It is a rare patient who always does everything healthcare providers
advise. Sometimes no harm comes from this; sometimes good does. But
occasionally, great harm comes from not listening, as when it results
in patients returning time and again for costly and invasive treatments
of, say, infections, valve replacements, pressure ulcers, and so forth.
No class of patients arouses more anger and resentment in healthcare
providers, who often put out a call to invoke some version of the three
strikes rule and refuse care. And if the patients are also unemployed
substance abusers who live in a local park, impolite or dangerous to
staff, disruptive to other patients, and have intimidating visitors,
the call to say “No” is louder. Can care ever be refused?
If so, when? These are the questions we take up in this article. The
answers we provide were developed as part of a Paraplegics and
Quadriplegics with Pressure Ulcers Project carried out at Vancouver
Hospital and Health Sciences Centre. Following an established usage,
we refer to patients who exhibit a cluster of the above characteristics,
the dominant one of which is a reluctance to heed medical advice, as
“noncompliant patients.” This term is offensive to some, but
the politically correct lexicon does not provide any alternative which is
as short and clear or substantially different. We use the term as a
convenient way of referring to a familiar class of patients and without any
imputation of blame.