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Journey of a DPT Student

Changing Goals

Published April 14, 2014 5:05 PM by Lauren Rosso

With one week left until graduation, I had my most challenging patient-care conversation since starting PT school. One of my current patients, whom I happened to work with in inpatient rehabilitation during my previous clinical rotation, is a very complex case. He suffered an anoxic brain injury that unfortunately was complicated by a transfemoral amputation with a very short residual limb. On top of that, his hospital course was protracted and he has a lot of other secondary complications as a result.

The conversation I'm referencing had to do with adaptive equipment and options for wheeled mobility. The family's initial goals were to progress to the point where prosthetic training could be considered. Despite multiple setbacks we made some great functional gains during therapy, but unfortunately not related to standing balance. Faced with the reality that the most appropriate form of wheeled mobility needed to be addressed, I sat down with the family to discuss the available options.

This was the first time that the family was told directly their son would require a wheelchair for functional community negotiation. Prior to this point, prosthetic training was such a focus that I think we lost track of long-term decision making. I take the blame for this. In hindsight if I had voiced my recommendations, I would have told them that a wheelchair would likely be required. We trialed manual propulsion, but my clinical recommendation was power from a functionality standpoint. In the end, I think the family felt like we went from talking about prosthetics directly to powered mobility. I can understand why they were upset, and I wish I had handled the situation more effectively.

I had long conversations with my coworkers about how I could have changed and improved this entire situation, and the common thread was that early transparent communication is key. Even when it's difficult to say and may not directly align with the family's perception, opening those doors at the start results in a better and less upsetting experience for everyone involved. Lesson learned.

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Hi Lauren! I'm Katrina and I'm also a DPT student.  Thank you for this particular post as I have also experienced a situation in which I've had to redirect the functional goals for my patient, and it's a hard place to be.  I had a patient also in the in-patient rehabilitation setting who had Guillain-Barré Syndrome.  She was making really great progress physically, but was struggling emotionally with not being with her family daily.  Our original plan of care was set for 3 weeks, but with the great progress, we communicated with our patient that we wanted to extend her stay an extra week to continue intensive therapy to maximize her functional gains before returning home.  This was brought up at the beginning of the third week, allowing the patient ample time to think it through and see her gains but also the continued mobility limitations that she needed to address before returning home (she was still using a slide board to transfer and she has multiple kids under age 10).  However, in spite of the time and reasoning provided, the patient was firmly decided in going home at the end of the 3 weeks and nothing and no one could change that.  So I want to let you know that even with early, clear communication, the situation doesn't always change.  I'm sure that you still provided the best possible care for your patient and sometimes that's all you can do!  It's really great to reflect and learn what you can change for next time though so thank you for reminding me to do that in my future career!

Katrina March 24, 2015 1:40 PM
Greenville NC

Hey Lauren!  Thanks so much for all of your blog posts, as a DPT student I have enjoyed reading through your many posts!  I can relate to how you feel here, as I am going through a similar situation with a patient on my last clinical rotation in an in-patient rehab center.  My patient essentially has an incomplete spinal cord injury at T4 from metastatic cancer, with slight returning movement and feeling below the injury.  My patient rightly has the dream that he will walk again, possibly influenced some by his oncologists high hopes, but his returns simply are not functional and cannot support ambulation.  I am struggling when to draw the line and really talk with him about expectations and functional mobility.  Your post has encouraged me, and reminded me that early and clear communication is best.  Thank you!

Andy Hayek March 5, 2015 8:12 PM
Greenville NC

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