From Medical perspective, patients who don’t comply with doctors orders are usually seen as deviant and deviance needs correction But many chronically view their behavior differently, as matter of self regulation American Sociologist Peter Conrad A good working atmosphere and healthy moral climate makes therapeutic efforts more easy in all Institutions

1. NON-COMPLIANCE:AN
ETHICAL ISSUE
PIR BUX JOKHIO
Assistant Professor, Nursing
14-01-12017

2. Objectives

3. • From Medical perspective, patients who don’t comply with doctors
orders are usually seen as deviant and deviance needs correction
• But many chronically view their behavior differently, as matter of self
regulation
• American Sociologist Peter Conrad
• A good working atmosphere and healthy moral climate makes
therapeutic efforts more easy in all Institutions

4. Definition
• ‘The extent to which the patient’s behavior (in terms of
taking medications, following diets, or following other
lifestyle changes) coincides with medical advice'.
(Polikandrioti M., Νtokou M, 2011)
• The compliance can also be defined on the basis of
outcomes. (Kyngas et al.2000)
• “ a situation that exists as present or absent or that exists in
more or less level and finally exerts either a beneficial or a
deleterious effect on the outcome of a disease.” (Luscher et
al.,1985)

5. compliance
• “an active, responsible process of care, in which the individual works
to maintain his / her health in close collaboration with the health care
personnel.” (Hentinen et al.,1996)
• “Correct use of medication, observance of appointment with the
therapist”. (Brown et al.,1995)
• “The major element of the relation between those who have power
and those over whom they exercise power”. (Edel, 1995)
• ‘The extent to which an individual chooses behaviors that coincide
with a clinical prescription. The regimen must be consensual, that is,
achieved through negotiations between the health professional and
the patient. (Dracup and Meleis, 1982)

6. • “Webster’s term” 'the act or process of complying to a desire,
demand, proposal or coercion…adapt (ing) one’s actions to another’s
wishes, to a rule, or to a necessity'. (Burckhardt,1986 & Hess, 1996)
• ‘Patient have to pay attention to treatment regimen and to
collaborate with therapists. (Hess,1996)
• ‘The positive behavior that patients exhibit when moving toward
mutually defined therapeutic goals'. (Hussey and Gilliland,1989)
• 'This definition disregards the ways in which a prescribed regimen
affects an individual’s life and assigns the health care provider the role
of “expert'. (McGann, 1999)
• ‘Between nurse-patient there is a mutual supportive relation where
nurses should help patients to promote compliance while patients
should participate in the process. (Vivian, 1996)

7. • Medical terminology
• Patients agreement with physician/nurses.
• Patients should not be partners but have blind obedience to the
instructions (NANDA Members)
• “Viewing the concept from three different perspectives:
• a) Evaluative: authors are interested in the issues arising from
'compliance' such as 'paternalism' and 'consensus'.
• b) rationalization: The authors acknowledge the issue of the shaded
connotation of term. However they continued to use the term when
appropriate
• c) Acceptance: use the word 'compliance' without any comment on
the controversy about. (Murphy et al., 2001)

8. Types of Non-complier
a) 'Exemplar case' Patient: “Do I really need to do all of these things that are listed on this paper
every day?”. 'Exemplar case' emphasize the role of passive patient but, also, expresses his/her
concerns so that to follow the treatment.
b) 'Contrary case' Patient: “You are crazy if you think I am going to get out of bed an hour early
to exercise and use all of my energy for the day!” No one of the characteristics of the concept of
compliance is shown above.
c) 'Borderline case' Patient thanks his/her provider, promised to comply with medication but no
to comply with diet and exercise program. Patient will comply with a part of the treatment.
d) 'Related case' Provider discusses with patient about the importance of the treatment
regimen and asked to meet with a family member in order to work as a team. Patient agrees to
take medications but he/she is not sure if the family member can meet with them because of
business. The 'related case' highlights the active patient and the collaboration between two
parties.

9. Adherence
• 'following a medicine treatment plan developed and agreed on by the
patient and his/her health professional(s)'.
• ‘an effort to reduce the paternalistic nature of the term 'compliance'.
• (The National Council on Patient Information and Education (NCPIE),
1995)
• Behaviorist Scientists terms (Christensen et al.,2004)
• ‘Offers greater liability to therapist in order to build a trusting
interaction between therapist and patient.’ ( Kyngas et al,2000)
• ‘Respects patient beliefs and reflects that only receiving medication is
not always beneficial.’ (Vermeire E, etal,2001)
• “Active role of patient to develop therapeutic relationship,
nevertheless failure may not result in blaming patients”

10. • Many physicians take the attitude, "If patients don't—or won't—
follow my instructions, whose fault is that? It certainly isn't mine.“
• "The only individual who is not responsible for their healthcare is the
patient”.
• Noncompliance is dangerous for the patient and frustrating for the
physician.

