By Nancy Collins, PhD, RDN, LD, NWCC, FAND
Clearly it is a legal liability when HCPs do not follow doctor’s orders but when the patient chooses not to follow doctor’s orders, things are not so clear.
Most of the lawsuits I deal with have more than one named defendant. For example, the plaintiff (typically a deceased patient’s next of kin) might be suing a hospital, a nursing home, and the attending physician at each facility. Sometimes they go a bit further and may even include the administrator, the director of nursing, and individual healthcare practitioners (HCPs) such as the wound care nurse or the registered dietitian.
When a lawsuit has multiple defendants one of the main things that must be worked out is how much responsibility for the outcome to assign to each party. Responsibility is a nice word for blame because that is really what we are talking about. Each defendant’s attorney will argue that their client is not to blame. That is obviously their job. What is not so obvious is that this means the attorney must deflect the blame to one of the other parties. It is truly every defendant for him or herself.
The Right to Refuse Treatment
While the intricacies and machinations of lawsuit settlement are eye opening to watch, the more important question is what if the patient is (even partly) to blame for his or her own dire situation? Where does patient responsibility fall in all this? Every day patients with diabetes chose not to follow diet recommendations and suffer the resultant elevated HgA1C levels. They then question why their diabetic foot ulcer is not healing. Patients with sacral pressure ulcers refuse to be turned and stay in the same flat position hour after hour. Every day in doctor’s offices, clinics, hospitals, and post-acute care centers, patients refuse advice and do not follow doctor’s orders. Clearly it is a legal liability when HCPs do not follow doctor’s orders but when the patient does not it is a much more touchy subject.
As Americans we all have the right to refuse treatment unless we have been declared mentally incompetent and have been assigned a court-ordered guardian or medical proxy. In long-term care, recent efforts for a culture change have encouraged a more participatory, home-like environment. In today’s world, the facility’s residents have free choice about many matters affecting their lives. These are rights we all cherish no matter what the care setting. The problem begins when we like our rights but then don’t like the outcome from exercising those rights. In our litigious society where suing medical professionals has become commonplace, this opens a very expensive can of worms without getting to the root of the problem.
Fostering Better Communication
One of the keys to this problem is better communication with patients. Every day patients relay stories about how they were rushed, didn’t fully understand what they had been told, did not get the results of tests, and were generally dissatisfied with their medical care. With this lack of satisfaction and by extension, trust, it is easy to understand why patients choose not to follow medical advice.
I recently conducted a survey on implementing basic nutrition interventions for wound healing. The majority of respondents said they did not follow nutritional advice because they didn’t believe it would have any effect on their wound. This was a gut wrenching finding because nutrition seems so fundamental to wound healing. Obviously this has not been well communicated to the patients so we need to go back to the drawing board and rethink how to impart this message. The takeaway is that changes must be made to get patients on board with their own treatments.
Steps to Improve Communication
Here are four concrete steps to begin practicing today.
1. Listen. One of the most common complaints of patients is that HCPs did not listen to them. Nowadays many HCPs are typing away in the electronic medical record rather than actively listening to the patient. Be aware if you are doing this.
2. Simplify medical terms. Talk in a language that the patient can easily understand.
3. Use a teach-back method of education. Ask the patient to repeat back to you what you have told them to be certain they understand.
4. Understand the patient experience. Most patients are scared, in pain, frustrated, tired, and angry or some combination of these emotions and more. Be empathetic. If you are burned out and have lost your empathy, be honest with yourself and understand it might be time for a break or a new direction. Most of the time in litigation, blaming the patient is not a successful tactic. A better tactic is to have happy patients who feel the medical community served them well and who do not feel the need to consult an attorney. If you want patients to follow your instructions, they must trust you and your advice. Open, honest, effective two way communication is the place to start.