Compliance

Lately I've been thinking a lot about how health care workers perceive their patients. Particularly the undesirable ones, the ones we blame for being sick. I know we do it; I'm guilty of it. The heart failure patient who is readmitted a few times a month when her edema becomes so severe she has difficulty breathing but who doesn't take her medication because it makes her pee too often. The asthmatic patient frequently seen in the emergency room for shortness of breath who refuses to get rid of the cat he's severely allergic to. The diabetic patient whose family smuggles donuts to him WHILE HE'S STILL IN THE HOSPITAL. I get so frustrated! If these patients would only be COMPLIANT!!!

But look at all these examples: Would you want to take medication if you knew you were going to have to get up 3 times in the night to pee? What about the cat who is the asthmatic patient's only companion? Would you say good-bye to your best friend just because a doctor told you to? Even the diabetic patient who eats donuts while still in the hospital and seems to be the most self-defeating of all: How would you feel if you contracted a disease that meant you had to completely change your way of eating and give up most of the foods you derive pleasure from?

But we get frustrated, blame them for not changing, send them home, and groan when we see them come through the doors again.

In nursing school we were taught to continue telling these patients that they need to change their ways. Even if they've already heard the same words over and over, we're told that "if we continue to repeat the message, maybe one day they'll get it." Does anyone really think that any of these patients are going to wake up one day and say "Gee, maybe I should _________ like my doctor/nurse/nutritionist told me and then I'll get healthy."

Every time I go to the dentist, the hygienist tells me I need to floss. I've been receiving regular dental care since I was a child and have been told this at every dental appointment for over 30 years. I know I need to floss. I don't hate flossing. I just never think to do it. I leave every dental appointment with good intentions; somehow this time will be different. Not once has a hygienist offered me any practical solutions to get into the habit of flossing. When I ask for suggestions, I'm met with "You just have to do it." I'm sincere in my desire to become a flossing person. It's just that no one has ever guided me in developing this habit and I can't seem to figure it out on my own. To the hygienist, I must appear like a lost cause, a very noncompliant patient.

Maybe no one has come alongside all those noncompliant patients and helped them solve their unique problem that would help them manage their chronic illness. What if Heart Failure had her dose adjusted so that she was taking her medication at intervals throughout the day and her fluid was restricted close to bedtime? Perhaps she could sleep through the night AND maintain an appropriate fluid balance. Asthma could be assisted in finding a new home for his companion where he could continue to visit when his disease is well-managed. Diabetes could be reassured that an appropriate change in diet doesn't mean that he can never have a donut again; a home visit with a nutritionist where his lifestyle and personal preferences are considered and a personal nutritional plan is developed could go a long way to helping him make sound nutritional choices more often.

That's not how we do things, though. We print out the generic heart failure/asthma/diabetes home-care instructions, circle a couple important points and say good-bye to the patient--until the next admission.

This is not the kind of nurse I want to be. Instead of reminding the patient that they need to make changes, I want to come alongside them, discuss barriers to health-enhancing behaviors, and help my patients overcome those barriers. Nagging doesn't work. Let's get down in the trenches with our patients and help them find a way to be healthier.

Now I need to go floss.