Vol. 19 •Issue 16 • Page 26
Treating Problem Patients in Home Care
Patients discharged from our care typically leave with instructional materials, medications and our high hopes they will remain on the road to wellness. Once they get home, their resolve to “follow doctor’s orders” may waver, however, landing them back in the hospital. In fact, many patients in home health care mode show resistance to maintaining their treatment program, sometimes in spite of sentinels dispatched to deliver therapy.
Passive resistance to care may be seen in the form of “forgetting” to fill prescriptions, not being home when therapists are due or countless variations on the avoidance theme.
To identify when and where patients go wrong, caregivers must watch for patterns. Cranky emphysema patients who return repeatedly during holiday seasons, for example, may reflect depression as a component for poor compliance.
Family members may be in collusion with a rebellious subject when they disapprove of medications or adjunct therapies like nasal CPAP. Uncooperative patients may cite adverse reactions like nervousness as a deterrent to compliance, with family members agreeing wholeheartedly. The extreme angle can be the family member who outright refuses to allow oxygen in the home saying, “It’ll run up the light bill.”
I once had a patient tell me he would never use his nasal CPAP unit because his wife didn’t want him to. In spite of our continued attempts at patient education, he remained adamant that NCPAP was not for him. Pressed for further discussion, he ended by saying: “I wouldn’t want my wife using that thing if she needed it either.”
Freedom to Ignore
In some instances, both patient and caregiver may turn a loathing for the disease process into scorn for treatment. In society, ignoring or being outright abusive to someone might make them go away. With disease, ignoring it only serves to enhance the illness. Unfortunately, few patients are educated with this ingredient of “sour grapes sangria.”
Infirmity is a costly pastime, affecting patient and family members who have become reluctant nurses and valets. Guilt trips sometimes accompany the high overhead of health care costs. As a result, rather than take a whole, prescribed dosage, a patient may portion it out in smaller amounts to avoid the cost of a refill. Patients may alter their dosing schedules or amounts but leave the doctor in the dark rather than ask for samples or prescription modification to include samples or meds within their budgets.
“I get by on half a pill” is a statement the physician who puzzles over a patient who does not quite get better never hears.
Rather than take accountability for handling their own care, some patients may foist it off on a spouse. Husbands often have their wives carry their diabetic supplies; wives sometimes leave inhalers at home and then blame a husband for the oversight.
In some families, members not only decline to care for the ailing, but also push the ailing parties beyond their limits, ignoring medical signs that require intervention.
During a stint in retail sales, I once helped host a special event. One family arrived as soon as the doors opened, staying well into lunch time. After they had been there for some time, I noticed the man’s hands shaking. He was sweating profusely, and I asked whether he needed anything. “Only food,” he answered. He had left the house with no breakfast because his family wanted to be at the event when it opened.
In this case, he not only dismissed his own needs several times over, his family did as well. It did not occur to anyone—the man, his wife or a teenage son—that a half block jaunt to a sandwich shop would have resolved the matter. I offered the man a granola bar, which he accepted gratefully. No one else, including the store owners who were well acquainted with the man and his family, bothered to intervene.
Too Many Distractions
Part of the problem with non-compliance may lie in a natural detachment we have to our environment and the people in it. Bombarded at all angles with Muzak, sales signs, gas fumes, cell phones that play any number of bizarre ringtones and our own private thoughts, it is only natural for us to short-circuit.
Family members push the disconnect button from time to time too. But the end result of patient and caregiver detachment can be far worse than someone merely having a bad day. Detachment can result in an extended visit in an ICU or rehab facility or a fast trip to a morgue.
Households with multiple patients often fare better on compliance issues than do others, because ailing individuals tend to watch over one another or at least encourage self- care. Although there may be mild skirmishes over who visits the doctor more, the chronically ill tend to understand the need for continual medical attention, because they experience that need as well.
In extreme cases, relationships abusive to begin with become more so when illness is present and new avenues for abuse appear to present themselves daily. If therapists suspect there may be abuse, they should report the matter to the proper authorities. If you are seeing the same patients come into the ER or being admitted with the same patterns leading up to the hospital visit, you should talk to administrators about the situation. Strange patterns that do not coincide with a normal process of exacerbation should be watched closely. RTs should at least raise an eyebrow when an asthmatic suddenly has an upsurge of outbreaks due to chemical cleaners or other products being used in the home.
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) documents hundreds of psychiatric conditions. Among them are rarely seen Munchausen’s (fabricating symptoms to gain attention) or Munchausen’s by Proxy (inducing illness in a patient so the caregiver can get attention). These must be diagnosed by a medical doctor, not a therapist. But in many instances, therapists who recognize such disorders can tip off medical staff that something is amiss and perhaps save someone’s life.
There are no lost causes totally. Non-compliant patients can become more compliant through patient education, support groups, and, most importantly, health care providers who take the initiative when they see something is wrong and a patient is not improving as expected.
Cheryl Ellis is a Florida-based freelance writer.