The answer may surprise you.

WHAT can you do with a patient who won’t comply with any of your directives? You’ve provided education until you’re blue in the face. You’ve given explanation after explanation to no avail. When can you say “enough is enough” and tell a patient not to return until he or she is ready to follow your advice?

The answer, in a word, is “never.” If you’re experiencing genuine personality conflict, and you’re humble enough to acknowledge it, then you can refer the patient elsewhere. Otherwise, no…you can’t fire a patient.

Investigate

Have you found out why your patient won’t comply? What is it about the disease that he or she wants (or needs) to keep it? Sometimes it isn’t the patient who “needs” the disease, but the family; it may be the one thing around which they’ve built a meaningful life. The family members have rearranged their lives around the patient’s illness, assumed new roles, quit jobs, found a mission to keep them going. I remember a stroke patient I cared for whose wife thought I was cruel to make him dress himself. Finally, he whispered to me that he could dress himself but it made his wife feel so much better when she dressed him, so he let her.

Sometimes it’s the patient’s life circumstances. I had a patient who kept getting pregnant despite our best efforts to “educate” her about contraception (she wasn’t a candidate for the pill because of a history of blood clots). After her fifth child, we conducted a family visit. We learned that she and her husband slept in the attic in a house with only one bathroom, which was on the first floor. The poor woman had to interrupt lovemaking, run down two flights of stairs, insert her dia phragm, and then run up two flights of stairs to resume intercourse. Once we finally understood, the woman’s problem could be solved.

Occasionally, a patient’s lack of adherence is because of addictive behavior, including the patient’s physiological need for the high, and the pleasure, escape, relief, or release that it provides. And sometimes a patient fails to follow our instructions and advice because the illness has given him or her new importance and attention.

Be curious, be patient

And sometimes, often in fact, there is nothing we can do to change matters—except to care, and to be there in a crisis. Many nurses shy away from patients who have powerful personalities and strong self-destructive drives—or they openly challenge them. When a patient is strong, don’t challenge strength for strength. That dance is too well known and leads to escalation and struggle. Allow the patient to lead—let him or her retain autonomy and control over the situation. The best you can hope for is to join, explore, and try to understand.

Be curious. Ask gentle questions that broaden your and the patient’s perspective. Keep wondering. Why? How do you understand this? How is the patient’s world put together? A good alliance requires that you not be too close or too far. Too close and you risk scaring or overwhelming the patient; too far and the relationship will be cold and ineffective.

Be patient. Stay close, but don’t invade. Always ask for permission. And never, ever give up on your patient.

Leah Curtin, RN, ScD(h), FAAN

Executive Editor, Professional Outreach

American Nurse Today