Explanation to a patient who is reluctant to receive treatment

Case Scenario: You are a junior doctor in a medical outpatient clinic. A 30 year old female who has come for a prescription of an oral contraceptive pills is found to have high blood pressure. Her BP has been measured on several occasions and found to be consistently in the region of 180/100 mmHg. It has been explained to her that she has high BP that requires investigation and treatment, but she feels well and only wants a prescription for the oral contraceptive pill, not any tests or medication.
Your task is to inform the patient why investigations and treatment are required.

Key issues to explore
The key to a successful outpatient consultation will be to understand the reason why the patient does not want further investigation or treatment.

• Does she feel that investigation and treatment are unnecessary because she feels well?
• Is she afraid of what may be found?
• Is she concerned about the effects of treatment?

Key points to establish

• It is very important to establish a rapport with this woman so that she will trust you and thus hopefully follow the recommended management plan. 
• Explain to her that hypertension is a common and often asymptomatic condition that is frequently detected on routine screening, or incidentally as part of investigations for other medical problems. 
• It is important that she understands what hypertension is and why it should be taken seriously, even in the absence of  any complaints or limitations: the potential harmful effects of long term high BP must be explained.
• She will need reassurance and an explanation that investigations are necessary to exclude a secondary cause of high BP, which might mean that the hypertension can be cured and that she would not need long term treatment. 
• If no specific cause for hypertension is found, then simple changes to her lifestyle may be adequate to treat her BP. But in some situations this is not enough and she may require medication.
• Your advice should be accompanied by provision of reading material and help with associated programmes for smoking cessation, weight loss and dietary advice.

Appropriate responses to likely questions

Patient: I feel very well and only went to the doctor for a prescription, so I can’t have much of a problem, can I?

Doctor: high blood pressure is a very common condition that can affect up to 20% of people. As in

your case, high blood pressure is often discovered when someone has their blood pressure measured for an entirely unrelated problem. The fact that it was discovered for that reason does not mean that having high blood pressure is unimportant.

Patient: what will happen if I have nothing done?

Doctor: over a period of many years high blood pressure can result in serious damage to many important organs in the body. For example, if untreated it can lead to major heart problems and strokes, and very rarely it can result in problems with the eyes that can affect normal vision and in extreme cases may result in blindness. However, all these problems can be avoided by achieving good blood pressure control.

Patient: what causes high blood pressure?

Doctor: a good question, and I wish I could give you a good answer. For most patients we don’t know, but in some cases it can be caused by problems with the kidneys or glands so we will recommend some tests – blood tests and urine tests – to see if this might be the case for you.

Patient: how can you tell if high blood pressure is causing damage to the body?

Doctor: by examining you and doing tests. For instance, we can look in your eyes to see if it is having an effect on the blood vessels at the back of the eye; we can do an ECG – an electrical tracing of the heart – or an echocardiogram – a special scan of the heart – and see if it is having an effect there; and we can do urine and blood tests to check kidney function.

Patient: what is the treatment likely to consist of ?

Doctor: the first thing is for us to look at your lifestyle to see whether we can help you make it more

healthy to bring your blood pressure down. Examples of things that can help are ensuring you take regular exercise, stopping smoking and looking at your diet. But it is likely that tablets will also be needed.

Patient: am I always going to have high blood pressure?

Doctor: not everyone who is started on medication for blood pressure continues with high blood pressure for the rest of their life. In some situations the changes to their lifestyle may mean that they do not need to continue taking medication long term. The treatment is something that your doctor will want to review on a regular basis.

Patient: will one tablet cure me?

Doctor: it might do, but a significant number of patients actually require a combination of tablets. We will start you off on one tablet and then review your blood pressure, and only add in additional tablets if required.

Patient: what if I get side effects from the pills?

Doctor: there are lots of different sorts of blood pressure pills, and we want to make sure that we get

one that suits you. If you do get side effects from the first one that we try, I’d like you to tell me so that we can try and find one that suits you better.

Patient: can I still take the oral contraceptive pill?

Doctor: yes, as long as we can get your blood pressure under control.