Shades of Gray in Prescribing Medications

I remember having a patient several years ago who had not been in for a visit in over a year but needed his insulin refilled. I considered the issue of him not being up to date on recommended testing and the potential danger of unmonitored insulin use and weighed that against the danger of hyperglycemia. I refilled the medication and arranged for a follow up visit. It was only after he continued to refuse to come in for another six months that I finally said "no" to any further refills. However, I did this with a heaviness in my heart.

In the last couple of weeks, this scenario has repeated itself three times with patients who either report that they cannot come in for an appointment because of copays or transportation or who simply have no-showed visits. In all three cases, they are on psychotropic medications that are likely necessary for their ongoing social and occupational functioning. I feel very torn as I consider the jobs and relationships that are in jeopardy once they stop their medication. However, I know from a standard of care and evidence-based assessment, I cannot continue to prescribe medication when I am not able to clinically monitor response and adverse effects. The fact is we do practice in an environment where our license and livelihood depend on our following specific safe practices.  We are vulnerable if we do not do so, even if we know the cost is that a patient will go untreated.

We have agreed to the adage of "do no harm". Usually this is pretty clear to me - I prescribe treatments and medications only when the benefit outweighs the harm. However, in situations in which the patient has a demonstrated need for a medication, but will not adhere to recommendations for follow up visits or lab monitoring, I am not sure where the burden of harm falls. Is it more harmful to continue insulin or fluoxetine even for a patient who refuses to come in for an appointment or to refuse to prescribe the medication? Are they in greater danger from hyperglycemia or uncontrolled depression or from side effects and adverse effects of the treatment?

I do what I do for the benefit of my patients. That is the reason why I have been entrusted with the awesome privilege to care for people as their physician. However, when there is conflict - a patient disagrees with my recommendation or refuses to abide by a safe care plan, how do I discharge my obligation to them? Do I "fire" them, withhold treatment until they comply, acquiesce as long as they understand the consequences? It is not always clear and it is never easy.

So, I will tell these three patients that I will not be refilling their medications. I will offer an appointment. When they fail to come, the only benefit I can seek for them is to hope they land softly in another's care.