The Ethical and Practical Challenges of Patient Noncompliance in Orthopaedic Surgery

Abstract

A fifty-five-year old man attends a trauma follow-up clinic six weeks after undergoing primary repair of a zone-II finger flexor tendon laceration. The patient has a history of substance abuse and has been noncompliant with postoperative treatment. He has not attended any postoperative outpatient or physiotherapy appointments, he removed his splint immediately on discharge, and he admits to moving the finger freely without restrictions, against advice. On examination it is evident that the patient has sustained a rupture of the tendon repair. Does the history of noncompliance with initial treatment affect decisions regarding the further management of this patient? The term compliance relates to the degree of constancy and accuracy with which an individual patient follows a prescribed treatment. Patient noncompliance is a common problem across all specialties and presents a major obstacle to safe, effective, and efficient health-care delivery. In this article, we discuss the risk factors for noncompliance, the difficult ethical and medico-legal dilemmas posed by this issue, and mechanisms for potential solutions to this common problem.

Effects of Compliance With Procedure-Specific Postoperative Rehabilitation Protocols on Initial Outcomes After Osteochondral and Meniscal Allograft Transplantation in the Knee

“…Led by a health behavior psychologist, the team also identifies patients at risk for noncompliance based on documented patient-related factors (eg, attitudes, motivation, sex, and understanding), socioeconomic barriers (eg, literacy, education level, support system, employment, and insurance status), and condition- and treatment-related factors (eg, BMI, pain, coexistent conditions, length of postoperative rehabilitation, and lack of early symptom relief). 22 The team works to overcome barriers to compliance before starting the process of insurance precertification and graft requests, and patients are asked to sign a “rehabilitation partnership contract” (Appendix 6, available as supplemental material) that documents their understanding of the prescribed protocol and timeline and their commitment to fully complying with it. In addition, postoperative rehabilitation protocols and patient management strategies are adjusted (eg, step count limits, educational videos, vitamin D supplementation, bone stimulators) on the basis of best current evidence from the peer-reviewed literature and the continuous real-time analysis of our registry data.…”

Ethical Concerns in Caring for Elderly Patients with Cognitive Limitations

“…Four widely accepted bioethical principles of autonomy, beneficence, nonmaleficence, and justice are particularly relevant in orthopaedics 3,4 . Briefly, respect for autonomy requires that mentally capable orthopaedic surgical patients be allowed to make voluntary treatment decisions without undue influence from others.…”

“…Nonmaleficence describes an obligation to not inflict unnecessary harm on a patient, and thus requires orthopaedic surgeons to balance the risks and benefits of various procedures and to avoid preventable injuries. Beneficence refers to a duty to promote the well-being of a patient, which is a basic tenet of orthopaedic surgery 4 . Justice deals with fairness, equality, and equitable treatment of all patients.…”

“…While further empirical research is needed to confirm whether or how other aforementioned decision and engagement-enhancing methods can help surgeons to optimize the time spent with patients, related data suggest that capacity-adjusted shared decision making can reduce dissatisfaction. Patient engagement, particularly when carried out in decision processes that match the patient's preferences for e16 (4) participation, has been shown to promote realistic perceptions of benefits and harms in total knee arthroplasty, thereby enhancing patient satisfaction with both the process and the outcome 37,49 . As patient satisfaction is in turn a key determinant of patient outcomes and an important component of payfor-performance metrics 50 , prospective collaborative studies including orthopaedic surgical teams and other health-care stakeholders may help to explore the long-term cost-effectiveness of capacity-adjusted shared decision making.…”

The complexity of patient adherence in orthopaedics: A qualitative study to identify barriers and develop strategies for adherence partnerships

“…(Avilucea et al., 2009; Mertz et al., 2019; Rayan et al., 2012; Schwarzer et al., 2008) Similarly, definitions of adherence have been primarily patient focused, failing to consider non‐adherence related to the healthcare team and/or healthcare system. (Erlen, 1997; Rucinski et al, 2022; Sciberras et al., 2013) As such, previous research has been largely assumptive, labeling patients as non‐adherent without considering the array of modifiable and non‐modifiable barriers to adherence that patients may face. (Erlen, 1997; Sciberras et al., 2013)…”