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Should 'we' pay for the cost of non-compliant obese patients?

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You are reading page 9 of Should 'we' pay for the cost of non-compliant obese patients?. If you want to start from the beginning Go to First Page.

The refusal of healthcare to selected groups puts us on a slippery slope.

What about those who engage in extreme sports and have spectacular accdents? Joggers who damage their knees over time? Executives who get ulcers and have MI's because they drive themselves so hard? People in dangerous occupations? Anorexics?

While the example of this obese woman might tempt us to deny health care to such people, I suspect that her behaviour (non-compliant, demanding, "obnoxious") were factors in jlcole's reaction to her. I wonder, if she had been sweet and apologetic, would jlcole have been so angry about her?

Folks with multiple problems like this deserve compassion and continuing health teaching. By all means, ventilate to peers about behaviour, but as nurses we can't pick and choose who we like and don't like, who we will serve and who we will deny.

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To gaia1214: Unlike the author of the myopic initial post, you are smart, insightful, professional, and-- most importantly-- compassionate. :)

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If a non compliant person (over eater, tobacco user, or a person who drinks alcohol abuser etc expects the tax payer to pay their bills I do think there should be some kind of consequence to their behavior. Even people who refuse to take their meds should have to anwer to these reasons, I believe so anyway.

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I think that there is an issue but my issue is with your attitude of judgement. How do you KNOW that she "choose a lifestyle of gluttony and sloth"? Maybe she has underlying issues that cause her to be noncompliant because thatis the one area of her life she CAN control, good or bad...

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My apologies to jlcole. I got so emotional about the post that I got off on a tangent, writing about nursing care or denial of it to various groups. He or she was talking about welfare and social security to people with bad lifestyles, not nursing care.

But I do feel that the same principle applies. I believe that people do the best they can at all times, and if they could do better, they would. Before we consider righteously denying life-sustaining benefits to people who live badly by our standards, we have to think about behaviours and choices across the social/financial spectrum. People at all income levels have health and behaviour issues...and the poor likely have more stressors than the well-off.

The poor are simply handier targets for control through funding than the well-off.

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I work in a Medicaid HMO and we have thousands of members like this lady - and worse. Rapidly increasing Medicaid costs are the primary reason so many of the states are in serious financial problems forcing layoffs of police, teachers and other government funded workers. Arizona's answer was to deny organ transplants to children but the obese diabetic drug addict with self induced heart failure and chronic renal failure who gets admitted 10 times a year is paid for. It sure doesn't seem right. But rationing MEDICALLY NECESSARY and proven effective treatment is not the answer. This country can easily afford paying for treating all of its ill people regardless of why and how. What we can't afford is over treating, over testing, and medically unnecessary admissions. The Patient Protection and Affordable Care Act is good start and it would behoove nurses to get behind this law and support it. It helps people and it helps our profession

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I know I said earlier I was going to steer clear of the topic of judgemental remarks--and I did, for a while--but at the risk of being PC, words do matter. I can't at the moment recall ever having occassion to invoke any of the seven deadly sins in describing a patient's symptomology, but it isn't "sloth" or "gluttony" that's bothering me, just now. I think maybe the term that summarizes what's wrong with this thread is "non-compliant." Maybe we would do a lot better to leave compliance out of our vocabulary.

It seems pretty clear that the patient cited in the OP was not participating effectively in achieving her health care goals. Frankly, she probably doesn't even have health care goals. And can there be any doubt that the patient will suffer the ultimate consequences for her self-neglect? It could be argued that disease, dismemberment, and death are pretty serious forms of accountability.

A recurring theme of this thread seems to be impatience with all of the "excuses" for patients' bad choices. I'd like to suggest that a lot of the patients are equally fed up with the accusations that prompt those excuses. And I'll go a step further to suggest that our pride may be a barrier to effective patient care. We're so incensed that our patients don't comply with the edicts we experts hand down that it doesn't even seem reasonable to ask what the patient wants. Can any honest reader find anything in the original post that indicates respect for the patient's priorities or invites her participation? The patient doesn't obey our plan, so let's write her off.

I was floated to our oncology floor the other night. It's never as bad an experience as I think it's going to be. But one patient under my care had lung cancer, and when I asked after my initial assessment if there was anything she needed, she said she "could sure use a smoke." Being the bad, bad nurse I am, I didn't tell her that was what had put her in her current predicament. I think she knew that. In fact, my exact response was, "Yeah, me too." I did ask whether she had been offered nicotine replacement therapy. She said she had a patch, but "it ain't the same." I didn't tell her she would immediately go into v-tach and die if she smoked with the patch on. If you OD on nicotine, the first symptom is usually hiccups, and when you cut back on the nicotine, they resolve. I've never seen or even heard of anyone dying from smoking with a patch on. I've done it, myself. I got hiccups.

So, okay, I'm a terrible nurse and probably an enabler for missing a chance to get righteously indignant that this lady whose life is hanging in the balance had the audacity to admit she missed her cigarette. And I'm a horrible person because a couple of hours later, when I had a few minutes free, I went outside and had one for both of us. So, I'm going to hell for sure--if not for smoking, then almost certainly for sarcasm.

But it occurs to me that if that patient declared, "I'm going to die. If not from cancer, then from something else. So I'm not spending the time I have left doing chemo and radiation and surgery," many of us would respect that decision. I'm sure we would discuss the prospects for successfully fighting the cancer and ways to mitigate the effects of therapy, but our healthcare culture has come a long way toward accepting a hospice model of end-of-life care.

