Non-compliance and non-adherence

Prof. dr. Wim J.A. van den Heuvel

Ten months ago Europe became aware of a new virus, which the potential to cause a pandemic. It took months before we realised that measures to control the virus did not work. The main cause, why measures did not work, were not the measures, but the behaviour of citizens, i.e. the refusal to follow the instructions and recommendations: non-compliance.

Besides non-compliance, non-adherence could be a problem but this does harm the individual, not the society directly. Non-adherence means unintentional refusal by an individual to follow instructions of a medical professional, which may cause serious (health) problems for the patient. And non-adherence significantly does not only impact clinical outcomes and health care costs, but also affects the outcome of clinical trials, which has potentially complex major implications (1).

There are various reasons why a patient does not follow an instruction: a patient may be overwhelmed, does not understand what to do, feels helpless or confused, and/or is concerned with healthcare costs (2). This may also be the case in palliative care, as the article of Current perspectives in supportive care demonstrates in this issue of PALIATIA. Non-adherence has to do with (lack of) common understanding.

In health care, it is important to distinct between non-compliance and non-adherence. In the case of non-adherence there is a lack of common understanding between provider and patient: what is the medical issue in question, are effective medications, treatments or procedures available, and what are the risks to the patient, if the medical issue remains untreated or undertreated.

In the case of the pandemic with Covid-19 there is no common understanding, which results in non-compliance. The lack of common understanding offers the virus endless opportunities to spread! But, if the patient is diagnosed with covid-19: there is – in practice – no room for non-adherence! Intensive care units do not offer much choice or time for common understanding. That is an essential difference with palliative care: common understanding is a condition sine qua non in case of palliative care.

What happens in de case of non-adherence in health care? Wat are the effects when a patient does not initiate or continue care that a provider has recommended? It results in major additional costs of health care (3). But even more important: it may lead to inadequate health care policy and it affects the quality of care (4). Therefore, although common understanding is a condition sine qua non for palliative care, we should always stay alert.


  1. Valgimili M et al. Standardized classification and framework for reporting, interpreting, and analysing medication non-adherence in cardiovascular clinical trials: a consensus report from the Non-adherence Academic Research Consortium (NARC).European Heart Journal 2019; (40): 2070–2085. 
  2. Causes of non-adherence. Available from: [Accessed 20th December 2020].
  3. Marcum ZA, Sevick MA, Handler SM. Medication nonadherence. A diagnosable and treatable medical condition. JAMA 2013; 2105–2106.
  4. Philipson T. Non-adherence in health care: are patients or policy makers ill-informed? Available from:  [Accessed 18th December 2020].