Update - Positional Sleep Apnea Therapy

[DoriC]

More nonsense from someone who has not a clue about what they are spouting off about. And how is the Therapist supposed to get the lady to a Sleep Doc. Kidnap her perhaps. "Failing in his duty" indeed - arrant rubbish.

Of course! He thought perhaps I "might" have sleep apnea... he didn't know I had sleep apnea. He suggested that perhaps a sleep study might give us both more ideas about why I had little energy or motivation and was tired all the time. He suggested other things during our sessions, a sleep study was just one of them. Whether or not I decided to have a sleep study or do any of the things he suggested from time to time, was entirely up to ME! For him to tell me he wouldn't see me unless I did everything he suggested is so ridiculous it's beyond the beyond.

Again, if he said he would no longer see me unless I did everything he suggested, I would have laughed in his face. I may have even shot him!

Ems, Shot! Was that before or after you sued him for malpractice?? Our doctor tried for several years to no avail to get my husband into a sleep study because he suspected that many of his symptoms were related to OSA. Yet he still treated him for all his other medical issues, some related to sleep apnea and some not until my husband finally saw the light.

[mars]

Hi Everybody

This just arrived in my in-tray, and is relevant to the previous discussion.

From Medscape Business of Medicine > Ethics: Today's Hot Topics
Noncompliant vs Noncooperative Patients: Treat Them Differently?
by Arthur L. Caplan, PhD

Here is the link, which includes the video talk -

http://www.medscape.com/viewarticle/747 ... mp&spon=42

and here is the large print version -

Noncompliant vs Noncooperative Patients: Treat Them Differently?

Arthur L. Caplan, PhD

Posted: 09/14/2011

Hi. I am Art Caplan at the Center for Bioethics at the University of Pennsylvania. Today I would like to talk to you about the noncompliant patient, which raises lots of fascinating ethical challenges for doctors and other healthcare providers. Let me break this topic into 2 parts. One is the noncooperating patient, by which I mean the person who says, "I'm not going to vaccinate my child" or "I'm not going to follow what you tell me to do about my weight." The second is the noncompliant patient, who really does want to change but seems to fall off the wagon, doesn't take their medicine, doesn't follow up from an office visit, [doesn't] do what they need to do to get on top of their healthcare problem. The latter group probably has a bit more chronic healthcare challenges. The former is just a question of whether you put them in your practice. Let's look at that one first.

If a patient's parent says, "I don’t want to vaccinate my child," should the pediatrician even take [that patient] into the practice? I think the answer to this one is yes, although I know that there is a lot of controversy about this. A parent comes and says that she is worried about vaccine safety. "I'm not going to vaccinate my child, but I want you to be my pediatrician." The temptation is to say that if you can't follow basic recommendations from me about what is good for your child, then I can't take care of your child. Some pediatric practices and some pediatricians just say, "That's it. We're not going to take you as a patient." I think that you have to make an effort to try to manage these people. See if you can get them to change their minds. Work with them. Find out what they are afraid of. What are they really worrying about? Are they familiar with the diseases that kids can get if they don't get vaccinated? Are they worrying about what is going to happen if the child has a side effect or problem? Are they going to feel guilty? How can you deal with that kind of emotion?

It is important for doctors to try to work with patients to change their minds when, for whatever reason, they have a fear or a kind of false risk/benefit calculation about something that is absolutely an essential part of medical practice. It is important that you get your shots. I think it helps if you go to a patient and say, "I've had my flu shot. I've had my other shots. My kids have had their shots." We want to be good examples to people who are uncooperative.

What about the noncompliant patient, the person who you give the prescription to but they don't take their medication? We know that this is a huge problem. Some estimate that it costs $100 billion per year when patients don't do what their doctors tell them to do. The tendency here is to kind of yell at the patient a little bit and tell them to take responsibility, to do the right thing. However, I think that working with the patient in a more cooperative fashion is really the key. Yes, they are morally responsible for their health, but what you want to find out is what the obstacles and difficulties are. Do they have difficulties remembering to take their medication? Do they have cognitive issues? Are they depressed and sometimes find it too hard to do it? Do family members not reinforce them? What is getting in the way?

In both instances, the noncooperating patient and the noncompliant patient, the job of the doctor is to try to go the extra mile to work with them to get to the right healthcare goal. Punishing the patient or excluding the patient is not the right answer. It can be difficult. It can be frustrating to work with them, but you have to make a really sincere effort in both cases. That is the way to get maximum health opportunity for our patients, and obviously, that is our longer-term goal for all of healthcare. Thanks for watching. I am Art Caplan at the Center for Bioethics at the University of Pennsylvania.

Medscape Business of Medicine © 2011 WebMD, LLC

Mars

[jnk]

Another nice link, Mars.

Thanks.

I believe it should be our goal as fellow patients to treat fellow members of this forum in the same fashion--to make them feel welcome even when their views may happen to differ significantly from ours on basic matters.

