The Act of Non-Compliance: Patient Control Over Illness
We rebel when we feel we are not being heard, when we want to make a point, or when we need to have control. As individuals we can create our environment. We define our boundaries and allow what is acceptable and reject what is not acceptable. Throughout our day, we are fluid as we give and take control. Every interaction is defined by our roles at work, school or in a social organization.
The fluidity of control is demonstrated by the relationship between a patient and a doctor. We seek medical attention when we are ill or injured. A doctor provides treatment and recommends care. After treatment is administered and follow-up care is recommended, the choice of whether or not to follow the doctor’s instructions falls to the patient. The doctor provides guidance but cannot force a competent patient to comply.
A colleague sought my advice regarding a patient. She wanted to know if she should compel her patient to follow her medical orders or try to reason with the patient. Her patient is resistant to receiving care at home. The patient can understand the importance of the care but refuses to carry out the treatments needed for recovery. My colleague expressed her frustration, stating that the patient could be further along in his/her recovery if he/she would follow through on the simple exercises that he/she has been prescribed to perform at home. She felt helpless and wanted to know how she could gain control over the patient’s home-healthcare.
After listening to her, I wondered if in the pursuit of recognition for patient autonomy, the knowledge doctors have is less influential Or, has the respect for patient autonomy forged a new path for patient-doctor relationships? I understand the exasperation of seeing a patient’s failure to thrive because he/she isn't following recommendations, taking a prescription, or following through on therapy. It is difficult to see someone experience a prolonged or impeded because he/she is not compliant. An essential part of patient care is to discover why a patient isn’t willing to perform the prescribed care.
Throughout my career, I have worked with patients who are compliant and those who are not. Compliance, for many medical personnel, denotes a willingness to accept treatment. Non-compliance is often attributed to a patient not having a stake in his/her recovery. However, both compliance and non-compliance are rooted in emotional responses to being ill.
Being ill is an announcement to those around us that something is wrong. Some patients view it as being weak while others see it as something to overcome. Furthermore,there are those patients who refuse to accept that they are ill. As I questioned my colleague about her patient, I realized that her patient is still in denial about his/her illness. While the patient receives the necessary care at the medical center because it will keep him/her alive, he/she does not follow through with the recommended home care because it is invasive. The act of following the doctor’s recommendations brings the illness into the patient’s home, makes it real, and takes away feelings of control over his/her environment. The patient wanted the care my colleague provided but didn’t want to bring sickness home. The patient was using non-compliance as a means of rebellion against what he/she could not control. My recommendation to my colleague was to discuss the fears and feelings the patient has about the illness and, if needed, suggest the patient talk to someone who may be able to help him/her come to terms with his/her condition. Facilitating a discussion allows the patient to regain a sense of control, while simultaneously giving the patient and the doctor a chance to strengthen their relationship.