Noncompliance

[Twinmom06, ASN, APN]

How do your outpatient clinics handle non compliance? As in missing treaments or coming off early AMA? Do they shift the patient to a less desirable time slot or make them sign a contract before dismissing them or finding them another clinic?

I do inpatient acutes and we have one pt in particular that just simply doesn't go to his OP clinic. This pt comes to the hospital about weekly at this point, having been discharged a week prior after 3 or 4 treatments in succession, then just doesn't go for a myriad of "reasons". Then a week later shows back up in the ER with a K+ of 7 or higher and fluid overloaded to the tune of 5+ kg. Amazingly enough, neither the clinic nor the doctor have dismissed. Do you see many patients like this (or am I the only lucky one)?

[AngelKissed857, BSN, RN]

While this is very frustrating, this patient is an adult, and gets to make these decisions. In my practice, I would sit down with patient and our social worker, and really educate patient on how this impacts not only his health now, in the future, but also his transplant list eligibility. I'd include the social worker to help determine if anything is getting in the way of him making his appts, maybe we can help with it. Our social worker is incredible, has resources up here sleeves to help with almost any situation. Dismissing the dialysis patient is almost never an option.

[Chisca, RN]

At least some part of "non compliance" may be untreated mental health issues. If the voices in your head are telling you not to go to dialysis are you going to argue?

[AlabamaBelle]

We have a few "frequent flyers," but for some of them it's a function of ESRD and the co-morbidities. I do know of a large acutes program that acts as the chronic for several patients. They have been dismissed from their respective clinics.

For the type patient you are addressing, we just do the acute dialysis and know that it won't be long before we'll see them.

I think Chisca brings up a great point of mental health issues. I think mental health should be addressed more aggressively than it is. In all areas of chronic issues, mental health should be given a higher priority than what I currently observe.

[Twinmom06, ASN, APN]

We have a few "frequent flyers," but for some of them it's a function of ESRD and the co-morbidities. I do know of a large acutes program that acts as the chronic for several patients. They have been dismissed from their respective clinics.

For the type patient you are addressing, we just do the acute dialysis and know that it won't be long before we'll see them.

I think Chisca brings up a great point of mental health issues. I think mental health should be addressed more aggressively than it is. In all areas of chronic issues, mental health should be given a higher priority than what I currently observe.

They've done psych evals in the past on this patient, and its amounted to nothing. One of the docs (is on the 3rd renal practice in the area) actually thought the pt was trying to commit "medical suicide" but again nothing comes of it. As far as social work is concerned, they've done EVERYTHING they can. the patient is getting weaker and weaker. Unfortunately its going to be a situation where they just don't wake up one morning...

[bugya90, ASN, BSN, LVN, RN]

I work acute renal and have known patients who were fired from outpatient dialysis clinics. Mostly due to drug use. It takes a lot of documentation for these patients to be fired and the legal team gets involved with it. Acute care we have to treat them so what it turns into is the patient being constantly admitted for dialysis due to overload since they can no longer go to the clinic for outpatient treatment. It's a vicious cycle

[Neats, BSN]

Working for an Insurance Company I see a lot of documentation, daily. I see patterns easily when it comes to the documentation. In my mind patient non-compliance is not an unusual occurrence. The only time I see patients being "cut" from their provider are when it is real apparent this patient will be non-compliant with everything i.e. I had a patient who would not respond to their home health nurse or therapist. After several attempts being made to assist the patient the patient just refused. The provider spoke to the patient and they told the provider to "go away". Most providers will keep the patient as long as they go to their follow up appointments, the treatment plan does change however to reflect "a more palliative care approach", if you will in that, the provider expects no change, they are just monitoring the patient.

I see patients that have direct family members with the same kidney disease but this is not enough to alarm them, people just live their lives the way they want to. I am considered overweight (by about 40 pounds) but continue to enjoy food.

I am not sure if there is anyway this can be stopped. I do not know if I would schedule the patient with different time slots "to make them think" about what they have done but I would certainly say to them we can schedule your first 4 at this time and then we need to schedule your 5th visit at this time. Let them know there are patterns emerging and show them their schedule...on the 5th time slot I would say look you are at prime time and you always seem to have a challenge as to this 5th visit, we can schedule you at a time where if you are a no show it will not affect us so much, would you consider this time? I see nothing wrong with this and I would think the patient maybe grateful to this as well.

I think chronic care patients have difficulty because the only life style change they have made is to accommodate what they think have to do when it comes to their disease. We do not focus on the whole person, we focus on the disease itself. The patient focuses on their disease itself and makes decisions based off of how they feel, it is all behavioral based, they need to be educated about the "why" this should be the focus not the disease. We need to do a better job about investing them in the treatment decision making, about their education/investment give them home work to do and make it fun...

...our approach in that the medical arena will fix you is all wrong.

[rizahawkeye, BSN, RN]

I am a Clinical Coordinator in a chronic dialysis setting. It's impossible to involuntarily discharge a patient due to missed treatments and signing off early. The Network will say no to this no matter the reason is, unless there is an obvious mental health issue. But if this patient is an adult, lucid and can make his/her own decisions, there is no way this patient is getting out of your clinic. This is where the interdisciplinary team comes and talks to the patient. The Charge Nurse, The Social Worker, The Dietician, the facility manager, and the MD. Always invite the patient for counseling/family meeting. Involve the family if possible. Talk about the patient's labs as a result of the missed treatments, the risks he puts himself each time he does this. His transplant status (if candidate or a possible candidate). The thing is, we can never stop educating this non compliant patients. DOCUMENTATION is the key. No matter how non compliant the patient is, if you do your part and your documentation, then you are secured to know you give it your best in educating the patient.

[rizahawkeye, BSN, RN]

Usually, the most compliant ones are in the first and second shift. I have encountered patients in the past that were put on 3rd shift from 1st or second shift due to missed treatments. Each patient's non compliance could be actually situation-specific. So, it is imperative to extract from the patient what are the reasons for missing treatments and try to solve those.