[NightMonkey]

In both instances, the noncooperating patient and the noncompliant patient, the job of the doctor is to try to go the extra mile to work with them to get to the right healthcare goal. Punishing the patient or excluding the patient is not the right answer. It can be difficult. It can be frustrating to work with them, but you have to make a really sincere effort in both cases.

Thanks for posting that.

The therapist in question did not "try to go the extra mile to work with them to get to the right healthcare goal" nor did he "make a really sincere effort". He only "made a suggestion" one time over 18 months.

Bottom line IMO is still the same: The therapist delayed appropriate treatment for 18 months. The therapist failed this patient.

I can only hypothesize that this therapist may have treated dozens of patients with "talk" when the appropriate treatment would have been CPAP. This therapist may have failed dozens of patients.

Cost, time, suffering. This has to stop. The talk therapy industry needs to reform.

BTW, Did the violent talk scare VW off?

[mars]

I believe it should be our goal as fellow patients to treat fellow members of this forum in the same fashion--to make them feel welcome even when their views may happen to differ significantly from ours on basic matters.

Sometimes JNK, your gentle hints have the power of a jackhammer

I have edited my previous post which had unnecessary offensive remarks, and which no doubt initiated the post above. However, still struggling with perfection as I am, I have left in the necessary offensive remarks

NightMonkey

The therapist in question did not "try to go the extra mile to work with them to get to the right healthcare goal" nor did he "make a really sincere effort". He only "made a suggestion" one time over 18 months.

NightMonkey

You do not know what was tried or not tried. No outcome is ever guaranteed, you need to work on accepting that.

cheers

Mars

[ozij]

Bottom line IMO is still the same: The therapist delayed appropriate treatment for 18 months. The therapist failed this patient.

I can only hypothesize that this therapist may have treated dozens of patients with "talk" when the appropriate treatment would have been CPAP. This therapist may have failed dozens of patients.

Cost, time, suffering. This has to stop. The talk therapy industry needs to reform.

Here's a theoretical alternative interpretation of why 18 months of talk therapy were necessary before the sleep study took place, with apologies to ems for making up stories about her:

18 month's of talk therapy helped the ems finally go and get a sleep study. She would never have gone at all if it hadn't been for those 18 months of therapy, and escpecially not so if the therapist had thrown her out.

Some reasons for not going to get a sleep study:

• She didn't value herself enough to face her husband's objections - he wouldn't ever let her sleep outside the home
• There were hidden gratifications to a life of being a zomby, and she hung on to them
• She couldn't talk to her PCP in a way the would make him refer to a sleep study
• she came for therapy to complain about her children, and was in denial of all the other problems cropping up in her life
• she came to therapy because she had been involved in a traffic accident where she feel asleep, and she was depressed about the injustice of being fined, because she insisted it was the other dirver's fault...
• She was so alienated from her body the she did nothing at all to take care of her physical needs -- proper sleep being just one of them

And so on.

[jnk]

gentle hints

Occasional temper-flares are not an unforgivable sin, to my way of thinking, especially when apologies follow. We are, after all, often talking about things close to our heart that matter to us very, very deeply.

I apologize for any jackhammering, my friend. That wasn't my intent. I just wanted to make sure it was clear to others that you were angered by an idea, not attacking a person.

I think it is obvious that you have a kind heart, and I find your posts to have exceptional value to me.

Besides, I respect anyone who has found a way to put up with me! That's why I feel free to misbehave in your threads to bump them.

[jamiswolf]

Hi all,

Regarding non-compliant OSA patients...England has taken a legal approach.

If you have a diagnosis of OSA and are not treating it, then it is illegal for you to drive.

I don't know all the details, but on a UK cpap forum I belong to, there's lots of discussion about it, If you lose your license, you can get it back with a note from your sleep Doctor to the DMV showing your treatment is working.

Jamis

[NightMonkey]

NightMonkey

You do not know what was tried or not tried.

I do know what was reported here. It was reported as "a suggestion" with no indication of followup by the counselor during an 18 month period. The counselor failed.

NightMonkey
No outcome is ever guaranteed, you need to work on accepting that.

I don't know what your "outcome" remark means. We have been talking about the failure of the therapist to recognize the seriousness of sleep apnea and to be a strong force in getting his patients to visit an appropriate specialist over a period of 18 months.

The outcome I would like to see is for upfront screenings for SDB and patient education to become routine for all counselors. Part of the counseling should be to get positive-screened patients to have consultations with sleep doctors ASAP.

You use the word "accepting" in reference to me. I will not accept that counselors cannot do a much better job than the very poor job many of them are doing today.

[Julie]

Hi Night Monkey -

Do you think every therapist who thinks a client might have a thyroid problem (a condition OSA is commonly mistaken for) should somehow enforce that the client be tested for that? And what about a slew of neurological conditions the therapist might perceive to be a problem? Where would it end after all - I think the therapist would be out of business very quickly!

