I know....

Have you discussed or referred out for depression workup? On my FM rotation, we had a T1DM teenage boy with multiple hospitalizations for DM complications and noncompliance with his insulin. His mother would always come in and talk for him. He would always say, "I forgot to take my dose," or, "I accidentally took too much," etc. One visit, she stepped out to take care of something and ok'd us continuing the appointment for his annual checkup. I started to ask some questions about why he really did those things. He opened up about how he didn't feel it was fair that he was born with T1DM and he just wants to be a normal teenager. He went on to say that he felt like his insulin was the only thing he had control of, reminiscent of bulimia/anorexia and the control of their food. By his mannerisms and speech, it was clear he had some issues to work through that hadn't been adequately addressed. I'm sure how overbearing mother didn't help. When she came back, I let her know that we discussed some things and I think counseling might help him cope with his lifelong illness.

 

Just a thought.

[UpRegulated]

Have you discussed or referred out for depression workup? On my FM rotation, we had a T1DM teenage boy with multiple hospitalizations for DM complications and noncompliance with his insulin. His mother would always come in and talk for him. He would always say, "I forgot to take my dose," or, "I accidentally took too much," etc. One visit, she stepped out to take care of something and ok'd us continuing the appointment for his annual checkup. I started to ask some questions about why he really did those things. He opened up about how he didn't feel it was fair that he was born with T1DM and he just wants to be a normal teenager. He went on to say that he felt like his insulin was the only thing he had control of, reminiscent of bulimia/anorexia and the control of their food. By his mannerisms and speech, it was clear he had some issues to work through that hadn't been adequately addressed. I'm sure how overbearing mother didn't help. When she came back, I let her know that we discussed some things and I think counseling might help him cope with his lifelong illness.

 

Just a thought.

 

Sed, your question reveals your desire to get to the root cause of the issue and being a caring and compassionate is obviously an essential aspect to be healthcare provider.  BUT in my short time of being a provider, I've learned there are 1000+ reasons for noncompliance, and spending too much time trying to figure out why certain patients refuse to comply with medical recommendations, (1) rarely accomplishes anything, (2) wastes your time and the patient's time, and (3) wastes valuable healthcare dollars.  People have the RIGHT to refuse recommendations and medical treatment for whatever reason.  Spending too much time and effort on them reduces the care you can give to those that ARE compliant.  Why spend time on someone that after their third office visit for diabetes who chooses essential oils over metformin -- whose A1C is 12 -- why not fire them?  If you don't, you are taking precious time and health insurance dollars from those that take you and their health seriously.

 

Depression?? Maybe.  But there are 1000 other reasons for non-compliance.  And do you know the percentage of people that have a truly positive response to SSRIs vs placebo vs counseling?  Very low.   And I'm sorry, depression doesn't keep people from swallowing a pill.  And if it does, their depression is inevitably intertwined with complex social issues that a provider can't fix.

 

Here's the rub.  Medicare requirements coming down the pike NOW are going to penalize providers for failing to meet metrics, despite the fact that those metrics that are not being met are on the PATIENT, not the PROVIDER.  I can't keep your blood pressure below 140/90 if $4 per month for your lisinopril is too expensive for you (while you text on your iPhone during my office visit with you).  I can't fix your 11 A1C if you refuse to take your metformin because of a scary lawyer commercial you saw on TV, or your uncontrolled lust for Pepsi, or because you believe your local chiropractor who says he can cure your diabetes with pomegranate powder or lavendar oil (or whatever bull****).

 

So yeah, maybe they are depressed.  Maybe they saw a stupid lawyer commercial.  Maybe they went to the hypochondriac.org message forum for advice. Maybe they think they can cure their triglyceride level of 800 by eating flax seed oil.  Maybe they follow Dr. Oz religiously.  Maybe they think you make money off prescribing medicines.  Maybe they think humans have never landed on the moon.  Maybe they think a spinal adjustment will fix their hypertension or ear infection.  Maybe they think insulin kills you.  Maybe they believe vaccines cause autism. Maybe they wear tin foil hats while at home to keep the government from reading their brain waves.  Maybe they think their witchdoctor can do some wooga wooga to cure their ailments.

 

You/we have 15 minutes with these people.  If you/we take more time or additional office visits to determine the "root cause" of their poor decision making, then you/we are shafting compliant patients and all of society in the form of time, money, and care and spreading the costs of their non-compliance to EVERYONE ELSE.  You/we are making you/me, and all compliant patients bear the burden of their poor decision making in terms of money and time. Spending too much time with non-compliant patients means compliant patients have less time with you/me and hence less access to healthcare all at a higher cost.

 

Think about that when deciding when to fire the non-compliant patient.