Managing differences: care and compliance
Summary: This factsheet reviews your options and responsibilities when you have a patient who does not accept your advice or refuses to follow your recommended treatment.
Monday, 9 March 2020
- Patients have the right to choose or refuse treatment.
- Provide adequate information and understanding to support and help the patient make a responsible choice.
- If the patient chooses to act against your advice, determine the best way forward for the therapeutic relationship.
Doctor vs patient: How far do you go?
At some stage you will encounter patients who do not follow or accept your recommended treatment. This may be through simple inaction, such as patient who does not attend for a test or take medication, or a patient may elect to continue with treatment you believe is of no benefit or may even be harmful such as some alternative treatments and supplements.
A fundamental principle of medical care is that a patient with capacity has the right to choose – or refuse – treatment. On the other hand, you are under a legal and ethical obligation to act in the patient’s best interests and to exercise reasonable care and skill in the provision of medical advice and treatment.
These two principles can collide and require balanced judgement and an individual approach. However, there are some strategies that may help you navigate these challenging scenarios when they arise.
Concerns regarding patient compliance
The principle of patient autonomy means it will always be the patient’s choice whether to accept or continue with particular treatments, provided they have relevant decision-making capacity. Your role is to ensure you have done enough to provide the patient with all the information and understanding they need to make an informed decision.
If you are concerned that a patient will not comply with your management advice:
- reiterate the information about your recommendations
- include the potential risks and benefits for your recommended treatment
- outline reasonable alternative management plans that you are prepared to provide
- explain why you consider your recommended plan is preferable.
- discuss the risks and implications of not following through with treatment.
Once you have provided the information, set the expectation for what you would like the patient to do and be clear with your recommendations. It is important not to be ambiguous or vague. Be clear, firm and offer distinct options making it clear why you think your recommended plan is in their best interest.
There are many reasons why a patient may continue to refuse a certain course of management or not follow through on agreed treatment. Understanding what lies behind their decision is a valuable tool in providing the necessary information or reassurance to allow the patient to make an informed choice.
For instance, the patient who repeatedly does not attend for testing may initially tell you it’s because they are simply too busy. However, if you explore more deeply, they may actually mean they don’t understand the significance of what they may be facing or the importance of the recommended management.
Sometimes, patients are simply overwhelmed by the enormity of complex treatment. By breaking it into small steps and explaining what to expect at each stage, you may encourage the patient to agree to at least some preliminary stages before making any further decisions.
Patient-centred care or respect for patient autonomy does not mean you cannot attempt to influence patients to accept your advice.
Listen to the patient, explore their concerns and put forward your own concerns. Do not be afraid to be direct in your approach as long as you remain respectful of the patient and their views. For instance, say “I’m concerned that if you do not do X now, Y might happen", or voice your concerns about the patient’s preferred treatment, explaining why you do not believe it will benefit them or may even harm them.
To persuade the patient to reconsider their options you could:
- ask them to return for a second appointment to give them some time to think things over
- supply further information for the patient to take away and read
- consider advising them to seek a second opinion.
You may wish to seek permission from the patient to discuss your concerns with their family members and involve them with the discussion. A collaborative approach to treatment will provide for better care and support for the patient. However, disagreeing with the patient’s choices is not a reason to breach your obligation to maintain privacy and confidentiality.
You have a professional obligation to act in the best interests of your patient according to your professional opinion. While the decision may rest with the patient, you have a duty to provide views and recommendations based on what you think is best for the patient. Always keep the focus on the patient’s own wellbeing and best interests.
Ultimately you can give the patient advice but it is their call whether to follow it. They can make a decision you do not agree with so long as they are fully informed.
Depending on your perception of the likelihood that the patient will not comply with your management plan and your assessment of possible harms that may result, you may decide to decline to treat the patient or refer them to another doctor who may better engage with them.
Despite a patient’s initial non-compliance you should strive to maintain the relationship. Leave the patient with the recommendation to come back and see you again, for example "I want you to come back and see me in xx time frame".
Ending the relationship
In some situations, it may be necessary to terminate the patient/doctor relationship. However, whether this is appropriate and how it is done needs to be carefully considered.
It is never ideal and almost never appropriate to terminate the therapeutic relationship during an acute illness or where there are no reasonable alternatives for the patient’s ongoing care. You are always required to act in an emergency even if you had formally ended your relationship with that patient.
When making the decision to terminate a doctor/patient relationship consider first discussing it with senior colleagues or Avant. Further information is available in our factsheet: How to end the doctor-patient relationship
Good documentation is essential when there is difference in your views and those of the patient, or when a patient makes decisions against your advice.
Document the discussions you have had with the patient, any concerns expressed, advice given, risks discussed and any other information provided. Clearly record your advice to the patient and, if the patient is choosing to act outside of this, the discussions you had with them about their choices.
No two situations are the same, just as no two patients are the same. Negotiating the best care for a patient and deciding how to manage a patient who acts against advice will always require your professional judgement on an individual case basis. However, you are not alone in navigating these difficulties and seeking the support of colleagues or Avant is highly advisable.