Re­spect­ing a pa­tient’s de­ci­sions

Los Angeles Times - - Health - Steve Dud­ley

I saw Mar­garet re­cently. I was happy that she came in, as she was over­due for a visit. She is a de­light­ful, mid­dle-age-woman who has been on the re­ceiv­ing end of more than her fair share of health prob­lems, in­clud­ing high blood pres­sure, di­a­betes and gout.

It’s that pesky gout that trou­bles her the most, and the rea­son why she popped into my of­fice. She had re­cently suf­fered an­other at­tack at the base of her big toe, and boy did it smart. Stoic by na­ture, she re­ported that it was “a lit­tle painful.” A lit­tle painful?

Af­flicted in­di­vid­u­als usu­ally liken the ex­pe­ri­ence to hav­ing a baby in your big toe, or hav­ing your foot smashed re­peat­edly with a sledge­ham­mer, or walk­ing on red-hot coals. I’ll say it’s “a lit­tle painful.”

I asked Mar­garet if she was tak­ing her medicine to pre­vent on­go­ing attacks. She was eva­sive and in­stead coun­tered with the fact that she was watch­ing her diet. I sur­mised that she didn’t want to dis­ap­point me by ad­mit­ting that she had ne­glected her pills. Of­fer­ing her a way out, I asked if her pre­scrip­tion had run out. She dodged again, telling me that her toe was a lit­tle bet­ter and that yes­ter­day was much worse.

Oh, Mar­garet. As Sgt. Joe Fri­day used to say, “All we want are the facts, ma’am.”

Flip­ping through her chart, I found a note from her car­di­ol­o­gist. As is com­mon among those of us in the med­i­cal pro­fes­sion, he had made a mas­ter prob­lem list of all the things that were wrong with her. There they were, neatly de­lin­eated in de­scend­ing or­der of im­por­tance (at least in the mind of the car­di­ol­o­gist): sys­tolic dys­func­tion, hy­per­ten­sion, Type 2 di­a­betes and gout, all of which I was well fa­mil­iar with.

Then, at the bot­tom, was a new en­try: “med­i­cally non-com­pli­ant.”

Now that’s an in­ter­est­ing term — non-com­pli­ant. In a nut­shell, it means that our pa­tients won’t do what we, the om­ni­scient doc­tors, tell them to do.

I sup­pose, in the strictest sense, the car­di­ol­o­gist was right. Mar­garet would let her car­diac med­i­ca­tions lapse, for shame. She didn’t ex­er­cise enough, more shame. She hadn’t lost weight, shame, shame, shame. And yes, in the case of gout, she had stopped tak­ing her med­i­ca­tion.

Last sum­mer, I had asked her to re­turn in three months for a recheck. It had now been nine months, and the only rea­son she was here in my of­fice was be­cause she was in pain — not be­cause she had any de­sire to wipe that “non-com­pli­ant” la­bel off her prob­lem list.

But I ob­ject to that whole line of think­ing.

For starters, who’s in charge here, the doc­tor or the pa­tient? Some of my col­leagues may dif­fer with me, but in my mind, the pa­tient is in the driver’s seat. I see my role as that of a con­sul­tant, of­fer­ing ad­vice and as­sis­tance to those who seek it. But in the fi­nal anal­y­sis, the pa­tient gets to de­cide whether to ac­cept or re­ject it. I can be em­phatic, force­ful — even an­i­mated at times — but in the end, if a pa­tient doesn’t take her med­i­ca­tion or get a needed test, that is a de­ci­sion I must re­spect.

The rea­sons are many. Per­haps the drugs are too pricey and the pa­tient is em­bar­rassed to ad­mit that fi­nances are a prob­lem. Some­times the drugs cause un­pleas­ant side ef­fects. Of­ten, it is tough to per­suade a pa­tient that they need a drug to head off a prob­lem they don’t even have. And some peo­ple just don’t like to take pills.

I wouldn’t say that these pa­tients are non-com­pli­ant. They have reached a de­ci­sion based on val­ues known only to them.

The “non-com­pli­ance” la­bel re­flects a very au­thor­i­tar­ian ap­proach to the doc­tor-pa­tient re­la­tion­ship. It pre­sumes that I am in con­trol, and it’s up to the pa­tient to toe the line. It’s not a role that I’m com­fort­able with. What is more im­por­tant to me is to try to fig­ure out the “why” be­hind the non-com­pli­ance.

To this busy car­di­ol­o­gist, how­ever, it was eas­ier to tack an­other line on the mas­ter prob­lem list.

I still don’t know why Mar­garet takes such se­ri­ous health prob­lems so lightly. But with each visit, I try to probe a lit­tle deeper.

As my visit with Mar­garet wound down, I spoke, yet again, about the na­ture of gout and how she may be able to pre­vent fu­ture attacks. She smiled and nod­ded, even ac­cepted the pre­scrip­tion from my out­stretched hand. She told me she’d be back in a few weeks for a checkup and some lab tests. I of­fered my words of en­cour­age­ment as she shuf­fled down the cor­ri­dor, then re­flected on the en­counter I had just had.

It’s my job to ed­u­cate and be a health re­source. I hoped that I had done that with Mar­garet, at least a lit­tle bit. Time will tell. I sus­pect I’ll see her again next Fe­bru­ary.

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