The ethics of cost for cure vs noncompliance.

[dudette10, MSN, RN]

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?

[blondy2061h, MSN, RN]

Who would be paying for this treatment? I wouldn't be surprised if they make him jump through hoops. It seems if he could do a 24 week treatment and be done and healthier it's worth it. I wonder if counseling or something like that might help his compliance?

[imintrouble, BSN, RN]

Don't those receiving organ transplants have to demonstrate a willingness to comply with treatment before a transplant can procede?

Is that because the transplant is costly? Or is it because there aren't enough organs? Or is it both?

I'm going out on a limb, but I would be in favor of restricting treatment for patients who are of sound mind, and refuse to participate in their own health care. If sounds brutal, but why waste millions of dollars on people who themselves don't care if they live or die?

If we can do it for transplant patients, and nobody thinks that's wrong, why not for the patient who is chronically noncompliant?

I've already thought of an example patient to test my resolve..

The COPD er who just can't get off the cigs. Multiple drugs, therapies, and family interventions have failed to help them stop smoking. THEY JUST CAN"T QUIT. Do we stop admitting them to the hospital and let them die?

It's not an easy question.

[tarotale]

I remember two theories of resource utilization from ethics class during nursing school, don't remember their names but one was about being benevolent and the other being practical. I'm all the way for what you reap, what you sow, so believe that the non-compliant should be given no eternal second chances wasting our valuable tax money that can go to helping people who will comply.

[dudette10, MSN, RN]

Interesting viewpoints, and as in most ethical situations, there really isn't a "right" or "wrong" answer...there's just an answer that more people are ok with. I don't know the answer myself, but your thoughts on it are appreciated. I'm still mulling it over, of course.

[Ruby Vee, BSN]

Don't those receiving organ transplants have to demonstrate a willingness to comply with treatment before a transplant can procede?

Is that because the transplant is costly? Or is it because there aren't enough organs? Or is it both?

I'm going out on a limb, but I would be in favor of restricting treatment for patients who are of sound mind, and refuse to participate in their own health care. If sounds brutal, but why waste millions of dollars on people who themselves don't care if they live or die?

If we can do it for transplant patients, and nobody thinks that's wrong, why not for the patient who is chronically noncompliant?

I've already thought of an example patient to test my resolve..

The COPD er who just can't get off the cigs. Multiple drugs, therapies, and family interventions have failed to help them stop smoking. THEY JUST CAN"T QUIT. Do we stop admitting them to the hospital and let them die?

It's not an easy question.

Most hospitals where I have worked only do a cursory check for compliance before Oking a transplant. There can be documented compliance issues over and over and they'll still transplant the patient because "he promised he'd do better." Active smokers have been given heart or lung transplants because "he promised he'd quit." An active IVDA-er was transplanted because "We translanted a male with this issue, it's gender bias if we don't go ahead and transplant HER despite this problem." A hospital where I've worked in the past transplanted illegal aliens, even though one of the boxes to be checked off before transplant is "no pending legal issues."

Health care in this country costs more than anyplace else in the world. (Or near enough as to be a real problem.) Part of it is because we don't deny anyone anything regardless of ability to pay.)

The Crushing Cost of Health Care - WSJ

This is an enlightening article!

[tarotale]

Most hospitals where I have worked only do a cursory check for compliance before Oking a transplant. There can be documented compliance issues over and over and they'll still transplant the patient because "he promised he'd do better." Active smokers have been given heart or lung transplants because "he promised he'd quit." An active IVDA-er was transplanted because "We translanted a male with this issue, it's gender bias if we don't go ahead and transplant HER despite this problem." A hospital where I've worked in the past transplanted illegal aliens, even though one of the boxes to be checked off before transplant is "no pending legal issues."

Health care in this country costs more than anyplace else in the world. (Or near enough as to be a real problem.) Part of it is because we don't deny anyone anything regardless of ability to pay.)

The Crushing Cost of Health Care - WSJ

This is an enlightening article!

Love your post! Exactly what I think. It's engraved in this culture that Healthcare is a right. Choice to live healthy is a right, but Healthcare is a privilege, a service which is bought with monetary responsibilities. Yes we should help some indigent as a society but when that goes beyond normal spectrum, we get this.

I'm curious whether or not this is due to the "stupid American syndrome". While the world thinks Americans are stupid and I agree this country holds proportionately more idiots than other countries, but would other 1st world countries whose people we deem "more with common sense" for example, Germany, Sweden, Norway, or Japan have similar problem due to noncompliance to this severity? Or do we as country just hold more dumb people making dumb decisions therfore affecting Healthcare even worse, or is it all just stemming from the fact that we are "too benevolent" to the freeloaders (frequent flyer, welfare milker, etc) ??? I don't know, working in healthcare really makes one exposed to how stupid people can be on daily basis.

