Communication skills can help to overcome noncompliance, a common problem in the ambulatory care of heart failure. However, the transformation takes time. Motivation is vulnerable, and fluctuates from situation to situation. Patients must be allowed space in which to reorganize their knowledge and develop new attitudes. The physician's task is to learn to recognize the (mainly verbal) indicators of the phases in the transformation process, and adjust his/her communication strategy accordingly.
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Indicators of lack of motivation include the denial of possible reasons for noncompliance (Doctor, you are not right. I am not overdoing it. I am not tired. I am used to this situation‚), the refusal to change attitude (Doctor, listen. You don't know all my problems, but next week, I absolutely have to take care of my grandchildren‚), or the self-sufficiency stance (Doctor, thank you, but I'm perfectly aware of what I have to do‚). Patients are discouraged by their perception of earlier failures (I started a diet before, but it was impossible for me to keep to it at the time‚), and may even be hostile (Doctors make mistakes too. I'm not convinced by what you say. Could you do what you're asking me to do?‚).
In such cases, the doctor should not judge (What you are doing is wrong‚) nor offer stereotyped solutions (You must take my advice if you want to feel better‚). It is better to ask open questions (What do you think brought you into hospital? What do you see as the risks if you carry on acting this way? ?), play the active listener role by reformulating the patient's position in your own words (If I've understood you right… ‚), and pay selective attention to the more relevant items of information supplied by the patient (I definitely agree with you on…, ‚ I can see you are trying to understand the best way of solving your problem by… ‚).
That a patient can conceive of changing indicates some awareness of the problem (with all these drugs, could I get back to what I was? ?), although this may often have magic overtones (Doctor, if I do as you say, you think everything will be fine, don't you? I am sure that you'll help me, they told me you're are very good doctor‚), and there may not be an immediate plan for change (There's still something I need to do yet‚). In such cases, try asking the patient to list the advantages and disadvantages of the right and wrong behavior (What do you see as the benefits of the treatment I'm suggesting? And its downside?‚… If you choose not to follow my suggestions, what do you see as the positive consequences? And what do you see as the negative consequences? ?). Make the patient believe that change is within their reach (I had another patient who, like you, was unable to drink one and a half liters per day, but then she tried melting ice in her mouth instead of drinking and it worked!‚).
Indicators that a patient is ready to take herself in hand include no more questions about her disease, no arguing, no interruptions instead, a willingness to listen, with open questions on the treatment, such as Doctor, what's the best way of increasing my fluid intake? ?. The next phase will be one of action in which the patient sets herself goals. At this point it is useful to identify short-term objectives and reinforce the success to date, if necessary with telephone feedback on the treatment.
It is best to minimize lapses (Patients are often unable to maintain such high standards for long. Don't worry, mistakes are also how we learn‚), perhaps with a little analysis (Let's try and understand what happened, so we can prevent it from happening again‚), and an introduction to simple problem-solving (You told me that you forgot the diuretic after a very hard meeting at work‚). Help the patient identify the strategies that will stop him forgetting again (Tell me everything you can think of that might remind you to take the medicine‚).
Noncompliance can also be an occasion for the doctor to reevaluate the advantages and disadvantages of the strategies employed to date, and perhaps replace them with new ones.
Majani G. Compliance, Adesione, Aderenza. I Punti Critici Della Relazione Terapeutica [Compliance, Adhesion, Adherence. The Critical Points of the Therapeutic Relationship]. Milan, Italy: McGraw Hill; 2001.
Miller W, Rollnkk S. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York, NY: Guilford Press; 1991.
Prochaska JO, Di Clemente CC. The transtheoretical approach: towards a systematic eclectic framework. In: Norcross JC, ed. Handbook of Eclectic Psychotherapy. New York, NY: Brunner/Mazel; 1986.
Management; communication; noncompliance; motivation; strategy.