Nancy Collins, PhD, RDN, LD, FAPWCA, FAND
The battle between optimal medical care and patient rights is one to fight with empathy and finesse to keep it out of the courtroom.
I recently reviewed a lawsuit filed by the family of a patient* with a spinal cord injury. The patient was involved in a car accident and sustained multiple traumatic injuries. The medical team worked tirelessly over the course of many weeks to stabilize him. Because of this catastrophic accident, the patient was understandably quite devastated and depressed. He refused all physical therapy and spent most days lying in bed on his back, despite encouragement from his medical team and pleading from his family. He frequently stated that he wished he was dead and that he wanted everyone to leave him alone, often escalating things to the point of screaming.
Before long, he developed a large sacral pressure ulcer and bilateral heel ulcers. Over the next several months, this led to an amputation and ultimately the patient died. While these are extremely brief highlights of a complex medical journey, the situation raises some valid questions because it pits optimal medical care against patient rights. Which one wins out? In this age of health care choice and competition, we are told the patient is our customer. If that is true, is the customer always right?
#1 Rule: Relieve Pressure
One of the most fundamental prevention and treatment principles for pressure injuries is to relieve pressure. We do this by frequently turning and repositioning patients. We routinely use pillows, wedges, and/or padding to keep patients in the new position and keep them comfortable. But no matter how comfortable we try to make patients, inevitably some of them refuse to stay off the affected area. This may take the form of an outright refusal to allow the moving when it comes time for repositioning or a more subtle refusal by allowing the repositioning but then returning to the original position as soon as the health care practitioner (HCP) leaves the room.
In the care setting, we respect a patient’s right to refuse treatment. We cannot force a patient to turn and shift. If the patient does not want to cooperate, we may encourage, plead, cajole, or even use scare tactics to increase adherence. Ultimately, it is the patient’s right to refuse. This sometimes is the end of the story…until a lawsuit is filed and the fact the patient was not turned becomes a real sticking point.
He Said, She Said Arguments
When situations like this happen, no matter the outcome of the case, no one wins. The plaintiff alleges that the HCPs caused the pressure ulcers by not turning their loved one. The HCPs protest that they tried to move the patient, but their loved one was uncooperative. You can feel the family’s pain and anguish over their loss. “Why didn’t you try harder?” their eyes beg to know. The defense team insists every protocol and policy was followed. Most cases eventually will hash out an out-of-court settlement, but there is no meaningful resolution for either the family or the hands-on caregivers involved. However, we can learn from this and, hopefully, lessen the number of times similar situations occur in the future.
Strategies for Dealing With Nonadherence
Nonadherence with medical advice is here to stay. Whether it is the patient with diabetes who refuses to make any dietary modifications, the patient who doesn’t want to take her pills, or the patient who refuses repositioning, HCPs always will need to deal with nonadherence.
Here are ten tips to use when confronted with this:
- Show empathy. Understand how patients feel and that this is hard on many people. The loss of control often is frightening.
- Don’t dictate. Rather than making closed statement like, “We’re going to turn you now,” say something like “You probably will feel more comfortable if I could get you in a different position. Would you like me to turn you now?”
- Get to the root cause. Ask questions about why the patients are refusing. Most patients have some reason why they don’t want to comply. In our example, the patient was severely depressed, and it was necessary to address the depression.
- Get a second opinion. Ask patients if they would like a second opinion on the matter. Sometimes, patients need to hear it from a second HCP to believe it.
- Don’t take it personally. A refusal of treatment is not a personal affront, so don’t take it that way. Keep your emotions out of it.
- Try for small steps. If patients won’t do everything you want, try to get them to do one small thing. Any movement in the right direction is positive.
- Educate about the facts. Most patients consult Dr. Google and feel they have an understanding of the medical facts of their condition. In truth, most need education.
- Act nicely. As the saying goes “you can get more bees with honey than you can with vinegar.” Patients tend to cooperate more with people they like.
- Consider patients as part of the team. Before setting a plan into place, make sure it conforms to the patients’ goals and wishes.
- Document, document, document. Make sure you have a complete medical record.
*Some patient details were changed to protect the identity of the patient.
Nancy Collins, PhD, RDN, LD, FAPWCA, FAND, is a registered dietitian with expertise in wound care, malnutrition, and medico-legal issues. Dr. Collins strives to improve patient outcomes and patient satisfaction through better communication. To contact her, visit her website, www.drnancycollins.com.