Patient Noncompliance: Time to Discard This Label

"The patient's decision not to accept medical advice may be quite reasonable, particularly in light of past compliance incidents that have been personally experienced, witnessed, or heard about" (1). These words, voiced by Dr. Eraker over 3 decades ago, continue to ring true today. Unfortunately, in our efforts to provide the best care possible for our patients, this fundamental principle is often forgotten.

The countdown was on. There were only 15 minutes left before morning ward rounds started, and I had 1 new patient left on my patient list to review. The patient was a young African American male with a new diagnosis of heart failure and history of polysubstance use who recently left against medical advice from another facility while being managed for cardiogenic shock. "Seriously?" I thought as I continued my rapid-fire clicks through the chart to learn everything I could about this intubated patient. As I continued to scour through the chart, out jumped the words "noncompliant patient," which at the time seemed quite appropriate given the history documented in the electronic medical record. The “noncompliant” label was assigned by health care professionals about a patient who seemed to fit the stereotype. My plan of action seemed clear. I would have a stern conversation about the high risk for mortality if he chose not to follow our advice and hope that I would be the one who finally communicated the gravity of the situation to him. After all, if he had self-discharged on the brink of death at the last hospital, why wouldn't he do the same as soon as his sedation wore off and he was extubated?

The next day, I was pleased to see that my patient was off pressor support and breathing room air on his own. It was time for my effort to convey the gravity of his heart failure and his need to heed our recommendations. As I stood at the bedside listening to the patient's version of events, I wondered if maybe I was the one who needed a reality check. In front of me was a young man who was not only very knowledgeable about his new diagnosis, having cared for a family member who previously struggled with this condition, he was also very agreeable to my proposed treatment plan. How could that be, considering the events of his previous hospitalization? On further discussion with the patient, it turned out that his self-discharge from the prior hospitalization was in the setting of a family emergency that required his immediate attention, and he returned to be readmitted as soon as the issue was resolved.

That day I got a much-needed reminder about something I had learned in medical school but, like many others, I sometimes forget. Sometimes we label a patient as being noncompliant because we fail to make the effort to understand a patient's decision-making process. As I reflect on this timely encounter, I implore my clinician colleagues to pause before you label a patient noncompliant.

References

1. Eraker SA, Kirscht JP, Becker MH. Understanding and improving patient compliance. Ann Intern Med. 1984;100:258-68. [PMID: 6362512]

Stacey C. Regis, MD

Dr. Stacey Regis is an internal medicine resident and rising chief at the University of Miami/Jackson Memorial Hospital. She is passionate about patient advocacy and has keen interests in preventative cardiology.