Dealing with non-compliant patients

Dr Richard Stacey provides a step-by-step approach to dealing with patients who do not comply

It is hard to dispute the view of Beauchamp and Childress that: “Respect for the autonomous choices of persons runs as deep in common morality as any principle.”¹

A doctor’s primary concern is to do their best for their patients; this includes giving advice and treatment, and arranging investigations in accordance with the current evidence base and the patient’s best interests.

"Given that there is no obligation to provide a treatment requested by a patient that is not to their overall benefit, this can give rise to clashes between doctor and patient"

All practices will have a cohort of patients whose autonomous choices conflict with the suggested course of action of their doctor. Given that there is no obligation to provide a treatment requested by a patient that is not to their overall benefit, this can give rise to clashes between doctor and patient.

The two most common scenarios in relation to non-compliance are as follows: 

1. A patient has been started on a treatment, but declines to attend for subsequent review and/ or monitoring checks. In an invidious position, in that a decision has already been taken that it is in the patient’s best interests to commence a particular treatment.
2. A patient who declines the investigation or treatment of symptoms with a potentially serious and/or treatable underlying cause.

In such circumstances, the doctor will commonly feel uneasy and frustrated; however, it is important to remember that it is unlikely that a doctor will be legitimately criticised if a competent patient has made an informed decision to pursue a particular course of action. The right to self-determination is reflected in the GMC’s publicationConsent: Patients and Doctors Making Decisions Together (at paragraph 5[c]).²

Irrespective of this advice, there will still be a small group of patients who pose a problem. The following two questions are commonly raised by MPS members.

Q. Should I simply refuse to prescribe the patient any further treatment?

Doctors should be extremely cautious about adopting such an approach. The difficulty in this scenario is that it has already been deemed that there is a benefit to the patient in prescribing the treatment in question, and it may cause harm to the patient if treatmen t is suddenly withdrawn.

The retort to this would be that the patient is placing themselves at the risk of side effects by not complying with follow-up; however, on the basis that this is an informed decision, the patient is entitled to take such a risk. There are certain circumstances when it may be appropriate to refuse to prescribe (for example, in the field of addiction) but such an approach should only be taken with caution.

Q. Should I remove the patient from the practice list?

When an impasse seems to have been reached, then it is not uncommon for a doctor to consider removing the patient from the practice list; however, this is fraught with difficulties and may leave you vulnerable to criticism. The GMC states that you should not end a relationship with a patient solely on the basis of a complaint, or because of resource implications of the patient’s care or treatment.³

"Removing a patient from the list is not, therefore, usually a helpful way forward and may leave the doctor open to criticism"

In addition, the NHS (General Medical Services Contracts) Regulations (2004) related to the removal of patients from the practice list, stating that there should be reasonable grounds for removal that should not be based on the patient’s medical condition, treatment needs or attendant workload implications.⁴  Removing a patient from the list is not, therefore, usually a helpful way forward and may leave the doctor open to criticism.

What can be learned

Whilst dealing with non-compliant patients poses a significant challenge and can be a cause of frustration, if a shared understanding is reached between the doctor and the patient, it can be a cathartic experience.

In order to protect themselves a doctor must put themselves in a position to justify the approach taken, and to demonstrate that they made the patient clearly aware of the risks of non-compliance.

References

1. Beauchamp TL, Childress JF, Principles of Biomedical Ethics, Fifth Edition, Oxford University Press (2001) page 57 
2. GMC, Consent: Patients and Doctors Making Decisions Together, paragraph 5 (d) 
3. GMC, Good Medical Practice, paragraph 38

Last updated: September 2010