NONCOMPLIANCE OR CHOICE?

Mr. Jones, a 78-year-old male, came into the cardiologist’s office for a 6 month follow-up regarding his coronary artery disease (CAD). He had a history of having a three vessel coronary artery bypass graft (CABG) four years before. His medical history included CAD, non-insulin diabetes mellitus (NIDDM), hypertension (HTN), and hyperlipidemia. The listed medications he was prescribed were Lipitor, Advandia, aspirin, Diovan, and hydrochlorithiazide (HCTZ). His blood pressure on his left arm was 190/98. This was repeated and did not change. His weight was the same as his visit six months before at 162 pounds. 

The office visit started as every other.

“Hi Mr. Jones. How have you been feeling?” I asked.

“I can’t complain,” he responded.

“Have you had any chest pain, shortness of breath, dizziness, orthopnea..." as I went over my review of systems. "No," he responded to everything I asked. "Let me go over your medications. Are you taking your aspirin everyday?” I asked.

“Yes. I am taking that one,” Mr. Jones resonded.

“How about the Advandia?” I asked.

“What is that one for?” he asked.

“For your diabetes. To keep your blood sugars under control,” I responded.

“No. I don’t take that one every day. I take it once in a while when I think about it,” Mr. Jones said.

“Do you check your blood sugars everyday?” I asked.

“No. Why should I?” Mr. Jones responded.

“It is important to keep your blood sugar under control to prevent future problems. Especially since you already have had a CABG and your history of CAD,” I said.

“I only take that one when I think about it,” he responded.

“Do you see Dr. Wilson as your primary care provider (PCP)?” I asked.

“Yes. I saw him once. I don’t like him one bit. I will not go back to him. I will come here instead because I like it here,” Mr. Jones responded.

“Well I understand if you did not like your PCP, but we need to find another physician to manage your diabetes and your primary care needs,” I told him.

“That would be alright. Do you have anybody in mind?” he asked.

“No. I need to research that a little bit and I will let you know,” I said.

“Okay. How about your Lipitor? Are you taking that one everyday?” I asked.

“No. I stopped taking that one! I heard on t.v. that drug can cause cancer. I stopped taking that one,” Mr. Jones said.

“Caused cancer? I have never heard of that. Maybe liver and muscle problems but not cancer,” I told him.

“No. It said Lipitor caused cancer. I will not take that drug,” Mr. Jones responded.

“That one is to keep your cholesterol levels down. High cholesterol levels can contribute to your coronary artery disease,” I said.

“I will not take that drug. The t.v. said it causes cancer,” responded Mr. Jones.

“Okay. What about the Diovan? Are you taking that one every day?” I asked.

“What is that one for?” he asked.

“For your blood pressure,” I responded.

“Yes. I take that one every day,” he said.

“How about the HCTZ?” I asked.

“Yes. I take that one too,” he responded.

“You know your blood pressure was pretty high today. Do you take your blood pressure while you are at home?” I asked.

“I take it once in a while,” he said.

“It says here from the last note you were supposed to keep a blood pressure diary. Did you do that?” I asked.

“No. I don’t need to do that. I just take it once in a while and they have been good. I think I just get nervous when I come into doctor’s offices,” he said.

“What has your blood pressure been running?” I asked.

“I think the last time it was 75,” he said.

“What is the larger number that would be on the top of your digital reading?” I asked.

“I think it was 75,” he said.

“Do you mean 175?” I asked.

“No. Well, maybe. I guess I should write them down to remember, huh?” he responded.

“That would give us an idea of where your blood pressures have been. If they are too high they can cause problems such as stroke and heart attack if they remain that high. Especially with your diabetes. We also may need to adjust your medications to keep them under control,” I said.

“I feel fine though. The blood pressure is high because my wife says I get anxious when I come into these offices,” he smiled.

“What about the aspirin? Do you take one every day?” I asked.

“Yes. I do take that one every day. They tell me it is good for my heart,” said Mr. Jones.

“You are right. It can help prevent a heart attack,” I said. I then got up from the roller stool and washed my hands to do the physical examination. I looked at his general appearance which he looked healthy for his stated age. I knew other people had told him that which could be the reason why he was not taking some of his medications. I listened to his heart which had the normal S1 and S2 sounds. His lungs were clear in all fields bilaterally. His capillary refill in his fingers and toes were less than 3 seconds. Pulses were 2+. There were no carotid bruits. His gait was steady and he did not have a difficult time moving around or standing from the sitting position. I needed to find out when was the last time he had his blood levels check for cholesterol, glucose, urine, and hemoglobin A1C. I also needed to find out what Dr. Wilson’s notes said from his last visit with Mr. Jones. I excused myself for a few minutes to have my preceptor look in the computer for his last labs and PCP notes.

