_________________________________________________________________ Managing Disruptive Patients
The Patient Who Signs Out Against Medical Advice Leaving the hospital against medical advice (aka AMA) may be an extreme example of nonadherence. It is rarely a spontaneous act. There are often warning signals or repeated conflictual interactions with staff members before the patient actually signs out of the hospital. Healthcare professionals and physicians react strongly when a patient leaves against medical advice. Healthcare providers may attempt to cajole or coerce the patient into staying, since there are often concerns about the patient’s safety and the providers’ obligations to the patient. Healthcare professionals may also feel a personal failure when a patient’s choice is to leave against medical advice. Patients should be free to leave against medical advice as long as they are competent and not endangering their lives. It is not appropriate to medicate a patient who is nonpsychotic and threatening to leave against medical advice. Using drugs as chemical restraints in this manner is battery from a legal standpoint. RISK FACTORS Nonadherence has meaning in the patient’s life. The health- care professional must be able to assess the patient’s situation carefully in order to understand this meaning. In this way, the healthcare professional can uncover and deal with obstacles to adherence. Patients’ individual characteristics and living conditions will influence the likelihood of their being com- pliant or noncompliant. For example, if the patient’s home has no running water, then maintaining cleanliness will be more problematic for them than it will be for someone living with modern plumbing. Knowledge of risk factors can help healthcare professionals be more aware of the possibility that patients may have difficulties following their treatment plans. This knowledge is most helpful when it is used to prevent possible problems with compliance. PSYCHOLOGICAL AND COGNITIVE RISK FACTORS The most important psychological risk factors include the following: • Cognitive abilities • Mental status • Denial and anxiety
At times, however, patients may be caught in a frustrating con- tradiction between the issues of adherence and competence. A patient may refuse a treatment recommendation. Healthcare professionals may label the patient incompetent because of the refusal. In this situation, a cognitively capable patient has made an informed decision. However, because the patient has made the decision, which opposes that of the treatment team, healthcare professionals view the patient as incompetent.
SPECIAL CASES Rights of Women Who Are Pregnant
Pregnancy offers a unique slant to the issue of patients’ rights. For some people, the fact that the fetus is affected by the mother’s behavior alters the mother’s right to personal free- dom. The legal system has increasingly over-ridden the right of the pregnant mother to disregard medical advice. The legal basis for these decisions is weak. However, societal support for protecting the unborn fetus can result in a disregard for the rights of the pregnant woman. The ongoing debate over the rights of the unborn fetus versus the rights of the mother evokes intense emotions on both sides of the issue. Withholding Nutrition There is little consensus on the ethics of withholding or with- drawing nutrition from patients. When a patient chooses to refuse nutrition, it is often difficult for healthcare providers to honor this wish. Healthcare professionals may be concerned about participating in behavior that will lead to hunger or thirst in the patient. The American Nurses Association (2017) maintains the position that the decision to withhold artificial nutrition and hydration should be made by the patient or the patient’s surrogate after consultation with the healthcare team. In some ethical deliberations, a distinction is made between allowing a patient to die and killing a patient. The difference lies with the intent of the actions. Nutrition may be withheld on the premise that, if given, it will prolong life and thus pro- long suffering. This is different from starving a patient with the intent to kill them. Others argue that the finality of the act of withholding nutrition makes the act untenable. It is imperative that every healthcare professional be familiar with the legalities surrounding the patients’ right to refuse treatment. They should find out if there are advance directives that have addressed this issue. In addition, careful thought concerning the healthcare professional’s ethical position on these issues is necessary. The answers are not always clear in the increasingly complex environment of healthcare today. Although it may be difficult for healthcare professionals to act on patients’ wishes that are contrary to their own beliefs, they are usually mandated to do so by the policies of the institution where they work. Although they may be free to operate on their own principles and beliefs, they should be fully aware that by doing so their job might be in jeopardy in some situations.
• Addictions • Depression • Past experiences
Psychological and cognitive factors influence adherence to treatment. To be able to comply, patients must understand the information presented to them. Teaching should be brief and focused. Complex information should be broken into smaller and more understandable parts whenever possible. It is helpful to simplify teaching material as much as possible. Use
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