So, let's go back in time ten years, and that same patient states (hypothetically): "I'm going to die, if not of cancer, then of something else, so I'm not going to spend my remaining time going through the misery of smoking sensation..." Well, clearly, that patient is noncompliant and has no willpower and we shouldn't be wasting our time and money on her beyond lecturing her a few minutes about her lack of character and need to be held accountable. God forbid we work with her to find some way of quitting that isn't so miserable, or ask her what measures she is willing to take.

A previous poster mentioned pragmatism and was promptly reminded that if you burn more calories than you take in, you lose weight. Excellent! And that simple truth has been so effective that obesity and it's comorbidities are not an epidemic in the US. Judgemental remarks and condescending attitudes haven't worked better because our patients are stupid and we haven't been judgemental and condescending enough. It's not our fault we are failing so spectacularly--it's all these people and their excuses.

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The Health Care Nazi says, "No health care for you!"

(For the easily offended, simmer down. It's a Seinfeld reference.)

I got it immediately. I love Seinfeld. I improved today and had a tomato/spinach egg white omelet for breakfast. I guess today, I get covered.

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As for the meta discussion re: the term compliance (or adherence). In my mind, it is not a loaded term. One either adheres to, or complies with, recommendations or not. Making independent, informed decisions is important and if it is incongruent with a plan for optimum health, it needs to be labeled as such. Pick a word. It is unnecessary to tiptoe around the obvious, in fact I think it does more harm. I don't attach judgment to pt noncompliance, but the elephant in the room must be acknowledged.

I am completely non-compliant with the recommendation for auto maintainence. My car is 6,000 miles overdue for an oil change. I'm going to get to it ASAP. I just hope my mechanic doesn't judge me too harshly.

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Mike, how dare you articulate what I wanted to say so much better than I could have?

I never thought about the way we in health care use the word 'compliance' until I studied health ethics. In essence, as Mike pointed out, it's shorthand for 'not prioritising our plan for your body.' And yet we are almost all non-compliant in some way, at some point - I suspect I've never completed a course of antibiotics where every dose was taken on time and none were missed. If I find it that hard to take four pills a day for ten days, I cannot imagine how much harder the arduous regime of managing a chronic condition is, let alone several.

So I have a few questions for the OP, and anyone else interested in actually creating consequences for 'non-compliant' patients.

At what point do we decide what non-compliance is? Fat people who have no medical issues? Fat people who are still fat but eating well and exercising, even if they're doing these as ends in themselves? Fat people actively losing weight but still obese, morbidly obese or super obese? People with chronic illnesses who prioritise other needs over health care? How will these people be monitored, who decides, and what happens when the rules change?

The 'obesity epidemic' began when the US government redefined the demarkations between 'heathy weight,' overweight, obese and morbidly obese. Not only have the parameters of healthy ranges narrowed for a multitude of conditions, we now have tersm for conditions that are not yet, and may never develop into, actual diseases: pre-diabetes and pre-hypertension, for example. What happens to people who go to bed healthy and wake up at risk?

Although Australia is apparently rapidly gaining (so to speak) on the US for most obese population, I can count on two hands the number of super obese patients I've cared for in the past two decades, so this aspect is less of a concern for me professionally than it is for many other members. However, I agree that caring for patients who multiply re-present with potentially avoidable of reducable issues is frustrating. I find this equally the case whether it's a drug addict with T1DM back in again with DKA or a fluid-overloaded dialysis-dependent frequent flier. It's certainly harder to take when the patient is unpleasant, rude, disagreeable or abusive. But if it wasn't for universal healthcare I wouldn't have a job with which to pay my taxes, and however difficult caring for some of my patients may be, it's ultimately them that have to cope with the consequences of their lifestyle decisions.

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One more thing - all those 450lb super obese people that have been mentioned over and over again do not represent the many overweight people among us. I know how easy it is to see that image when hearing the term 'obese' but the vast majority of fat people are well and able-bodied.

Interested in how varied different people of the same BMI can look? Check out the BMI Project - it's fascinating.

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My response maybe not be well accept but we all need to focus on the realities of life. YOU WILL ALWAYS HAVE NONCOMPLIANT PEOPLE. I am not talking about those who have to choose between medication or food on the table. These people really need help especially if they are trying. I am talking about patients who comes in and Diabetes Type 2 or hypertension and you have them give you a diet recall and they had macaroni and cheese, potato salad rice fried chicken, and barbeque pork the day before. And look at me and say "I wonder why my blood sugar is high". My answer is NO, NO, NO. They should be responsible for their health like everyone else. My supervising physician and I was discussing noncompliance. She said the patient told her that she(the phyisician) had to live with her sugar being high. Now please tell me what sense does that make. I guess when she face with amputation ,renal disease, heart attack or stroke I guess she will have to LIVE with it. I am not at the best health either but I do exercise and watch what I eat. And my favorite meal is not a restaurant but in my kitchen where I know exactly how much calories and fat are in my meal.

As nurses we need to tell people the truth about their health. Be honest and truthful and some will listen. But those who refuse we must let it go. Sometimes you can not fix it. WE need to make these people responsible. Because let me tell you what will happen they will use all the resources and when you need it. You won't get.

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