A reasonable person makes a suggestion, may follow it up in a while, but beyond that, it is not the place of a therapist to do more after all, not actually being trained to screen for medical problems, plus clients could possibly even stop trying to get help for emotional trouble if it became obvious that in fact they were being looked at as potential candidates for medical intervention and they did not want that, but still wanted help for the emotional problems.

You can't be all things to all people, nor can you treat them like children. Better education all around is certainly a good idea, but to be used appropriately, within reason.

[DoriC]

ems, Show me one therapist who screens all patients for sleep disorders upfront and sends the positives to sleep doctors and it will give your statement some credence.

My therapist. If I had listened to him a year and one-half ago, I would have started CPAP a year and one-half sooner. He didn't "screen", but suggested I go for a sleep study.

Well that is something, but not much.

I could not with good conscience continue to practice talk therapy on a patient for 18 months when I suspected a sleep disorder. Every session would begin with, "Have you had a sleep study yet?" and end with, "I have to discontinue your therapy unless you immediately make an appointment to see a sleep doc."

Ems certainly doesn't have to discuss her personal life here but I'm pretty sure she got some very helpful treatment from her therapist in all that time regardless of the fact she didn't immediately take his suggestion for a sleep study. Ems sounds very smart to me and she wouldn't be completely wasting her time in these sessions if she weren't getting some benefit on unrelated issues.

[ems]

Ems certainly doesn't have to discuss her personal life here but I'm pretty sure she got some very helpful treatment from her therapist in all that time regardless of the fact she didn't immediately take his suggestion for a sleep study. Ems sounds very smart to me and she wouldn't be completely wasting her time in these sessions if she weren't getting some benefit on unrelated issues.

Thank you, Dori!


Nightmonkey... I give up on you. You don't want to get it, so you won't. You seem to be one of those people who think... it's my way or the highway. Well, my new friend, you are wrong! Again, do you think he should have taken my hand and walked me to a sleep specialist? I'm a grown woman for heaven sakes, with a mind of my own. There were suggestions he made that I went along with. Seeing a sleep specialist wasn't one of them because I was 150% certain that I didn't have sleep apnea. Again, seeing a sleep specialist was only one of the suggestions he made. Being the good therapist he was, he allowed me to decide what I thought was best for me!

Oh never mind... with all due respect... you'll never get this.

[ems]

The outcome I would like to see is for upfront screenings for SDB and patient education to become routine for all counselors. Part of the counseling should be to get positive-screened patients to have consultations with sleep doctors ASAP.

Yes, that would be wonderful... and I also would like to see every unemployed person in the US find a job today, the stock market close at over 16, interest rates drop to 2% on home mortgages, and world peace.

[NightMonkey]

I will continue to have a different standard than most of you who have replied. My expectations will remain that all counselors are trained in screening for sleep-disordered breathing and perform screening on the first visit. Added to that would be an expectation that if the patient is screened positive and is recalcitrant to visit a sleep doctor, the counselor will work tirelessly to get the patient to act on this issue.

The only thing to be added would be that all GPs should have already done the screening before the patient ever gets to a counselor.

Hey, I am headed to the airport this minute to pick up my girlfriend. We have a big weekend planned.

Hope youse all enjoy yours,

[mars]

I have simplified the issues,

The issue is already quite simple and none of the posts were as long and complicated as yours.

This is not about refusing to help the patient. It is the exact opposite. It is about helping the patient in an effective and timely way.

Mental health counselors should be trained to screen all patients on the first visit for SDB. The same for GPs, hospitals, and many of the specialists.

A person contracted with a mental health counselor should not have to wait 18 months to find out they have sleep apnea. That is extremely poor medical care.

It is a very simple issue.

Hi NightMonkey

and here's me thinking I was clarifying it for you

Of course, you did say

Your therapist is either ignorant of the mental health problems that sleep disorders cause or was too gutless to say, "I have to discontinue your therapy unless you immediately make an appointment to see a sleep doc."

and that is what I thought I was responding to.

Trying to prove that you got something right by responding about something that was not questioned is an old trick, not in the least honest or helpful. Sorry you took it that way, but I never continue discussions with those who use spurious arguments.

cheers

Mars

So now - without arguing with you further - I hear you say -

I will continue to have a different standard than most of you who have replied.

Well, being a bully, being dishonest, being illogical, having a closed mind, and denigrating those who are trying to help others within their training and capabilities, and disrespecting the original poster, does mean you have a different standard than most of us

Together with your abysmal understanding of human nature it is a standard most of us will not aspire to.

Sadly, it also means you are missing out on continued learning, and using those opportunities to see that vulnerability is a strengh, not a weakness.

No doubt you will have the last word, but what good will it do you ?

Mars