3 Strike Rule: Non-Compliant Patients

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I think there should be a three strike rule for patients who are consistently non-compliant with medical advice and medications following discharge. After 3 strikes, we don't take them back.

For example, a frequent flier, non-complaint patient with alcoholism, tobacco use, COPD, and HTN, comes in at least every week for alcohol withdrawal, gets put on CIWA, gets valium, but then either leaves AMA or does not comply with medical advice or use any of the resources provided (ETOH rehab, housing, getting a PCP, medications provided thru medicaid, respiratory meds/equipment), or take any of his/her medications, or be willing to stop smoking (even with nicotine patches provided), follow up on appts, or get any help for ETOH addiction.

I think after 3 strikes of being non-compliant and showing no effort to change or take advantage of what is provided, we shouldn't take them back for the same issue.

Of course, if the patient has another unrelated, serious problem, such as broken leg, gun shot wound, stroke, PNA, etc...we should treat them.

I feel like if we keep taking these types of patients back, we are enabling their destructive behavior. They can drink and drink, run out of money, come in with withdrawal, and we basically bail them out until they recover, then they go back out and do it all over again. The same thing for dialysis patients who consistently miss appointments, eat and drink whatever they want, and then frequently come in to the hospital in crisis with a weight gain of 12lb, K of 8.5, creatinine of 5.7, and a BUN of 85.

And yes, I know this would never be a realistic idea. I know we can't refuse care to patients (and I don't treat these patients differently, just internally I'm very frustrated at their waste of resources). And yes, I know ETOH withdrawal can be deadly, I'm just very frustrated at the moment :banghead:

Specializes in Med-Surg/ ER/ homecare.

I think that for patients that are non compliant, they should receive increased insurance premiums. And this should be stated clearly as soon as one signs up for any plan.

I had a patient that was a noncompliant diabetic that constantly drank soda and ate like crap despite the doctor telling him he was going to lose his remaining leg (he already lost one) and our education about the risks. Why should an insurance company pay for treatment that isn't going to do any good because a patient insists they simply can't drink water because "it has no taste". People really need to be made accountable for their own actions.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

Oh and before anyone thinks I am on a high horse: I have STRONG and VISCERAL opinions about some patients. Some of them will push us to our very limits of patience. But like another poster said, we have to work hard to leave our judgments at the door and keep those opinions to ourselves when talking with our patients. They can pick up on our bad "vibe" and become even more difficult when we let show our disgust, annoyance and sometimes, anger, at the things they do or say. It's not easy. We have to put on a game face and do our best not to let these things show through when we are with them.

We are only human; so are they . With all the faults and warts being human brings, we see it all.

I often go home and "vent" (not using names of course) to my spouse about patients making me crazy, on many occasions. But when I step in the door to care for them, I leave it there.

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While I can understand your frustration, I have to disagree wholeheartedly with you.

I used to be a smoker, it took me SEVERAL tries to quit, I can't imagine my PCP terminating me as patient because I kept trying over and over again till I actually quit and stayed quit in 2013. The encouragement from him such as "Hey, keep trying, the great thing is you ARE trying, quit again" was actually really helpful to me. It also created a trusting doctor-patient relationship because I could tell him things without being judged.

There is no better way to turn off a patient from healthy lifestyle choices by making them feel judged by their current ones.

That attitude towards patients is really a sore subject for me because I was a GI patient for years. I made every single lifestyle change they asked me to make (I was initially diagnosed w/ IBS) but they didn't believe me because I kept getting worse. I was diagnosed with Crohn's 5 years later after I had lost 30 pounds and severely deficient in nutrients. And yes, many patients do not make lifestyle changes they need, but the point is you never know what's going on behind the scenes.

But like you said you are human and it can be a very frustrating situation to deal with over and over again. I also think it can be generational in some aspects, I see way more non-compliant patients of baby boomer age in family practice than any other age group. Obviously, you deal with more problems as you age, but those under 40 currently seem to be more receptive to lifestyle changes and hearing the hard truth of your getting sicker because of your choices and the only person who can stop it is you advice without immediately balking at the idea.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

Agreed, at least on the surface. But we all know that being human, and struggling, patients often fail to comply. Sometimes we just have to let it go and breathe. I don't think it's fair to have to continually pay to cover bad behaviors and decisions made by patients who are self-destructing and destroying their health. But still, as I said, many, many factors affect patient behaviors and non-adherence.

I think that for patients that are non compliant, they should receive increased insurance premiums. And this should be stated clearly as soon as one signs up for any plan.

