Patience and Compliance

I had a patient this week who is being discharged post CABGx3. I was going over discharge planning with him yesterday which included a referral to his local cardiac rehabilitation facility for follow-up classes, and a generalized home exercise program for him to follow in the interim.

It is not uncommon for patients post heart surgery to be full of questions and be generally quite anxious about going home, leaving the security blanket of the hospital staff behind. But this patient was different.

I explained to him that part of his program would include some graduated cardiovascular exercise in order to increase his exercise tolerance post surgery. In the hospital prepared booklet, it gives examples for this such as either walking or cycling on a stationary bike. My patient immediately developed a huge grin as he had just bought a bicycle prior to his admission. I explained to him though that it was not ideal to use at this time (over the stationary bike) as he would be putting too much force through his upper limbs, and that the steering of the bike could cause sheering forces across his sternum (another big no-no post op!). My patient wasn’t happy about this and became quite argumentative, demanding further answers as to why he should not be allowed to use his bike on discharge. Then, somehow (I’m not really sure how it got to this point as I was a little flustered), he got onto the topic that he should be allowed to go swimming in the ocean as soon as he is discharged. Again, I explained about how no pushing or pulling is allowed through the upper limbs (even the resistance of water) and that even freestyle stroke can produce sheering forces across his chest. I gave him the option to do some water walking/running in a hydro pool once his incision had healed, but according to my patient, this would just not do! My patient was not going to be satisfied until I would agree with his point of view….

After nearly 30 minutes of going through the do’s and don’t’s of his HEP (a task that normally takes less than 10 minutes), I was extremely flustered and was starting to lose patience. How can this man, who has just had his sternum cut open, his heart stopped, and had multiple arterial grafts want to put himself at risk for delayed or worse yet, non healing? How can he want to put himself at risk for returning to hospital when he’s already been in hospital for nearly 3 weeks recovering after his second… yes, SECOND CABG surgery?!

Looking back now, perhaps he’s just a man who needed to have someone tell him he’s right to do whatever he wants, and perhaps he was just giving me a hard time because I wasn’t telling him what he wanted to hear. In the end, I explained to him that all I could do was give him the information to make an informed decision, and these were the guidelines that are set in order to optimize a healthy recovery. He looked at me and said ok, and we left it at that, but I really wonder how compliant he will be once he has left hospital and is out on his own. I have a feeling he won’t be very compliant, and for that I am disappointed.

Has anyone else had a difficult patient like this? I really struggled with this because all I wanted to do was help him get better and back on his feet, and yet he seemed determined to put himself right back in hospital.