Patient Care

CASE VIGNETTE<\/h2>\r\nMr A, a 63-year-old man who had worked odd jobs until being placed on disability due to heart failure approximately 25 years previously, had coronary artery disease, heart failure (with a moderately reduced ejection fraction), chronic kidney disease, type 2 diabetes mellitus, chronic obstructive pulmonary disease, obstructive sleep apnea, hypertension, morbid obesity, and posttraumatic stress disorder. He presented to an outside hospital with shortness of breath and was subsequently transferred to our academic medical center after pulmonary edema was diagnosed. This was Mr A\u2019s fourth hospital admission within the past year for heart failure and\/or pulmonary edema. He had been having difficulty accessing primary care due to mobility issues.\r\n\r\nPsychiatry was consulted to evaluate and manage his irritability and intermittent refusal to take his medications (olanzapine 2.5 mg twice\/d, bupropion 150 mg\/d, and buspirone 5 mg 3 times\/d) and to abide by dietary recommendations. Mr A noted that he had been irritable and was challenged by his repeated hospitalizations, having spent much of the past year in hospitals. He abhorred feeling \u201ccooped up\u201d and struggled with having limitations placed on him by hospital staff, which he believed was related to having had traumatic experiences. The psychiatry team recommended increasing his total olanzapine dose, while consolidating his regimen to olanzapine 5 mg twice\/d, increasing his bupropion dose to 300 mg\/d, and discontinuing buspirone.\r\n\r\nMr A was placed on a diabetes carbohydrate control diet with fluid restriction. However, he often demanded water, ice chips, and ice cream. He repeatedly ordered potato chips and other salty snacks from Amazon, which were delivered directly to his room.\r\n

DISCUSSION<\/h2>\r\n

Why Don\u2019t Patients Follow Their Physicians\u2019 Treatment Recommendations?<\/h3>\r\nAlthough treatment nonadherence is typically conceptualized as a phenomenon of outpatient treatment, it should be considered in inpatient settings as well. While there is a paucity of literature describing how often patients fail to follow treatment recommendations in inpatient settings, this may underestimate how frequently these behaviors occur.\r\n\r\nPatients choose not to follow treatment recommendations for myriad reasons, and it is important for clinicians to understand and anticipate common scenarios. For instance, patients may not have been told about the recommended treatments and thus may be unaware that they are not following them. In other instances where treatment recommendations have been communicated, patients may neither understand nor agree with the recommendations. Furthermore, patients may prioritize other aspects of care (eg autonomy, lifestyle) or feel unable to follow recommendations due to functional or logistical concerns. Finally, the meaning of illness for each patient should be understood to guide interventions. In inpatient settings where patients often feel vulnerable, patients may not follow treatment recommendations due to anger or frustration at their situation, condition, or health care team.\r\n\r\nIn addition to not following treatment recommendations, patients in inpatient settings can undermine treatment recommendations in other ways. Patients may minimize or obscure nonadherent actions, both of which may make it difficult for treatment teams to address nonadherence. Patients may also circumvent some recommendations, such as diet orders. Modern technologies, such as cell phone applications, make this easier to accomplish in inpatient settings.\r\n