■ Safety of care:

Improving patient safety and reducing risks

What to do when patients do not follow the doctor’s advice: Dealing with non-adherence

Originally published December 2013; revised July 2020

Physicians work in partnership with patients to achieve the safest and highest quality of care possible. But what happens when a patient does not follow the physician's advice? Addressing non-adherence—when a patient does not adhere to advice for investigative or treatment plans that a physician has set out in the patient's best interests—can be challenging.

Non-adherence to public health requirements during COVID-19

Public health legislation in some provinces and territories includes reporting obligations when an individual is not following treatment advice related to a communicable disease such as COVID-19. Patients who have tested positive and fail to self-isolate may be considered to not be following treatment advice. Physicians are encouraged to be familiar with the specific reporting obligations in their jurisdiction. Physicians may also have an ethical duty to report a patient to the relevant public health agency if they have a reasonable belief that the patient is posing a risk of harm to others by refusing to self-isolate.

Non-adherence can be either intentional or unintentional. “Intentional non-adherence is a process in which the patient actively decides not to use treatment or follow treatment recommendations, whereas unintentional non-adherence may be the result of forgetfulness, not knowing exactly how to use medications, or other unplanned behaviour.”1 It may also include missing appointments, not following up on referrals, missing tests, failing to fill prescriptions, or stopping medication. Often patients may not tell their doctor.

Patients may not heed the guidance provided by their physicians for many reasons. Changes may be difficult for the patient, either because of other obligations, lack of commitment, interest, or understanding. Socio-economic conditions may mean treatments are unaffordable or living conditions are difficult. Issues of language, culture, or literacy may also come into play. Non-adherence generally may be as high as 40%.2

It is important for physicians to document the treatment plan and the consent discussion in the patient’s medical record. The medical record should show that the patient was made aware of and understood the expected benefits of adhering to the advice, along with the risks of non-adherence. In the event of a regulatory authority (College) complaint or legal action in which patient non-adherence is a factor, proper documentation allows the physician to demonstrate that the patient was advised of the recommended approach. 

Case example: Non-adherence for referral

A patient with a recent negative cardiac stress test presents to the emergency department (ED) complaining of substernal chest pain following a large meal and heavy drinking.

An electrocardiogram shows non-specific changes and a single set of cardiac enzymes is negative. Reflux esophagitis is diagnosed and the patient is discharged home.

The following day the patient is reassessed at her family physician’s office. The patient complains of intermittent substernal pain with eating. Esophageal reflux is diagnosed. The physician recommends an urgent referral to a cardiologist and gastroenterologist, but the patient refuses. The physician does not document the discussion or the reasons for the patient’s refusal.

The patient subsequently suffers a myocardial infarction and dies. Autopsy confirms the cause of death and reveals a 95% obstruction of the anterior branch of the left coronary artery.

Experts are critical of the family physician's failure to document his advice and referral to a cardiologist, and about the patient's refusal. The case is settled in favour of the patient, in part because the physician was unable to prove that the patient was informed and understood the potential consequences of refusing the test.


Patient-centered care

Fostering patient-centered care entails being as open as possible when a patient challenges the proposed treatment plan.

When patients appear hesitant or react with skepticism to your advice, consider asking them about their reasons—what are their concerns or fears? Doing so may also reveal whether a patient’s refusal is adequately informed, and can lead to a more frank discussion about the likely benefits and potential risks of the proposed treatment. Consider supplementing your advice with multi-modal education materials targeted to the patient’s literacy level. Use of shared decision-making tools may further enhance patient-centered care. 

Following up 

Every patient will react differently to your recommended treatment plan—which may encompass lifestyle changes, diagnostic testing, or medication—and following up with the patient is key to encouraging adherence to that plan. During follow-up appointments, consider reviewing the treatment plan, the patient’s progress, and any barriers to adherence the patient may be encountering. If the plan includes smoking cessation, for example, ask the patient about his or her success with that to date and if more assistance or resources might be needed.

Having in place a reliable system for following up on laboratory tests, diagnostic imaging, and consultations may help to identify when a patient is non-adherent, giving you the opportunity to reach out to the patient and potentially reassess the treatment approach. See the CMPA article “Closing the loop on effective follow-up in clinical practice” for more information about using systems to track whether a patient has followed through with a recommended test.

Medication prescribing and monitoring

Affordability of prescribed medication may be a factor in non-adherence, and has been found to affect one in 10 Canadians.3 If this is an issue for a particular patient, consider proposing less expensive, but effective, alternatives—including the possible availability of generic versions rather than brand-name medications.

The availability and standards regarding the use of e-prescribing vary across the country. Generally speaking, the electronic transmission of prescriptions to a pharmacy may help improve patient adherence as this practice encourages patients to consistently use the same pharmacy over time and potentially requires the patient to spend less time there when picking up medications. Indeed, a study of dermatology patients observed a 47% reduction in non-adherence when the prescription was in electronic format compared with a paper prescription.1 E-prescribing may also generate increased discussion between the patient and physician about adherence,4 as well as between the patient and pharmacist about affordable medication options. Physicians may encourage patients to have such discussions with their pharmacist. While pharmacy management systems track whether patients pick up their medications from a pharmacy, the mechanisms to enable this information to flow back to the prescriber may not be available everywhere, precluding physicians’ ability to reach out to patients if they notice that prescribed medications were not dispensed.1

Non-adherence might also occur when patients change their mind about taking a prescribed medication after they have reviewed the handout information supplied by the pharmacy. It may therefore be beneficial for physicians to know what drug information the patient receives so that the patient’s questions or concerns can be addressed at the outset.

The bottom line

Consider the following strategies, which may encourage adherence by patients to your recommendations.

  • Communicate clearly and frankly with patients about why the treatment plan or lifestyle change is important and how best to implement a recommended course of action. Explore patients’ fears or concerns that might pose a barrier to carrying out the plan.
  • Use multi-modal communication materials to enhance your patients’ understanding and to foster patient-centered care.
  • Consider using office systems to help identify patients who frequently miss or cancel appointments, or do not follow through on diagnostic tests or referrals.
  • Document the consent discussion in the medical record, as well as incidents of refusal and non-adherence.

References

  1. Gheorghiu B, Nayani S. Medication adherence monitoring: implications for patients and providers. Healthcare Management Forum [Internet]. 2018 [cited 2019 Jan]; 31(3): 108-111. Available from:   https://journals.sagepub.com/doi/10.1177/0840470418767966

  2. Martin LR, Williams SL, Haskard KB, et al. The challenge of patient adherence. Ther Clin Risk Manag [Internet]. 2005 Sep [cited 2019 Jan]; 1(3):189-199. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1661624

  3. Law MR, Cheng L, Dhalla IA, et al. The effect of cost on adherence to prescription medications in Canada. CMAJ. 2012;184(3):297-302. doi:10.1503/cmaj.1112704.

  4. Lanham A, Cochran GL KD. Electronic Prescriptions: Opportunities and Challenges for the Patient and Pharmacist. Adv Heal Care Technol. 2006;2:1-11. doi: https://doi.org/10.2147/AHCT.S64477


DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.