Handling Purposeful Medication Nonadherence

00:01 Hi, I'm Dr. Rhonda Lawes.

00:03 And in this video series, I'm going to talk to you about something that is really frustrating sometimes as a prescriber or provider.

00:10 I'm talking about handling purposeful medication non-adherence.

00:15 Now, that's a very professional way to say when patients make the choice to not take medication in the way that you've prescribed it, how do we handle that as professionals? So, I'm going to start with a story.

00:28 Now, this is a story about a patient who had hypertension and heart failure, but here's the problem.

00:34 She didn't really want to take her water pills, so particularly on things when she was going to play bingo.

00:40 Now, I think you can probably imagine why.

00:43 She was convinced that if she got up and went to the restroom, she would lose the bingo game or miss that magic number calling.

00:51 So, she didn't want to have to get up all the time to go to the bathroom.

00:55 Now, it means she just did not take her diuretic.

00:58 She didn't take her hypertensive medications.

01:01 She just thought, I'll take them when I get home, which likely she didn't take them when she got home either, otherwise she'd be up all night going to the restroom.

01:09 Now, here's the saddest part of the story from our perspective, One night in the bingo hall, she ended up having a massive stroke, had to be life flighted from the hall, and ended up passing away.

01:21 Now, from our perspective, we're thinking, "Why didn't she take her medication? That would have made life better." That's our perspective as a provider, healthcare team member.

01:31 But that really wasn't her perspective.

01:34 And we always have to keep in mind the patient, if they have the capacity to make the decision, also has the right to make the decision about their own healthcare and which meds they will or will not take. So, it is a sad story.

01:50 But again, it highlights individual autonomy.

01:54 And the right to choose how you want to live your life.

01:56 So, I'm sure you're already aware that in some situations, the patient may choose to take medications we've prescribed in ways that have not been prescribed.

02:05 For example, they might take doses that are too high or too low or not taking it in the ways that they were directed.

02:13 Sometimes it's because their choices challenge the advice we've given them regarding their lifestyle.

02:18 Now, when you start talking about lifestyle, that gets really personal.

02:22 For example, if you give them advice to stop a particular pattern of behavior, that is when it gets really personal.

02:30 Even if these behaviors are associated with the development of illness, such as risky sexual behaviors, tobacco, or substance misuse.

02:38 In today's video, we're going to talk you through how to handle the situations in which patients make deliberate decisions to disregard medical instructions regarding medication therapy.

02:49 Now, as medical providers, until we have evidence otherwise, we make some assumptions.

02:54 Every individual has the right of autonomy, meaning that they have the right to control their own bodies.

03:00 They make 100% of the decisions of what does or does not happen.

03:06 A second assumption is that every individual is rational and competent to make medical decisions.

03:12 Now, that means if they want to refuse medical treatment or take medication in a way that is not prescribed, they have the right to do so.

03:21 Our role as medical providers is to clearly and carefully communicate and document our conversations with our patients about medication treatment plans.

03:31 Now, pause. Keep in mind, they have the right to say yes or no, but you need to be meticulous about documenting those types of conversations.

03:42 So, be careful to communicate clearly and take the extra time to document those conversations.

03:49 That's what you need to do to protect yourself as a professional and to also ease your mind if the patient decides to make a different choice.

03:58 Now, this includes not only what we say, but what the patient responds.

04:02 So, it's very important to include what questions they had, what concerns they expressed, and how we responded to those questions and concerns.

04:12 The term's "capacity" and "competence" are frequently utilized interchangeably, yet they have traditionally maintained distinct albeit intersecting definitions.

04:21 Capacity, that refers to an individual's decision making capabilities within a particular situation, such as medical treatment.

04:28 Now, it's assessed by health care professionals in specific situations.

04:33 Here's an example.

04:34 Suppose a patient is diagnosed with a serious illness and needs to decide whether to undergo a risky medical procedure.

04:41 Health care professionals would assess the patient's capacity to understand the risks and benefits of the procedure, as well as their ability to weigh alternatives and communicate their decision effectively.

04:51 If the patient is deemed to have the capacity, they can make the decision themselves. Competence involves a legal determination of an individual's overall ability to make autonomous decisions within broader context.

05:04 Example. A court might appoint a guardian to handle the financial affairs of an elderly individual with dementia, if they're found to lack the competence to make sound financial decisions, even if they can still retain some capacity to understand the basic concepts. It's critically important that health care providers know how to assess capacity. While the legal definition of capacity varies by jurisdiction, the concept of capacity for medical consent is based on four legal and ethical standards or decision making abilities.

05:34 Number one, understanding.

05:37 Number two, expressing a choice, number three, appreciation, and number four, reasoning. When you are assessing capacity, you need to use face to face interviews using open ended questions.

05:50 Make sure you evaluate the four decision making abilities.

05:53 So first, let's look at understanding.

05:55 This involves the ability to explain the meaning of relevant information such as diagnosis and treatment options.

06:01 Sample question: can you summarize what I just told you about heart failure? Second one, expressing a choice.

06:10 This refers to the ability to state a decision based on the information provided.

06:15 Sample question: considering our discussion about heart failure, what would you prefer? The third one is appreciation.

06:23 Now, appreciation you will assess the ability of the client to relate information to themselves.

06:29 Sample questions include asking the patient to explain their understanding of their medical condition, the potential benefits of treatment, and the potential risks.

06:38 The fourth decision making ability is reasoning.

06:41 This involves comparing information and predicting the consequences of choices.

06:46 Sample questions include asking how one treatment option may be better than another, and how a treatment decision may impact daily activities.

06:55 There are validated instruments to measure capacity in these are available.

06:59 Now, they're not usually used in routine care, but they may be used in complicated cases. The results must be integrated with other data, particularly the risk and benefits of the decision to reach good clinical judgment.

07:12 There are two instruments that are used.

07:15 The first, MacArthur Competence Assessment Tool for Treatment.

07:19 Now, this will need to be purchased from the publisher.

07:21 The second, the Assessment of Capacity for Everyday Decision making is similar in design and structure, but it exists in the public domain.

07:30 There are certain risk factors for diminished capacity.

07:33 Any diagnosis or treatment that compromises cognition, examples: dementia, psychiatric disorders, traumatic brain injury, and delirium.

07:41 Now, a diagnosis or brief cognitive assessment is insufficient for capacity assessment. Severity of cognitive impairment correlates with the likelihood of diminished capacity. So when should you assess capacity? Formal assessment is warranted when cognitive impairment is present.

07:59 Decisions with high risks or inconsistency with prior choices may also prompt assessment. So what do you do when a patient lacks capacity? Well, urgency and extent of action are based on factors like severity and duration of impairment. The health care provider has an ethical obligation to identify a substitute decision maker.

08:20 So as we wrap this up, capacity assessment is crucial for informed decision making, and balancing autonomy and best interests of the patient is essential in clinical practice.