Self-Study Modules on Tuberculosis
Module 9: Patient Adherence to Tuberculosis Treatment
Patients' Rights and Due Process of Law
As a general rule, individuals have the right to ignore a doctor's advice or refuse treatment if they wish. However, persons with infectious TB may lose that right if health officials believe these persons risk infecting others by not taking their prescribed medicine. Patients who are unwilling or unable to adhere to treatment may be required to do so by law or may be quarantined or isolated until noninfectious. State governments have legal responsibility for TB control activities, including treatment protocols for nonadherent patients; the health care worker should refer to the laws in his or her state for those procedures.
The Advisory Council for the Elimination of Tuberculosis (ACET) defines nonadherent behavior as an inability or unwillingness to follow a prescribed treatment regimen. Examples of nonadherent behavior include
- Taking medication inconsistently
- Missing clinic appointments
- Consistently failing to report for DOT
- Refusing medications
Health care workers should notify the appropriate supervisory clinical and management staff when patients are nonadherent. The health official or a representative should find out why the patient is nonadherent and begin strategies that will help the patient finish treatment. Before legal measures are taken against a patient who has been taking TB drugs on a self-administered basis, DOT should be offered to the patient.
ACET recommends that before a court orders involuntary confinement, state and local TB control programs should have a treatment plan that goes step-by-step from voluntary participation to involuntary confinement as a last resort (Figure 9.8). The plan should begin with learning the possible reasons for nonadherence and addressing the identified problems using methods such as DOT, incentives, and enablers. The patient should be told orally and in writing of the importance of adhering to treatment, the consequences of failing to do so, and the legal actions that will have to be taken if the patient refuses to take medication. Figure 9.9 is an example of a letter given to patients who demonstrate nonadherent behavior and who may be candidates for legal action. If the patient does not adhere to DOT voluntarily, the next step may be DOT that is court-ordered. Court-ordered DOT is DOT that is administered to a patient by order of a public health official or a court with the appropriate authority. It is used when patients have been nonadherent despite the best efforts of TB program staff. It can be successful in convincing a patient that his or her TB treatment is an important public health priority.
TB control programs should not begin procedures for confining patients to a treatment facility until after the patient has shown that he or she is unable or unwilling to follow a treatment regimen implemented outside such a facility. Involuntary confinement or isolation for inpatient treatment should be viewed as the last step. However, when a patient with infectious TB refuses treatment and voluntary isolation, emergency detention to isolate the person is appropriate. Confinement can be either in a hospital or in some other institution with TB isolation facilities.
Figure 9.8 This is a flow chart that gives an example of progressive interventions for nonadherent patients to a TB treatment plan.
Figure 9.9 This is a sample letter (written at a low reading level), given to patients who demonstrate nonadherent behavior, and who may be candidates for legal action.
Throughout the process, there must be detailed documentation of the patient's nonadherence and the steps taken to address it. Although nonadherence laws are available in some areas, they may be hard to enforce and should be used only when all other measures have failed. When legal steps are taken, the health care worker must make sure that the patient's rights are protected; patients undergoing these procedures should have legal counsel.
Criteria for Determining the Need for Involuntary Confinement
When deciding whether to legally confine a TB patient to protect the public, local health officials must decide whether the person is at real risk of infecting others (now or in the future). To determine this risk, these factors are considered:
- Laboratory results (acid-fast bacilli smears and cultures)
- Clinical signs and symptoms of infectious TB
- An abnormal chest radiograph, especially if cavities are present
- A history of nonadherence (not caused by factors outside patient's control)
- The opportunity to infect others
An order to confine a patient should require that he or she be isolated until no longer a public health threat. This decision should be based on
- The patient becoming asymptomatic, with documentation of at least three negative sputum smears taken on different days
- The local health officer's decision that the person has completed therapy according to the most recent American Thoracic Society/CDC treatment recommendations
The patient should be ordered to receive treatment in a proper
facility until cured, unless it is certain that the person will
voluntarily complete therapy at home once noninfectious. If the
patient refuses the ordered treatment, the health officer should
have the authority to extend the confinement order as needed.
Study Questions 9.33-9.35
9.33. Give four examples of nonadherent behavior.
9.34. Describe the progressive interventions that should be attempted before a court orders involuntary confinement.
9.35. List the criteria for deciding if a patient should be confined.
Case Study 9.10
Walter, a 50-year-old single, unemployed male, was diagnosed with smear and culture positive, pulmonary tuberculosis one month before he was released from prison. The prison doctor telephoned the health department to report the case and asked them to take over managing Walter's TB treatment upon his release. The case manager assigned a health care worker to work with Walter. The health care worker met with Walter while he was still in prison and set up a plan to continue DOT upon Walter's release. For the first 2 weeks after his release, Walter adhered to treatment. He then began missing appointments at the arranged DOT site and at the clinic, stating he felt "okay." For the next few weeks Walter's visits to the clinic became rare. On Walter's latest clinic visit, his sputum smear was positive for AFB. The health care worker assessed Walter's problems and tried everything he could think of to get Walter to adhere to his treatment -- gave DOT at Walter's house or his favorite hang out, offered incentives, changed health care workers, and threatened legal action. When the health care worker mentioned legal action, Walter got very upset and threatened the health care worker. He stated that he felt "okay" and he was tired of the health care worker "harassing" him in front of his friends. The health care worker documented all of his efforts to get Walter to adhere to treatment.