11. Reasons for non compliance
• Patients can’t afford
• Patients are not willing to make effort (non Motivational)
• Patients don’t understand
• Sometimes patients are misguided by different persons
• Poor Insight or Lack of insight (in psychiatric Patients)

12. Non adherence
• a 'disorder' and specifically as a manifestation of the syndrome of
'weakness of will'. (Reach,2008)
• ’The failure to follow a treatment regimen, early termination of
treatment and poor implementation of instructions.’(Nose, M, 2003)
• “Can occur in various forms, such as not having a prescription, not
taking the correct dose, or taking at the wrong time, forgetting to take
doses, or shortening the therapy.” (Nichols-English, 2000)
• Adherence: ‘The extent to which a person’s behavior coincides with
the medical advice given (Sackett & Haynes 1976).

13. Concordance
• ‘Patients should take more responsibility even if everyone is not
willing to do this.’ (Marinker ,1997)
• 'a new approach to the prescribing and taking of medicines.’
• ‘An agreement reached after negotiation between a patient and a
health care professional that respects the beliefs and wishes of the
patient in determining whether, when and how medicines are to be
taken.
• ‘An alliance in which health care professionals recognize the primacy
of the patient’s decisions about taking the recommended
medications'. (Nichols-English, 2000)

14. Continue
• The agreement may arise after an interaction procedure. (Marinker
,1997& Jones, G, 2003))
• Nevertheless, no one could know if patient wish to take part to this
interaction and if this could lead to useful outcomes. (Marinker ,1997)
• it is not clear whether patient’s agreement or common decision-
making process leads to behavior change. (Bissonnette J.M,2008)
• ’Doesn’t take into account the cases where some patients refuse
treatment either because they do not know about cost and benefits
or prefer to be hurt .
• ‘Compliance' and 'adherence' indicate patient behavior while the
term 'concordance' is not associated with behavior. (Horne et
al.2004)

15. Question of the day
• ‘A problem located in irrational patient beliefs that contradict
scientific evidence, or in patients’ lack of knowledge or
understanding’
• “Non-compliance fails to take sufficient account of the social context
of patients’ lives”

16. Ethical issues
• 'disease-centered model' according to which decisions about patient
treatment were taken by health professionals with little participation
of the patient
• the interest focused more on illness individually rather than on
patient as a whole.
• There was the perception that patients who seek health advice would
follow or will comply with the recommendations. Therefore, the
likelihood of disagreement with the recommendations of health
professionals or the likelihood of ambiguity and imprecision of the
recommendations, such as those presented by health professionals,
are not dealt with.

17. • ‘The difficulty of making a clear distinction between adherence to
medication and adherence to scheduled appointments, and these
two categories, were in many cases ambiguous and somewhat
artificial (Nose et al. 2003)

18. 'adherence', ta change towards approach to patient care
(patient-centered). Patients have the right to express a different
opinion regarding diagnosis and treatment regimen.
‘Patients evaluate instructions about treatment and they make
up their mind after having being informed. offer greater
satisfaction to the patient and yield better results. Patients are
treated as collaborators, are deep informed about their health
issues, are more involved in planning and decision-making and
encouraged to take responsibility in taking care of their health.
facilitates the patient-therapist interaction and help patient to
be aware of the therapeutic regimen. (Playle et al.,1998)

19. Conclusion
• . Patient refusal to follow a treatment regimen also affects the
nation's healthcare system. "If we could improve compliance, we'd be
well on our way to fixing the healthcare system regardless of what
reforms are ultimately passed.
• If health care advice is based on scientific evidence that the
treatment will benefit the patient, it is rational to assume that
patients will follow this advice.

20. • “A participatory relationship between patient and physician appears
to be the most important factor promoting medication adherence”
• “the more actively the patient is involved, the higher the level of
adherence and the greater the chance that the patient engages in
healthy diet and exercise behaviors.”(Bodenheimer, T, 2007)
• Coercion, the act of compelling someone to do something by the use
of power, intimidation, or threats, has been deemed a necessary
weapon in the public health

21. References
• Alikari,V &Zyga, S. Conceptual analysis of patients compliance in
treatment. Health Science Joiurnal