By Ryan Pferdehirt, D.Bioethics, HEC-C

March 2022

Bioethics case study on non-adherence and doctor/patient relationship.

A 45-year-old female-identifying patient is brought to the ER for suspected cardiac symptoms. Her name is Peggy. Peggy is accompanied by her son Michael, who informs the attending physician that his mother has been complaining of chest pain.

After learning more about her medical history, the physician suspects her symptoms are indeed cardiovascular related and untreated hypertension. A brief phone call with Peggy’s primary care physician confirms this; her PCP notes that Peggy was prescribed blood pressure medication several years ago, which she has not been taking despite her family’s constant pleas. After a cardiology consultant examines the patient and runs some tests, it is determined that the patient has sustained heart damage, which is correlated to medication nonadherence for hypertension. The cardiologist assures Peggy that the cardiovascular issues are still treatable. However, to avoid ER readmissions in the future, the patient is urged to make significant lifestyle changes and start taking her hypertension medication. The attending physician subsequently meets with Peggy and her son to discuss this diagnosis, prognosis, and the proposed treatment plan. Peggy nods her head enthusiastically in agreement and promises to start taking her prescribed medications. Peggy says she wants “to get better,” that she wants “to live a long, healthy life for my children and grandchildren.” Michael doubts, however, that his mother will make these changes. He says, “Mom, you’ve made these promises in the past and yet we’re here in the ER. Your family loves you so much, but how can we be sure you’re telling us the truth this time?”

The physician is concerned. Peggy’s history of nonadherence and Michael’s plea signal a potentially deeper issue. The attending physician wants to provide the best medical care possible, to see his patients recover and remain well. But he tells a colleague that he isn’t convinced that this patient “gets it.” “She knows what she needs to do to get better, yet there seems to be no desire on her part to get better. It’s a shame that we have to send these noncompliant patients home only to see them right back here again a few weeks later.”

What should be done?