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Toni Talks about PT Today

Not All Refusals Are Created Equal

Published February 8, 2008 10:18 AM by Toni Patt

Last week I heard something that made me stop in my tracks. A PTA was going to treat a CVA patient who was new to her. When the PTA attempted to initiate the treatment the patient refused the standing frame. The PTA sent the patient back to the room, threw up her hands and said she didn't know what else to do with the patient. That really bothered me. I don't know what made me madder, the PTA not knowing what else to do or the PTA not even trying to convince the patient to work with therapy.

Patients refuse. It is a fact of life for a PT.  There are many reasons: pain, fatigue, the BR, dislike of a specific treatment, laziness and not wanting to miss "The Price is Right".  A confused patient is as likely to refuse as participate. Often a patient can be convinced to participate with therapy after refusing. It is the responsibility of the therapist to try. Not all refusals are a set in stone, no. By asking questions the reason for the refusal can be uncovered. If I know why a patient doesn't want to do therapy, I can do something about it. The reason may be as simple as needing an extra blanket or to go to the restroom. The point is, if you don't ask, you don't know. The PTA I overheard didn't ask. She just gave up and moved on.

Compromise is an important part of therapy. This patient didn't want to use the standing frame. She may have been agreeable to doing exercise or balance activities in sitting. Patients who don't want to walk may still be willing to get up and do therapy, just not walk. As therapists we know the importance of moving patients pushing them. If the choice is between no therapy and a little therapy, I choose a little therapy. I've had patients who won't do anything for me, happily work with someone else and vice versa. Some people are just not morning people and being in the hospital won't change that.  You have to at least give it a try.

Sometimes patients refuse because they don't feel well. Not feeling well can run the gamut from mild nausea to a racing heart rate and V-fib. Patients don't always accurately verbalize what they are feeling. Have you ever tried to describe dizziness? It is the responsibility of the therapist to find out if there has been a change in medical status or another reason the patient might be ill. Therapy is supposed to help the patient recover, not send them to the ICU.  Of course there are those who just don't want to do anything. I've long given up on arguing with those. If someone refuses to do something, nothing will make them.  

When I say refusals I'm not talking about those who will participate with constant cooing and encouragement. I'm also excluding those who are confused and don't know what they're saying. Confused patients will refuse one minute and agree five minutes later. Depressed patients will participate. They might suck the life out of you, but they will work with you. I've had days where if I walked away from everyone who refused, I could be home in two hours. It's our responsibility as therapists to try.  I wish the PTA would have made the effort. Her patient would have benefited from some sort of intervention.

Okay, I have the reputation as being mean and I'm proud of it. Refusals don't mean anything to me. I talk them into therapy.  There are days when I don't try too hard to convince someone. But I try. At the end of the day I feel good about what I've done or attempted to do. I wonder how that PTA feels.

*My apologies to all PTAs who read this. I'm not picking on you. You have my respect. I would have written the same thing if it were a PT.

posted by Toni Patt

5 comments

I worked as a psychiatric technician in an intensive care unit for 2 years. One of our policies was that after breakfast, the pt's bedroom  doors would be locked behind them and everyone would be out on the unit. We would literally drag patients out of their rooms (blankets and all) and put them in an environment with other people. This seemed so cruel when I first started. It seemed cruel to others also so we allowed pt's to stay in their rooms. What we realized was that when they were allowed to do that, they stayed in their beds for days at a time, urinating and defecating on themselves. We even had a drug overdose and a hanging. My point is, patients dont always know whats best for them and when you can overcome their objections to therapy, despite their unpleasantness, they will realize it was in their best interests and quite possibly thank you for being so forceful.

Steve February 25, 2008 10:01 AM
FL

Good point Jane.

A supervising PT should have intervened or suggested to the PTA to try a different approach.  Perhaps a change in patients would have been appropriate.

Toni, for you to run and "tell" the owner I find that horribly unprofessional.  What could have been a simple pull the PTA aside chat can now turn into animosity between the two of you.

We as professionals should have the decency to talk to one another in a professional manner without it going beyond the therapy gym.  I would hope someone will have the courtesy to say, "Hey Jason maybe you need a break, why don't you take five and I'll see that patient".  

At the same time I hope I will have the insight to realise that I do need a break when and if I get to the point of giving up on patient care.

Jason, PTA February 12, 2008 1:08 AM
CA

I was only present for the tail end of the incident.  As Jason stated it could have been the 3rd or 4th refusal so I waited for an opportunity to talk to her.   What I posted are her comments.  As it so happens she works for the same company I do.  Since the incident already happened I notified my company.   Knowing the owner she hasn't heard the last of this.

Toni February 11, 2008 6:02 PM

Yes, Jason, patients do have the right to refuse.  But Toni is also right, we have the obligation to encourage participation.  Since we weren't there, we don't know precisely what happened.  But Toni took a situation and made a number of valid points.  The points shouldn't be discarded trying to second guess what really happened.

Toni, first let me say I'm a fan.  I enjoy your thought provoking posts.  But there is one element to this situation you didn't explore.  What about your responsiblity to intervene when you see inappropriate care being delivered?  From the scenario you present, it does not appear you the supervising PT for this patient.  Nevertheless you are in a supervisory position as a PT.  Beyond the supervisory status, as a PT you have an ethical responsibility when observing substandard care.  

You shared what you feel the PTA should have done.  I'm curious, what did you do to take steps to see that this behavior isn't repeated?

Jane February 11, 2008 1:14 AM

Yes, patients refuse therapy all the time.  When you saw the PTA perhaps this was the 3rd, 4th, or 5th refusal of the day and the PTA was frustrated at the refusal rate that day.  

There are times if patients refuse I allow them to. (Provided they are not confused) My rational, the patients I see are adults and are able to make sound medical decisions about their health, ie, what medicine to take and which doctors to see.

In the patient bill of rights patients have the right to refuse treatment and therapy is included in this.  Should we "trick" patients into getting therapy, should we "bug" them every hour and somehow convince them that we are saving their life if they get up?  Would the M.D. come back every hour and "bug" the patient to take the medicine he prescribed if the patient refused?

What we do is medically necessary but if patients do not want our services we can only educate them on the benefits of the services and the risks involved if they refuse.

I say, "Let them refuse."

jason, PTA February 10, 2008 1:08 AM
CA

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