non compliance

[Guest guest]

Jane Jeffrie Seeley asks: Whose regimen is it anyway? Are we taking the time

to ask patients how they choose to manage their diabetes? What are their

goals?

Have we presented both the benefits and the costs (in time, money, and

energy) of the treatment we are recommending?

Noncompliance Versus Diabetes Self Care: Are We Still Playing a Blame Game?

Jane Jeffrie Seley, MPH, MSN, GNP, CDE

Feb 3, 2009

Back in 1993, I published an article titled " Is Noncompliance a Dirty Word? "

in which I expressed sadness that people with diabetes were being blamed by

their healthcare providers for not following treatment advice (1). I

suggested that the patient's " failure " might really be a failure of the

partnership

(or lack thereof) between patient and provider. Fifteen long years ago, I

challenged diabetes educators to work with medical practitioners to change

noncompliance

from a dirty word to a rare occurrence. So, how are we doing today?

From noncompliance to self care

Well, the diabetes lingo has evolved from " noncompliance " to " nonadherence, "

and then to " the inability to perform self-care, " but they all describe a

patient

with diabetes who is not following the prescribed regimen. No matter what we

call it, the outcome is the same. Patients are not doing what we tell them

to do.

The result can be the onset and progression of the complications of diabetes

that we all know and dread, but the consequences all belong to the patient,

not to us. My question to my fellow diabetes educators is: Whose regimen is

it anyway? Are we taking the time to ask patients how they choose to manage

their diabetes? What are their goals? Have we presented both the benefits

and the costs (in time, money, and energy) of the treatment we are

recommending?

Does the patient know how to follow the regimen safely and comfortably?

Until we do this, the patient is not ready to be independent and perform

self care.

's story

Several years ago, I was asked to see a new patient as a favor to a former

colleague. She was in tears as she told me that her husband, , was not

taking

care of his type 2 diabetes and related her fears that he would develop

serious complications, or worse. Both she and his primary care physician

labeled

as noncompliant and blamed him for his poor glycemic control and A1c

of 8.8%.

On his first visit, I asked to bring in all his medications so that I

could review them with him. I was sad to learn that he was taking

sub-therapeutic

doses of three oral agents and had stopped taking exenatide because it

" didn't do a thing. " When I questioned him further, I learned that he had

been taking

the exenatide at the starting (non-therapeutic) dose at the wrong time

(post-meals) and in the wrong place (injecting in his forearm) because he

had received

instructions from an office " nurse " who very likely was not a nurse at all.

He had stopped monitoring his blood glucose because the numbers never

improved,

despite intensifying therapy.

Lessons learned

As you read 's story, you are probably filled with anger at 's

physician for not properly managing 's diabetes. To make this story

even more

heart-wrenching, let me add that was in his early forties, had young

children, and worked at a blue-collar job that required physical labor. He

needed

to be healthy to support his family.

Over time, I worked closely with to develop a partnership with him,

and he learned how to manage his diabetes through lifestyle changes and

optimal

pharmacological interventions. I am happy to say that keeps in touch

to let me know how he is doing, and he is filled with pride that his hard

work

is finally paying off.

Why am I telling you all this? For this reason: We are all taking care of

many " s " who are getting substandard treatment because they've been

labeled

noncompliant. How can we turn this around? I have made it my personal

mission to react whenever the term noncompliant or nonadherent is used to

describe

a patient referred to me. I take the time to explain that a breakdown in the

partnership between patient and provider has led to the point that the

patient

is not capable of safely and comfortably performing self care. I share with

the provider the secret to my successes, and I try to help them do better,

one intervention at a time. I hope that you will take the time to do the

same.

References

1) Seley, JJ (1993). Is Noncompliance a Dirty Word? The Diabetes Educator;

19; 386-391