Two weeks into my placement now I am beginning to feel more at ease and have noticed an increase in confidence in my role as a cardiothoracic physiotherapist. In previous placements, I have always been given positive feedback about my ability to build rapport with patients. Even today, I had my midway assessment and both my clinical tutor and my supervisor commented on this as one of my strengths. The problem is, I have one patient who for the life of me I can’t seem to get onside. We’ll call him Mr. C.
Mr. C has been a patient on my ward for two weeks now, and I have tried everything I can think of to get him to participate in physio sessions. Every morning I walk into his room, smile and ask him how he is doing, and suggest I help him get ready and get him out of bed to go for a walk (to progress his mobility). And every morning, I get the same response: “Not today, maybe tomorrow”. After a few days of this, I thought to myself perhaps he’s just not a morning person. So after lunch I tried the same approach but got the same response… maybe tomorrow.
After a week of not being able to ambulate Mr. C (who by the way, was keen to ambulate with any of the nurses… but only to the toilet and back), I figured it was time for some drastic measures. I coordinated with the nurse and after she had ambulated Mr. C to the toilet she came and got me so that I could ambulate him once he had finished. When Mr. C called out to the nurse that he was done in the toilet and ready to go back to bed I opened the door and saw the look on his face when he saw me and said “Oh, it’s you… not today, maybe tomorrow”. He made me go get the nurse instead.
So far progressing Mr C’s ambulation has been Mission Impossible!
I understand that it’s not just me, as Mr C has been refusing physio input from my supervisor as well. It is very difficult and frustrating however, as unless his mobility is progressed to his pre-admission status he will be unable to return home. My supervisor is a recent new grad and she too is out of ideas on how we can get Mr C on side with us for his treatment.
Does anyone else have any suggestions?
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4 comments:
It's patients like that who you just want to let stay in their bed and deteriorate. But as physios I know we can't do that :)
I don't know if you've tried this, but I would get his doctor to speak to him. As matter of factly and harshly as possible without being rude the doctors need to tell him that there is no way that he will be allowed out of the hospital until he's back to his preadmission levels. And that if he doesn't start to do his physio he will never get to that point. And then to ice the cake the doctor should tell him that if he really doesn't want to do physio the alternative is to discharge him to a nursing home.
:) Looking back on what I just typed, that sounds like a bad idea, but it's too late in the nite to type a better suggestion :) sorry megs.
Hi Megan, I would have to agree with Calvin, that approaching the doctor would be a good idea, as doctor may have more authority in patient’s eyes, and he may listen him better. In addition I would also speak with patient’s family and would find out the best way in approaching him, as family hopefully would know his personality better and would come up together with some strategies to deal with this current issue.
Good luck Megan!!!!!
Hi Megan, I would have to agree with Calvin, that approaching the doctor would be a good idea, as doctor may have more authority in patient’s eyes, and he may listen him better. In addition I would also speak with patient’s family and would find out the best way in approaching him, as family hopefully would know his personality better and would come up together with some strategies to deal with this current issue.
Good luck Megan!!!!!
this is Kate's and my exchange re the issues raised b this blog
Hi Stephanie
This is not an unusual situation and can be very frustrating for both students and clinicians! Some patients do have the opinion that they should only start doing 'exercise' once they are 'better'! It can be difficult to communicate to the patient that the exercise is part of the process of getting 'better'! Going to the loo is a basic need so there is rarely a problem in encoraging that sort of 'exercise'! How many days post-op is this gentleman and is he stable? Does he have any specific mobility problems? I would strongly suggest that if possible he should be ambulating to the bathroom independently.
I am very comfortable with what has been suggested. (see my entry below) Bottom line is that the patient has the choice whether to engage with physiotherapy or not. This choice needs to be informed though. I would outline to the patient very simply and in an extremely non-confrontational manner why the intervention is important, the consequences of not partcipating and give lots of reassurance about the safety of ambulation at this stage of his recovery. I would certainly discuss this with the rest of the team and ask for their support in reinforcing the message. But it is a fact of life that patients have different levels of respect for the various professions - often the big Dr stick does do wonders! Many patients do not see physiotherapy as a part of their medical management.
Patients aften use refusal of intervention as a method of maintaining some control over a situation they feel they have absolutely no control over. He may be livid that he has heart disease and has had to have an operation that has resulted in a (temporary) loss of independence and having to suffer all these people doing things to him. He may also be very afraid that something will go wrong if he 'does too much'. Cardiac surg patients aften need more reassurance than any other. The heart is somehow special. Some really do think that walking could lead to their chests coming open and their heart falling onto the floor!!! Being as empathetic as possible, acknowledging these concerns and giving lots of reassurance may help.
If the patient continues to refuse, c'est la vie! The consequences are his responsibility, not the students. The student must also document (again very simply and objectively) that the patient has refused physiotherapy intervention and that the medical staff are aware of this. This needs to be countersigned and if possible the supervising clinician should add a note.
Sorry that was so long-winded! Hope it helps!!
Kate
Subject: Could you spare me a minute to read over a comment of mine to a BLOG?
Hi Kate,
I wonder if you could spare me a couple of minutes for this email question?
I was reading through one of the students blogs (have included it below for
your interest but just wanted your opinion on my next paragraph I've
written so reading student blog is optional) and I was going to comment on
the blog as I felt the students were having some trouble negotiating between
their responsibility, the patients responsibility and freedom in our
society. Would you say anything else for a cardiopulmonary patient not
compliant with walking with PT but compliant walking with nurses to toilet
and back.
Stephanie's comment
It is important to have discussed with the patient his/her reasons for non
compliance and tried to deal with those issues, educated the patient as to
the advantages of the particular physiotherapy intervention, explained the
possible consequences of non performance, discussed issue/s with nursing
coordinator, more senior physiotherapist and medical team, then the
patient's life is his/her their own and pt can choose to comply or not.
It will be interesting to hear if you obtaining the medical teams assistance
helps with compliance with this patient. This often works-however some
patients will listen to the resident, some to the registrar and some only to
the consultant. The patient may well be discharged at a functional level
less than on admission ( may receive hospital in the home post discharge if
this is the case). It is important to have discussed nursing home issue with
multidisciplinary (DR nurse OT etc) team before issue is raised with
patient.
Regards
Stephanie
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