The Problem of Non-Compliance in Wound Care

One of the most difficult aspects of patient care is dealing with non-compliance. How do we help those who refuse to help themselves? This question is very convoluted indeed! The best treatment protocols in the world will be unsuccessful if the patient does not follow the recommendations. Patients with chronic wounds are usually those with multiple comorbidities such as uncontrolled diabetes, autoimmune disease, and uncontrolled hypertension. This complex medical picture is challenging enough for all of us trying to heal them, but add the patients' lack of concern for their own health and it is quite frankly maddening. I find myself often saying, "Help me help you" or "Healing is a team event," although mostly my genuine pleas for partnership fall on deaf ears.

I find navigating non-compliance to be a jigsaw puzzle, a lot of maneuvering and strategic planning. I realized that my frustration was only burning me out, not improving outcomes, so I needed to make a change. How do I save my sanity yet mitigate my patients' self-destructive tendencies?

One Patient's Story of Wound Healing

For me, it all started with a patient of mine whom I affectionately call "Mr. Puzzle Piece," and he embraces this moniker. When I started my limb salvage program, he was one of my first referrals from another physician within my department. It was widely believed that Mr. Puzzle Piece would never heal because of his uncontrolled diabetes with severe peripheral neuropathy. He already had a history of digital amputation and now had burn wounds on both of his feet from walking barefoot in the sand. I found him to be "pleasantly unaccountable" in terms of his health and that he felt as a city contract patient (charity care coverage through the hospital) that he was not important at all. We worked together regularly, growing our mutual trust and seeing the positive results of this collaboration. I felt so confident that we would see full healing in a reasonable amount of time... until the "Colorado trip."

My patient announced one day that he would not be able to make his upcoming weekly appointments because he was going to Colorado for a month or two to visit his family. Instantly I was filled with worry because I knew he had no insurance coverage outside of the city of Jacksonville, Florida. Given this lack of insurance coverage, he would not go to the ER in any other location because of the financial burden. I did my best to provide written wound care education and basic supplies to aid him during his sabbatical from our clinic. All I could do was wait for his return and hope for the best.

His return brought about an immediate hospital admission with surgical intervention for an exposed Achilles tendon through his wound bed. I was horrified at how quickly his condition had deteriorated. Together we worked to get back on track and resumed his weekly treatment. As time went on, we made healing progress with some of his wounds, only to have another wound develop or worsen. This was the genesis of his title, "Mr. Puzzle Piece," a constant jumble of progression and setbacks.

So a year later, all of Mr. Puzzle Piece's original wounds have healed, as well as two new ones that surfaced because of lack of offloading (not wearing the insoles with metatarsal padding that I made specifically for him). He announced that he planned to return to Colorado again to see his grandchildren, and my heart sank. I very candidly explained to him that I do not want him to regress like he had previously, and this is out of a place of concern. He agreed, and by now, recognized my sincerity. I asked him, "How can we make this work better this year while you are away?" My patient thought for a minute and stated, "This time, I will call you to check in," and I agreed to this plan. So along with written dressing change instructions and basic supplies, I gave him my cell number. About three weeks into his holiday, I received a call to verify how much saline to use to lavage his wound. We discussed the steps again, and he related that everything was going well. At the end of our conversation, I said, as I always do at the end of our visits, "make good choices." One month later he returned home to us. His wounds had actually improved, and he was proud of himself. He said, "My daughter said you must care about me, so I should probably listen this time," and we both laughed.

Conclusion

Patient compliance cannot be forced, and is tricky for all health care providers. For me personally, I have learned to accept what I cannot change. I still provide full support and hope that my patients will reach out to me, if they are in need. When I feel defeated, I concentrate on the positive outcomes that we have achieved. We are all a work in progress, some of us more puzzling than others.

About the Author
Christine Miller DPM, PhD is a certified wound specialist by the American Board of Wound Management and a Fellow of the American College of Clinical Wound Specialists. She currently serves as the Co-Director of the Limb Salvage Program at the University of Florida, College of Medicine-Jacksonville.