Saturday, January 20, 2007

To Cudgel or Not to Cudgel

cudgel \KUH-juhl\, noun:
1. A short heavy stick used as a weapon; a club.

transitive verb:
1. To beat with or as if with a cudgel.

Good ol' Almost always food for thought, grist for the mill, and fodder for blogging.

Apropos of yesterday's post, the concept of cudgeling is something worth consideration. When a patient refuses to take his or her medications, misses appointments either through avoidance, sabotage or outright self-neglect, how far does the earnest medical provider go to cudgel such an individual into action? As described yesterday, I managed to frighten my patient enough that she decided to restart her medications. Pummeled by visions of amputations, dialysis, blindness, and imminent myocardial infarction, she felt an impetus to take her metformin and pay a little closer attention.

The "scare-'em-to-death-technique" may be effective in the short-term, but I do ask myself if it actually engenders real change from within, or simply cudgel the patient into compliance out of fear or a simple desire to please the provider. Some patients respond well in the moment, but time has shown that change not necessarily coming from within may very well not remain fixed and strong.

Motivational interviewing is a non-confrontational technique of counseling aimed at assisting clients to recognize their potential problems, the potential consequences of those problems, and how those consequences might be avoided by way of self-directed change. There is a small voice in my head that this may be a way to increase one's skills to direct non-compliant or passive patients towards change while avoiding the techniques that simply use fear and warnings of dire consequences to alter behavior. How does one convince a very sick person that their illness simply cannot improve without their active participation? How does one help that patient decide whether or not to take proactive steps towards change? When does the earnest nurse just let go?

Of course, I have certainly found myself in situations where there was little to do but watch and wait. In yesterday's post, I mentioned the gentleman who I simply cannot protect from his own self-neglect as he heads down a path that will probably result in the most dire of consequences. Can I save him? Absolutely not. Does he want to be saved? Certainly not. Will I just watch him self-destruct? Seems that way.

To cudgel or not to cudgel? That does appear to be the question. The answer is apparently a double-edged sword.
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