I had a patient that was a noncompliant diabetic that constantly drank soda and ate like crap despite the doctor telling him he was going to lose his remaining leg (he already lost one) and our education about the risks. Why should an insurance company pay for treatment that isn't going to do any good because a patient insists they simply can't drink water because "it has no taste". People really need to be made accountable for their own actions.

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Specializes in Psych.

How unbelievably judgmental and holier-than-thou. The word ' compliant ' itself should be thrown out. It implies that we have some charge over these people, who are actually free.

Secondly, you speak as if patients just don't follow treatment plans because they're lazy, when in fact you just don't want to keep dealing with their illness. Which one is lazy?

Patients stop with treatments and meds for a MILLION different LEGITIMATE reasons that get chalked up ti being 'noncompliant.' Cost, unbearable side effects, interaction with other drugs, addiction, transportation...

Your tunnel vision is astounding. Heaven forbid you should be in a situation where you end up labeled as ' noncompliant ' because you can't afford your medicine, or your kids flushed it down the toilet and you can't get a refill because you can't get another appointment for six weeks.

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Specializes in Psych.
I think that for patients that are non compliant, they should receive increased insurance premiums. And this should be stated clearly as soon as one signs up for any plan.

I had a patient that was a noncompliant diabetic that constantly drank soda and ate like crap despite the doctor telling him he was going to lose his remaining leg (he already lost one) and our education about the risks. Why should an insurance company pay for treatment that isn't going to do any good because a patient insists they simply can't drink water because "it has no taste". People really need to be made accountable for their own actions.

If losing body parts isn't making a pt accountable, what makes you think higher premiums will?

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Do you understand why psych patiebts are some of the least to be compliant?

I'm sure Meriwhen does indeed know. She was stating a fact that they have poor compliance.

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Specializes in critical care, ER,ICU, CVSURG, CCU.

Hard to compete with "the human condition".... On a good day I may control my behavior,never been able to contro. A patient.....not really

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This is absolutely insane.

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I appreciate your frustration, but judging patients is not our job. Providing needed care is. where do we draw the line? No more care for diabetics after 3 times of elevated blood sugar? Cease care for hypertensives after 3 episodes of elevated pressure? No more pandering to pregnant women: no admissionafter 3 episodes of preterm labor, or 3 visits for false labor? yes, I am being rediculous, but I feel we need to realize that it may make 20 visits for respiratory problems before deciding, and successfully quitting smoking. If ee keep track of drug seeking frequent fliers, and they realize that you are no longer going to supply them, they will stop coming to your facility. And of course alcoholics trying to.stay sober take it one dsy at a time. sometimes they fall off the wagon. If your compassion gets him to try again, isn't that a good thing? You may not be aware of issues genetic, social, psychological that affect their willingness and ability to change. Change is very difficult for most people, even if it will be a positive thing in their lives

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No, this isn't real. Just some angry ranting. And I'm not talking about the CHF patient who eats too much salt at Thanksgiving one time and comes in with fluid overload, I'm talking about people who just don't care and take no responsibility over and over again, yet expect us to fix them so they can go back to their unhealthy habits and addictions.

And yes, I CAN judge people. I may be a nurse, but I'm still human. And spending 12+hrs taking care of a repeatedly non-compliant patient who is basically a leech on the healthcare system is frustrating. I come from a family of alcoholics, I know what alcoholism does to people. I know it is a disease, but people have to take responsibility for their health, the burden shouldn't just be on the healthcare system. When battling an addiction, failure along the way is an normal part of it. I just want people to try, even if they make mistakes. However, if someone sees no problem with their drugs or alcohol addiction, and just expect us to "fix them" over and over again so they can go back and do it again, how can I not judge?

And I know healthcare is a business, I'm reminded of that everyday at work and with my BSN courses. Yet someone has to pay for the REPEATEDLY non-compliant patient's hospital stay, maybe it was some of the tax dollars from my hard earned paycheck?

I apologize if this came off as rude, bitter, and angry. I make sure my feelings do not interfere with my patient care, which is why I need to rant here every so often. Thanks for your insight.

How do you know they're not trying between visits when you see them?

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Wow, I love reading the posts on my most controversial topic ever. It's interesting to come back and see where I was 3 months ago. Since then, I've realized that I can't change people, but I can educate and provide the best care possible, hoping that the patient will agree to go to ETOH rehab and I won't see him walking into a liquor store on my way home from work. I've learned to play the role of a caring, non-judgmental nurse, but once I clock out and get to my car, then I'm free to think and feel like a normal human rather than a robot :borg: Also, I loved reading every comment on this thread, so entertaining (and lots of great advice and support that I needed at the time). Thanks everyone!

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