In Taking Lessons from Infectious Disease, Carrie Arnold at ED Bites makes an intriguing comparison between DOT and non-negotiable management of eating disorders. Hers is a unique perspective because her experience being treated for anorexia is complemented by her work as a state TB Program Coordinator, a position with the authority to invoke court-ordered hospitalization for noncompliant patients.

She points out the similarity of DOT and the Maudsley Approach to treating anorexia:

Commentary

The entire post is worth reading if for no other reason than the author’s point of view and consequent insight into noncompliance with treatment.

In addition, however, the point that coerced treatment is sometimes necessary is important because it belies the typical, almost automatic, and all too simplistic responses clinicians and academicians offer when confronted with noncompliance - educating and empowering the patient. Those are indeed wonderful tactics, but only when they work.

In circumstances such as life-threatening anorexia and population-endangering infectious disease (see also Proposing Coerced Treatment Compliance), healthcare professionals dealing with a noncompliant patient have the obligation to recognize the when education and empowerment are ineffective and take appropriate action even when that places them in opposition to the patient.

In such situations, to paraphrase Ms Arnold,

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Drug Courts: A Way to Lower Costs and Reduce Recidivism? by Bob Ellis. Dakota Voice 8/02/2006
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Drug Court Background

Drug courts, combining substance abuse treatment with a pending criminal case, began in the late 1980s and have been promoted as a means of relieving an overcrowded court system and reduce criminal behavior. The March 2004 National Drug Control Strategy Update, issued by the White House, called drug courts “one of the most promising trends in the criminal justice system,” and one cost-benefit analysis calculated that drug courts saved $2,329 in direct cost to the criminal justice system and another $1,301 in victimization costs. As of December 2005, there are more than 1,500 drug courts in the United States with another 391 planned

The 2006 Assessment of Drug Courts

A National Institute of Justice report, Drug Courts: The Second Decade, released in June, 2006 provides an overview of this model, based on the examination of 26 drug courts. Findings include:

• Drug courts can decrease recidivism. Between 1993 and 1997, 53% of drug court participants were rearrested versus 65% not placed in the drug court system.
• Treatment was more effective in programs that were based on formal theories of drug dependence and abuse and implemented evidence-supported therapies. Programs based on mixtures of philosophies or idiosyncratic philosophies were not as effective.
• Drug courts saved $1,442 per participant ($1,172 in incarceration costs and $908 in probation costs) compared to “business as usual” processing of drug convictions.
• 64% of the participants failed to attend the required number of treatment sessions; 36.5% “graduated” from drug court programs without completing the required number of sessions.
• 54% of participants did not receive the minimum number of drug tests (70% of the standard) called for by the program requirements. 33% of participants “graduated” from drug court programs without completing this requirement.
• 76% tested positive for drug use one or more times, and 61% tested positive two or more times.

The report concludes that drug courts can lower recidivism and save money, but the results of a given program is contingent on (1) the use of effective therapies and (2) adherence to program.

Commentary

I selected this report for today’s post because it conveniently disproves the simplistic notion that, with sufficient authority and/or threat, compliance is a given. Adherence is a determinate of success in drug court participants and it is major problem in these court-mandated drug treatment program despite their capacity to leverage criminal charges and imprisonment to enforce compliance.

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He Wasn’t Thinking Straight. So How Do You Get Through?
Sandeep Jauhar, M.D. New York Times July 11, 2006
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This is a first-person article sketching the author’s experience with a patient refusing cardiac catheterization and the difficulty in the real world of clinical practice of making the judgment of whether a given patient, if obvious signs of psychosis or dementia are lacking, is competent to make the decision to comply with treatment or refuse it.

Dr. Jauhar also discusses the 1978 case of Mary Northern, who was ruled incompetent to make a rational decision about having her gangrenous feet amputated because, while generally sane, she had the psychotic belief that her obviously diseased lower limbs were blackened only because they were dirty.

Dr. Jauhar’s own case, however, is more ambiguous. The exchange between physician and patient is described thusly:

The patient then threatened to leave. Dr. Jauhar reports his judgment that the patient was not competent to make medical decisions because the patient “did not understand his medical condition or its treatment options and the risks and benefits,” an inability to recognize his medical problems which Dr. Jauhar views as the equivalent of Mary Northern’s psychotic view of her condition.

Dr. Jauhar notes that the patient could not be released because “if something happened to him, I would be liable.” When threatened with security, the patient “backed down.” By the next morning he appeared more reasonable, was judged to be competent, and then signed out against medical advice.

Commentary

Dr. Jauhar’s article is, I believe, useful in dispelling the all too common notion that the determination of a patient’s competence is simply a matter of applying legal criteria.

In this case, in fact, I am less confident than Dr. Jauhar that his patient would have been adjudged incompetent by a court, at least those operating in the jurisdictions where I have practiced. Of course, Dr. Jauhar’s database re this patient – and his responsibility for the patient – is infinitely greater than mine, but my dissent may illuminate the problems in determining competency.

Dr. Jauhar’s patient was sarcastic and skeptical, not delusional as was Ms. Northern. He didn’t attempt to explain his situation by expounding an alternative theory that was bizarre or nonsensical. By the written account, at least, he simply didn’t agree with the diagnosis or the recommended treatment. While neither psychosis or dementia is an absolute requirement for a declaration of incompetence, mere disagreement with the physician’s diagnosis or treatment plan is not sufficient evidence of an inability to make ones own medical decisions.

To judge a patient as incompetent to refuse to follow a physician’s recommendations exclusively because the patient denies the validity of the physician’s findings is clearly a circular argument.

On the other hand, I suspect Dr. Jauhar’s concern that “if something happened to him [the patient], I would be liable,” is well-founded.

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