August 3rd, 2017
“As I Lay Dying” — Patient Readmission and Non-Compliance
As I tie the last knot in a neat row of nine sutures, the night nurse calls me to room two. I drop my hemostats, peel off my gloves, and tell my patient I will be back. Across the hall, I find a girl thrashing around the gurney, chest heaving up and down, hands clasped around her abdomen. She stops moving only to retch into a bag. Her gasping breaths smell of pear drops, nail polish, and sugar candy. The ER attending is soon by my side. We know this girl. She presents this way every one to two months. I give her a nod of recognition, then start looking for IV access. Later, the labs confirm our clinical suspicion; she is in severe diabetic ketoacidosis (DKA).
When I review this patient’s records, I count seventeen admissions (to various facilities) for DKA in the past two years. Her HbA1c averages 14. Each time, the patient is admitted to ICU, treated and stabilized, then discharged with a plan for follow-up. Prior to discharge, the patient receives education regarding the management of diabetes, a consultation with a dietitian, a referral to a specialist clinic, and resources to aid her with her healthcare. Both psychiatry and social work have evaluated this patient. In spite of this, the patient continues to miss appointments, fails to refill her meds, and pays little attention to important factors, such as diet, exercise, and glucose control. Reasons for non-compliance, include: I am tired of being sick, insulin makes me fat, my boyfriend stole my meds, and I don’t like doctors.
The patient’s recurrent admissions have resulted in job loss, relationship breakdown and economic stress. The patient is stabilized during every admission, but she never appears to retain any of the education or advice given to her. Or if she does, she pays little attention to it. Control of her diabetes worsens. She lives crisis to crisis.
Truth is, she is not alone. Most emergency medicine providers have encountered patients like this, as have most of the broader medical community.
Let’s face it — the thoughts, actions, and motives of our patients frequently don’t make sense to us. And every human has a thought process that tumbles with varying levels of rationality, sometimes intentional and other times unintentional. Delusions and rationalizations along with a layer of narcissism and a sad tendency for self-destruction are part of the human narrative. But for the most part we don’t dance with death. Certainly, our patient’s narrative may sometimes seem irrational, but as clinicians we need to find ways — must find ways — to work around it.
Way back, Flexner et al in their article, “Repeated Hospitalizations for Diabetic Ketoacidosis: The Game of Sartoris” compared such patients to Faulkner’s Sartoris family. The Sartoris family appears hell bent on self-destruction. After the loss of a beloved son and brother in World War I, the family lives life on the edge and suffers for it. Their lives spiral out of control and the only resolution seems to be death, which inevitably comes. The authors liken the behaviors of this family to those of patients with recurrent admissions for DKA. They suggest that these patients – with theoretically manageable diseases – are, like Faulkner’s family, hellbent on a not-so-glamorous death. I am unsure whether these patients are truly hell-bent on death but I found the idea thought-provoking.
Recurrent admission for the same diagnosis is a serious problem for patients, providers, and healthcare systems. Non-compliance with medications and failure to follow up is associated with greater mortality and morbidity. The long-term complications of poorly controlled diabetes are devastating. We don’t want this for our patients. It contradicts the basic tenets of medicine, what we are about. Additionally, patients who are repeatedly readmitted consume a disproportionate amount of health care resources. Readmissions create problems with reimbursement. Furthermore, physicians and other healthcare providers struggle to manage these patients: they consume more time and resources, appear to not care about their health, and can trigger both frustration and compassion fatigue. The hard part, it seems, is not the management of the crisis but the prevention of future crises.
If we look at this problem logically, we can identify some manageable factors associated with patient non-compliance and readmission:
• Poor patient understanding of the disease or treatment
• Inadequate follow-up or confusion about follow-up
• Comorbidities such as substance abuse and psychiatric diagnoses
• Financial difficulties
• Lack of insurance
• Premature discharge
• Lack of discussion about care goals
• Low health literacy
I like to believe that there are ways we can improve the health of these patients. I do not think we have to resign ourselves to the fictional games of Faulkner. Undoubtedly, I have my own thoughts on how we do this. But I would prefer to hear the perspectives of my esteemed colleagues in the wider medical community rather than focus on my own narrative. So —
1) What can we do to prevent these readmissions?
2) How do you establish an effective care partnership with these patients?