Helping noncompliant patients cheat more effectively

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Helping noncompliant patients cheat more effectively

Editor’s note: The following column was adapted from HCPro’s Case Management Mentor blog site. To read more posts about case management issues written by case managers, visit

by Kathryn Bradshaw, RN, BSN

Teaching noncompliant patients how to cheat seems counterproductive, but this strategy saved lives in one medical center’s renal patient population.

A large teaching hospital surveyed its renal patients and found that most didn’t adhere to their very restricted diet. Salt was the main culprit. Potassium-rich foods came in a close second, and, unfortunately, street drugs were the third problem.

Salt substitutes

The case manager assigned to the renal patients worked closely with the nursing director and unit staff to create realistic diet goals.

They tackled the salt problem first. The team created five reduced-salt spice recipes taken from a renal cookbook and conducted a taste test. Each patient rated the spice concoctions from best to worst. Staff and physicians contributed money to buy the highest rated spices and gave them to the patients along with the recipes.

Potassium compromise

The team then took on potassium-rich foods. First, the case manager ordered a dietary consultation to ensure that educational deficit wasn’t the problem. 

She then met with each patient who admitted to eating more potassium-rich foods than allowed. They reached a compromise that allowed patients to have these foods twice per week as long as it was two to four hours before dialysis. 

The team knew that dialysis would help eliminate excess potassium and that cheating only twice weekly was far better than indulging daily.

Illegal drug use 

The most telling conversations were with patients who had used illegal drugs. One major problem was when they used them. Some patients had used them just prior to their dialysis treatments, which often caused the patients to go into full cardiac arrest during the procedure.

The team approached the nephrologists to discuss their proposal and get consent to talk with specific patients. The physicians’ agreed as long as patients had been offered rehab and either refused or failed.  

The case manager (and team) spoke with these patients confidentially. She explained that using drugs prior to treatment would cause them to arrest while on the machine, and one day nurses might not be able to save them. She also told them the dialysis machine removes the drugs from their systems, and they were simply wasting their money. 

The case manager offered drug rehab as the best option, but just as they had several times in the past, the patients refused. She then outlined the worst times for them to use drugs, which prevented future cardiac arrests for at least three patients. 

Case managers need to be aware of what patients’ lives are like outside of the hospital. When patients understand that the case manager is simply trying to help find a workable solution, they will be more open to following a regime they can truly live by—hopefully for a long time.

Editor’s note: Bradshaw is the managing director of Bradshaw Healthcare Solutions, Inc., in Richmond, VA.