The Present-Oriented Patient

Even though the telephone conversation took place more than four years ago, I remember the details with striking clarity.

My best friend, who was working as a nurse at a county-owned clinic in a low income area at the time, called me to talk about a patient she had seen that day. The patient, a pleasant African-American female in her late forties, visited the clinic for treatment of poorly controlled hypertension and type 2 diabetes.

"I wake up some days and I just don't feel like taking my medicine," the patient chimed with a very matter-of-fact tone of voice. "I just don't want to take it."

The youngish internal medicine physician responded, "Your fasting blood sugar is 260 and your blood pressure is really high. High blood pressure and diabetes are two diseases that will kill your kidneys if left uncontrolled. You'll end up on dialysis in the distant future if you don't take your insulin and antihypertensive medications." He paused for a few seconds before continuing. "Is there a specific reason you don't want to take your medications? Are they too expensive? Do they make you feel physically sick?"

"Most of my medicines are on the $4 Wal-Mart list," the patient said. "And they don't make me feel sick or anything like that. I just don't want to take them. I don't feel like taking them."

The young doctor offered another blunt response. "Diabetes makes your blood vessels inelastic if uncontrolled. If your blood pressure gets too high, you might have a major stroke. Many people who have had major strokes are wearing diapers, have feeding tubes, and will never walk again."

The patient smiled and shrugged, seemingly unconcerned. "I just don't like taking my medicine."

Although my friend and I privately express our frustrations about patients who do not want to comply with the plan of care, we are not surprised. After all, both of our families are full of relatives who are present-oriented. My friend's mother is a present-oriented lady who lives from moment to moment. My father is present-oriented, lives for the day, and does not think much about the future. Predictably, her mother and my father have both reached upper middle age without saving a dime of retirement money or planning for the future, but they seem perfectly happy living in the 'here and now.'

And yes, the patient she saw in the clinic that day most likely had a present time orientation. According to Jenko and Moffit (2006), present-oriented individuals have difficulty incorporating the future in present-day plans. Patients with a present time orientation tend to live for the day since they believe that tomorrow is not guaranteed. Due to their minimal or nonexistent focus on the future, present-oriented people are prone to seek instant gratification and immediate pleasure without any thought on how their behaviors today will impact them in the future. These patients might not respond favorably to preventive care that focuses on preventing future health problems.

On the other hand, future-oriented people are more apt to delay gratification and engage in present inconveniences to ensure comfortable futures. These patients examine all current pursuits for any future advantages. For instance, the patient who jogs several miles every morning is participating in a time-consuming activity that some would deem grueling, but the future benefits include enhanced cardiovascular health and excellent weight control. Patients with future time orientations generally keep medical appointments, comply with the plan of care, and set up advance directives and living wills to prepare for future events.

Are there any tips on effectively dealing with present-oriented patients? Yes! Since they generally enjoy social interaction, healthcare facilities can set up inpatient or outpatient group activities such as diabetic education classes that offer prospects to socialize and learn about disease processes at the same time. Present-oriented patients also prefer instant relief when they feel bad, so this is the golden educative opportunity regarding their medications. You can inform them that their headaches might instantly ease up if they take their blood pressure medicine on time, or their edematous legs will quickly improve if they take their diuretic pills as prescribed.

Dealing with present-oriented patients requires a degree of cultural competence on the part of the members of the healthcare team, but we can effectively reach them with some creativity, plenty of patience, and the right approach.

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