Medication Noncompliance

We have a patient who had severe, New York Heart Classification III heart failure. He didn't take his medications. Not because he couldn't figure them out or couldn't afford them, but because he didn't think they would help. He was an educated guy, didn't think these Western medications would help. Instead, he went on a purification diet, felt better, and relapsed on his diet/alcohol and of course, went into florid decompensated heart failure. Over the course of his hospitalization, we tried to negotiate - his cardiology, our attending, our social worker, chaplain, family members, and now outpatient primary care doctors (2!) tried to explain the seriousness of his disease. We said hey, it's up to you, taking these medications; you're not to appease us but we've explained the risk/benefits and want you to make an informed choice. The guy has an EF < 20% for goodness sakes! He has a big clot in his left ventricle! We discharged him feeling better and he has been seen a few times by the primary care center. He is still noncompliant.

I have very mixed feelings about this but this patient makes me angry. Yes, that's right, angry. It is not an emotion that I often feel when I'm practicing medicine and I feel incredibly guilty about being angry at a patient. It is not in the ethos of medicine and sets up a terrible "us vs. you" mentality. I dislike patient conflict but also feel obligated to confront patients about their choices because 1) it affects their overall well-being and 2) it affects the well-being of the health care system. His prognosis is not good, especially without taking his cardiac meds like Lasix, an ACE inhibitor, spirinolactone, Coumadin, and will likely need an implanted cardiac defibrillator (ICD) in the future because of increased risk of sudden cardiac death. The next step after that is cardiac transplant. I mean, what's the ethics of giving people like this an ICD or transplant when they will not adhere to physician instructions? Yes, it is ultimately his choice, but we are paying for this every time he bounces back to the hospital in decompensated heart failure. I suppose this is a slippery slope argument but where's the line draw, say when in a few years, he becomes NY heart classification 4 and wants a donor heart?