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Education Materials > Publications > Improving Patients Adherence to TB Treatment > Legal Remedies

Improving Patient Adherence to Tuberculosis Treatment (1994)

Legal Remedies

Section Topics

Patients' Rights and Due Process

As a general rule, people in our society have the right to refuse to follow health advice. However, persons with infectious TB may lose the right to refuse such advice that is, instructions to complete prescribed TB treatment if health officials believe these persons are putting the public at risk for infection. Patients who are unwilling or unable to adhere to treatment may be required to do so by law. Since state governments have legal jurisdiction over TB control activities such as treatment protocols for nonadherent patients, refer to the laws in your state for those provisions.

The Advisory Council for the Elimination of Tuberculosis (ACET) defines nonadherent behavior as the inability or unwillingness to follow a prescribed treatment regimen (34).

Examples of nonadherent behavior are

  • failing to report for DOT
  • refusing medications
  • taking medication inconsistently
  • missing clinic appointments

Notify the appropriate health official when patients are nonadherent. The health official or designated representative should determine the reasons for the nonadherence and begin the appropriate interventions.

Although legal remedies for nonadherence are available in some areas, they should be used only when less restrictive measures have failed. When legal remedies are used, measures should be taken to ensure that the rights of the patient are protected. Patients subjected to these proceedings should be represented by legal counsel.

The legal remedies commonly used by public health officials to address treatment nonadherence are court-ordered DOT and involuntary isolation, hospitalization, and confinement.

Progressive Interventions to Ensure Treatment Completion

Commitment is defined as the confinement of a person who has infectious TB or who is not infectious but has not adhered to prescribed treatment. The purpose of commitment is to prevent the development of drug-resistant organisms or to ensure that a person receives a complete course of treatment.

ACET recommends that before committing patients to involuntary confinement, state TB control programs should adopt a step-by-step treatment plan that progresses from voluntary participation to involuntary confinement (34). The plan should begin with an assessment of the potential reasons for nonadherence and procedures for addressing the identified obstacles which include the use of DOT, incentives, and enablers.

If the patient does not adhere to DOT voluntarily, the next step may be DOT that is ordered by a public health official or a court. TB control programs should not initiate procedures for confining patients to a treatment facility until after the patient has demonstrated an inability or unwillingness to follow the treatment regimen.

Involuntary commitment or isolation for inpatient treatment should be viewed as a last resort. However, when a patient with infectious TB refuses treatment and voluntary isolation, emergency detention to isolate the person is appropriate.

Criteria for Determining the Need for Involuntary Confinement

When determining whether the legal commitment of a person with TB is necessary to protect the public, local health officials should determine whether the person is at substantial risk of infecting others (now or in the future). To determine this risk, assess the patient's situation by considering these factors:

  1. Clinical evidence such as laboratory results (acid-fast bacilli sputum smears and sputum cultures)
    • clinical signs and symptoms of infectious TB
    • abnormal (cavitary) chest x-ray

  2. History of nonadherence for reasons not related to treatment or delivery system failure
  3. Risk of infecting others

The commitment order should require the isolation of the person with infectious TB until the patient is determined to be noninfectious. This decision should be based either on laboratory results demonstrating that the person is smear negative and asymptomatic or on the local health officer's determination that the person has completed a course of therapy consistent with the most recent recommendations of the American Thoracic Society and CDC (35).

The patient should also be ordered to receive treatment in a hospital or other appropriate facility until cured, unless the person's voluntary completion of the ordered therapy can be ensured. If the patient refuses to consent to the ordered treatment, the health officer should have the authority to extend the commitment order as necessary.

Final Note

When asked for a recommendation for improving patient adherence to TB treatment, an experienced public health nurse from Arkansas said, "What we do is whatever it takes!" These words seem to summarize all the preceding strategies and to embody a philosophy that no longer accepts nonadherence as inevitable and tolerable. Doing whatever it takes to ensure the completion of adequate therapy is a challenge, but one that must be successfully met if this curable and preventable disease is to be controlled.




Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination -

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