[imintrouble, BSN, RN]

Most hospitals where I have worked only do a cursory check for compliance before Oking a transplant. There can be documented compliance issues over and over and they'll still transplant the patient because "he promised he'd do better." Active smokers have been given heart or lung transplants because "he promised he'd quit." An active IVDA-er was transplanted because "We translanted a male with this issue, it's gender bias if we don't go ahead and transplant HER despite this problem." A hospital where I've worked in the past transplanted illegal aliens, even though one of the boxes to be checked off before transplant is "no pending legal issues."

Health care in this country costs more than anyplace else in the world. (Or near enough as to be a real problem.) Part of it is because we don't deny anyone anything regardless of ability to pay.)

The Crushing Cost of Health Care - WSJ

This is an enlightening article!

I've taken care of transplant patients, but have never worked in a facility where they were performed. The patients where I work are rigid about taking their transplant meds.

Your post was an eye opener. I honestly thought people were turned away because they were noncompliant.

I don't necessarily think people should be denied care based on if they can afford it or not. But I do believe there should be a cap on how much money we squander on people who just won't take care of themselves.

[imintrouble, BSN, RN]

Love your post! Exactly what I think. It's engraved in this culture that Healthcare is a right. Choice to live healthy is a right, but Healthcare is a privilege, a service which is bought with monetary responsibilities. Yes we should help some indigent as a society but when that goes beyond normal spectrum, we get this.

I'm curious whether or not this is due to the "stupid American syndrome". While the world thinks Americans are stupid and I agree this country holds proportionately more idiots than other countries, but would other 1st world countries whose people we deem "more with common sense" for example, Germany, Sweden, Norway, or Japan have similar problem due to noncompliance to this severity? Or do we as country just hold more dumb people making dumb decisions therfore affecting Healthcare even worse, or is it all just stemming from the fact that we are "too benevolent" to the freeloaders (frequent flyer, welfare milker, etc) ??? I don't know, working in healthcare really makes one exposed to how stupid people can be on daily basis.

I don't agree with your "stupid" theory. Patients are noncompliant for a variety of reasons, with stupid being way down on that list.

If you want to think noncompliance automatically = stupid, that's ok, but I don't think it's that simple.

I have a patient who has a chronically ill daughter who we admit frequently. The mother gives her meds to her daughter who can't/won't pay for her own.

I guess you could say the mother's choices are stupid, but I'm not sure I wouldn't do the same thing.

A 400 lb man who's so depressed about being 400 lbs, he just continues to eat himself fatter. Of course he has every health problem r/t to his obesity and he's an inpatient at least twice a month.

Is he stupid? No. We just can't fix the real problem.

I agree with most of your post. Be prepared, it's not a popular position.

[RNperdiem, RN]

I don't agree with "stupid" either. The USA is both first and third world. IMHO, any country that has been touched by a history of slavery will be at least partly third world.

There is a lot of relative poverty and a certain mindset that goes with that. Noncompliance is a symptom of a poverty mindset.

[elkpark]

Most hospitals where I have worked only do a cursory check for compliance before Oking a transplant. There can be documented compliance issues over and over and they'll still transplant the patient because "he promised he'd do better." Active smokers have been given heart or lung transplants because "he promised he'd quit." An active IVDA-er was transplanted because "We translanted a male with this issue, it's gender bias if we don't go ahead and transplant HER despite this problem." A hospital where I've worked in the past transplanted illegal aliens, even though one of the boxes to be checked off before transplant is "no pending legal issues."

Health care in this country costs more than anyplace else in the world. (Or near enough as to be a real problem.) Part of it is because we don't deny anyone anything regardless of ability to pay.)

The Crushing Cost of Health Care - WSJ

This is an enlightening article!

I work for the psych C&L service of a large, urban academic medical center, and we are directly involved in the large, busy transplant service here. Our transplant service requires that people be clean/sober from whatever they were using, and completely compliant with all recommended medications/treatments for six months to a year (depending on the individual circumstances) before listing people for organs.

Of course, that's no guarantee that people won't relapse or backslide after they've gotten a transplant (and we see that sometimes in our service). But there are programs that have strict standards ...

[classicdame, MSN, EdD]

the example does not really have to be that extreme. I am a diabetes educator and have people tell me all the time they cannot afford their insulin or strips. Many, however, are carrying cell phones and smoking cigarettes, but the point is, they made the choice. I am for autonomy.