In today’s healthcare environment, more treatment is taking place at home, rather than in a hospital setting. While this is often beneficial for patients, it can also be a problem for patients who have problems getting around or who are less mobile. The question is, who is responsible when a patient has a treatment plan but can’t or won’t follow it?
Dr C, 62, was a general practitioner who worked in a practice with several other physicians. He had been with the same practice, and at the same location, for close to 25 years, and many of his patients had been with him for well over a decade.
One such patient was Mr F, 70. Mr F had a history of obesity, hypertension, high cholesterol, atrial fibrillation, and cardiovascular disease. Dr C had been treating Mr F, a former truck driver, for the past 20 years and had increasingly lost hope in being able to change Mr. F’s behaviors. The physician had early on advocated for lifestyle changes, including losing weight and exercising, but Mr F had made little effort. At this point, the patient had long stopped working and was largely homebound. Mr F would periodically wind up in the hospital.
At the most recent hospitalization, Mr F was put on the blood thinner, warfarin. When Dr C came to visit his patient, he was glad to see that Mr F’s wife was there as well.
“You’re going to be discharged soon,” the physician told his patient. “But with this new medicine you are on, you are going to need to have blood work done regularly.” He then explained to the patient and the patient’s wife how the blood thinner worked, why it was important, what the risks were, and how important it was to have the blood work done each month.
“The nurse is going to schedule your first blood test for you and she will give you that information when you are discharged, later today,” said Dr C. “Once you get home, please call my office to schedule a follow-up visit.” Dr C knew about the importance of good documentation and was meticulous in his note-taking. He noted what he had told the patient and that Mr F was to call the office when he got home to schedule a follow-up.
Later that day, the discharge nurse gave Mr F the information about where and when his blood work would take place, and she reiterated the information and warnings about warfarin. The patient was discharged home, with instructions to go for his blood work and to follow-up with his physician.
When the patient got home, however, he neglected to call Dr C’s office to schedule an appointment. In addition, the patient could no longer drive and relied on his wife to take him places, but because she was still working she was not home to take him to his blood test appointment. Both Mr and Mrs F shrugged it off, figuring that as long as Mr F was compliant with taking his medication, he would be fine.
A week after the missed blood test, Dr C asked his receptionist if Mr F had ever called to set up an appointment. When the receptionist replied that he had not, Dr C asked her to call the patient and schedule an appointment. She called, but Mr F did not answer, and did not return the call.
Two days after the phone call, Mr F fell at home, hitting his head. His wife took him to the emergency department where she told the staff that although she had been unable to take her husband to his blood work appointment, she made sure that he took his warfarin as prescribed.
Blood work at the hospital revealed that Mr F’s INR was extremely elevated at 8.8. He was diagnosed with a bilateral subdural hematoma and underwent a bilateral craniotomy. The patient was discharged home, but due to problems with his coordination and confusion, he had to return to the hospital several times over the next few months.
A few months later, Dr C was stunned when he was served with papers informing him that he was being sued by Mr F. The lawsuit claimed that the physician failed to properly manage the medication regimen and failed to monitor blood levels, resulting in the fall, subsequent injury, and poor recovery. He also claimed that the physician failed to warn him of the risk of bleeding due to warfarin.
Dr C felt hurt and outraged that his patient would turn on him like this, but he understood that the patient’s mental and emotional status had changed drastically since the head injury. Still, Dr C was determined to fight this case, and his defense attorney was supportive after looking at the detailed notes and documented calls to the patient which were never returned.
The case went to trial, and because of Dr C’s excellent documentation the jury agreed that he had properly educated the patient and that the patient’s injury was due to the patient’s own failure to go for his lab work and to schedule a follow-up appointment with his physician. Dr C was found not liable.
Dr C did a good job of protecting himself by thoroughly documenting his instructions and his office’s attempts to reach the patient. This case, however, highlights the risks of miscommunication as a patient is transferred from a hospital setting to home.
To minimize your risks (and increase your patient’s likelihood of success in following instructions), it’s important to consider the patient’s age, ability to drive, economic status, and history of failing to comply with instructions. Investigate if resources are available to overcome compliance challenges, and document those. Always document when you or your office makes follow-up calls or tries to intervene when patients are noncompliant.
It’s often a good idea to schedule a follow-up appointment before the patient leaves the hospital or your office, rather than ask a patient to call to schedule one. Remember that patients may have challenges that you are unaware of that make it difficult for them to get to appointments or to be compliant with their medication. Protect yourself with good documentation, but also try to protect your patients by providing education on community resources.