I accessed the computer system to see Mr. Jones saw Dr. Wilson three months before. Mr. Jones’ cholesterol levels were elevated and his last A1C level was 9.1. The A1C level was to check the glucose level in the blood over an average of three months. The guidelines liked to see the level for diabetics under 7 which was an average glucose level of 140. Dr. Wilson’s notes also made the comment Mr. Jones was noncompliant with his care and did not want to follow his medical instructions or opinions regarding his health or take his medications on a regular basis as instructed. I told my preceptor my findings and what Mr. Jones had told me regarding taking his medications and blood pressure. We were ready to go back and talk with Mr. Jones.

“Mr. Jones, your A1C level the last time Dr. Wilson checked was 9.1. This is over the recommended 7 for diabetics. We really need to check your blood glucose levels to see where they are and to get them under control,” I told him.

“What for? I feel fine. Everybody tells me I look good for my age. Hell, I did not expect to live this long,” he responded.

“It is very important to keep your glucose levels and blood pressure under control. If not in control they could lead to more problems with your CAD and a good chance of getting a heart attack or stroke,” my preceptor told him.

He smiled back at me. “Well, if that happens then I will call you,” he responded. “I feel good. If I get a pain I will take an aspirin. Then I will feel better. Why should I take something if I am feeling good?” he asked me.

“Because CAD affects the body silently. You will not know or feel what is happening in your body until something like a heart attack or stroke occurs. That could be debilitating or fatal. That’s why it is important to take your medications every day instead of when you think about taking them. It is important for your health,” my preceptor told him. I nodded my head in agreement.

“Well, I will not take that Lipitor. About the other one, I will take it when I think about it. And if I start feeling bad, I will give you a call,” he smiled.

I knew trying to tell him why he should take his medications and watch his blood pressure was getting nowhere. He obviously had his mind made up and talking about it any further would not make the situation any better. I had the feeling my preceptor thought the same thing. He looked to be getting somewhat frustrated.

“Well, since you are due for your labs to be drawn, would you agree to get them done today?” I asked.

“Sure. I can do that,” he said. My preceptor smiled. At least Mr. Jones agreed to something during the visit.

“That will at least give us an idea of where your blood sugars have been since the last time it was drawn,” I said.

“Okay,” said Mr. Jones.

“I will also like you to keep a blood pressure diary and bring it with you every time have a doctor’s appointment,” I said.

“I guess I can do that if I remember,” he said.

“We also need to find a PCP for you to manage your overall health,” my preceptor told him.

“That will be okay. Who will that be?” he asked.

“I do not know at this time but I will let you know as soon as possible,” my preceptor said.

The lab slips were filled out and given to Mr. Jones to have his blood drawn on the way out of the office. I was happy he agreed to do that much. I also wanted to get him with a diabetic educator to teach him about his disease. I was not sure if he would listen but it needed to be attempted. Mr. Jones left the office with the same smile he walked in with. I smiled back and told him to have a nice day.

I knew Mr. Jones needed more teaching regarding his CAD, diabetes, high cholesterol, and HTN. Since he was not from the area I was not sure if teaching had been attempted from his previous providers. As a health care provider I knew detailed documentation with a patient like Mr. Jones was important to basically “cover my butt.” That had been drilled into my head since nursing school. But do patients have the right to choose the way they manage their health as long as they have been well informed? I wonder if a patient had been informed and educated regarding their disease processes, the consequences of not maintaining a healthy lifestyle, and the reasons to take their medications -- if they choose not to follow that medical advice would it be considered noncompliance -- or would it be “choice?” Does the medical profession put the label of "noncompliance" on their patients too quickly? I am certain that will be an issue (problem) I may encounter once I begin practicing on my own and become a medical provider. How to handle the situation on an individual basis will only come with more experience. From this visit I knew my documentation skills needed to improve considerably. I know Mr. Jones was almost 80-years-old and really did not want anybody telling him how to live his life. I have heard on more than one occasion the geriatric population tell me they will die anyway, and why not allow them to live their life the way they wanted? As a provider I still have to attempt to educate my patients and help them understand why it was important to follow medical advice. That in itself will be the challenging part. But I also believe once educated the patient has the right to "choose" to follow my advice or not. Would they still be labeled "noncompliant?" Maybe there needs to be another label, such as "informed and chooses not to follow medical advice." I don't know.