Ethical duties of nephrologists: when patients are nonadherent to treatment

When providing care, nephrologists are subject to various ethical duties.
Beyond the Hippocratic notion of doing no harm to their patients, nephrologists
also have duties to respect their patients’ autonomy and dignity, to meet their
patients’ care goals in the least invasive way, to act impartially, and, ultimately,
to do what is (clinically) beneficial for their patients. Juggling these often conflicting duties can be challenging at the best of times but can prove especially difficult when patients are not fully adherent to treatment. When a patient’s nonadherence begins to cause harm to themselves and/or others, it may be questioned whether discontinuation of care is appropriate. We discuss how nephrologists can meet their ethical duties when faced with nonadherence in patients undergoing haemodialysis, including: episodic extreme agitation, poor renal diet, missed haemodialysis sessions, and emergency presentations brought on by nonadherence. Further, we consider the impact of cognitive impairment and provider-family conflict when making care decisions in a nonadherence context, as well as how the COVID-19 pandemic might affect responses to nonadherence. Suggestions are provided for ethically informed responses, prioritising a patient narrative approach that is attentive to patients' values and preferences, multi-disciplinarity, and the use of behavioural contracts and/or
technology where appropriate.