The ethics of cost for cure vs noncompliance.

[dudette10]

This is just a hypothetical discussion, but we all know the scenario is all too real.

Let's say you have a patient whose Hep C is causing kidney and heart problems. There is now a cure for Hep C, but it is very costly, and the patient must take the med along with others religiously to be effective. You are the nurse for the patient, and you are overhearing the conversation between the docs and the patient about the new medications that they are on. The patient tells the docs, "Oh, yes, I will take them!" However, in the three days that you've had the patient, the only med he has taken--and actually asked for on time--are the narcotics. All other meds, including lasix, the patient initially refuses, and you spend much time educating and persuading the patient to take them. With the docs in the room, you say to the patient, "Are you sure you are going to follow the medication plan? You have tried to refuse all your meds every time I've administered them to you." You do it because you want the docs to be aware that there is an issue with noncompliance.

The docs are thinking of prescribing Sovaldi to cure the Hep C in order to address some of the kidney and heart problems too. You are convinced that the patient will not follow the strict medication regimen for Sovaldi, and you also know the cost of the full treatment can be more than $150k.

Two questions: what would you do to help ensure that, if the patient is prescribed Sovaldi, that he will be compliant?

Also, a more philosophical question: if there is evidence of noncompliance with medications, SHOULD a patient be prescribed a very costly medication that can cure them, but probably won't due to the chronic noncompliance?

[monkeyhq]

As the old saying goes, you can lead a horse to water...

As an individual, it is frustrating that the cost of care is out of control and that some medications are abused, not used, or wasted by some people. But that is only part of the problem. The cost of HC in the US is astronomical in comparison to other industrialized nations. Our system does not negotiate for the best rates on supplies, prescription medications, etc. Most other nations do, and their costs are measurably lower. Much lower. And they also have non-compliant patients.

Americans do not have equal access to the full range of healthcare services offered in this country. Many generations have been raised without medical or dental care, or have not had equal access to quality education, quality foods, or quality support services. This, combined with other cultural and socioeconomic factors, results in the patient that is sitting in front of you who won't take their meds. And even those who have had access to everything, and have enjoyed the benefits of prosperity, will sometimes be non-compliant with their meds. I am certain that psychology and denial have a great deal to do with it.

Every individual must be free to make their own choices about their health and their body. My job as a nurse is to teach. If there are resources available to help with compliance, such as social services/psych services, it is my job to help with the referral. What the patient does with the teaching and referrals is up to them, and I would not support withholding medications. The patient may get an 'ah ha' moment, and if they have a condition that requires medication, the condition itself will force their hand, or take their life. My job is to try to convince them to take the better path.

Diabetes is a great example. So is heart disease, or lung disease (and a host of other conditions). Exercise, nutrition, stress management, medication, lifestyle (no smoking, no drinking), etc., are all components of managing health. How many of us in the nursing profession even meet the ideal standard for our own lives?

Organ transplantation is a different story. The ability to take daily anti-rejection medication for the rest of your life is key in a health area where the supply never meets the demand. I think that is an entirely different issue than the one proposed by the OP.

[TU RN, DNP, CRNA]

I can't help but feel that the noncompliant are a drag on healthcare. As classicdame said, people who often have the means to pay for medication are also noncompliant for their own reasons. They are autonomous adults afterall. But how many times are they noncompliant to the point of crisis, and then requiring utmost (expensive) care to correct the issues? This guy is hypertensive, doesn't take any medication, and lives with a MAP at 115-130 for weeks until he has a headache and comes in. MDs and RNs work for days trying to find a regimen that works for his resistant HTN, only for him to be noncompliant when discharged. Some weeks later his kidneys start to fail. Weeks after that he's on dialysis.

A preventative approach would've saved money and hospital resources if the patient had - sorry for this - the good sense to do what's right for their health. In the meantime somebody who needs and wants care suffers. And why would a patient noncompliant with medication regimen be compliant with a health insurance payment, no matter how affordable? Hence, the noncompliance issue becomes a perpetual expense on the tax base. And for what? Some desire to be autonomous? A power struggle with a healthcare "authority" that an ignorant individual views to be a power apparatus? Or are they slaves to a culture that has taught them that superficial beauty and consumerism take precedence?

Jeez I don't know the answer to the problem, but thinking about it too much makes me feel very Darwinist so I digress.