The CPM Saga
We're having drama on the ortho unit of my hospital. An orthopedic doc is angry at the PT department. He believes we're not following his TKR CPM orders. He wants a CPM on every patient set at 120 degrees the day of surgery. He says he writes the orders but it doesn't always happen. He's right. It doesn't always happen. We're not ignoring his orders. We're listening to our patients who say that setting is too painful. They refuse to allow us to set the CPM that high.
I can see why the doctor believes we're not following his orders. It's not that we don't want to set the CPMs at 120 degrees. We're trying. But instead of forcing that setting on the patient, we're setting the CPMs at patient tolerance. Once we get the CPM going we try to increase to the 120 goal. We usually get there, but it's not the first day. Dr. L, the ortho doc, says that isn't good enough. He told us to have nursing increase the pain medicine. Dr. L believes his outcomes will be worse if the CPM setting is obtained and maintained on every patient.
Dr. L is forgetting something. Patients have rights. One of them is to refuse treatment. The treatment could be a medicine, a test or therapy. Patients refuse things that hurt. If a CPM at 120 degrees is painful, the patient will not allow us to set it there. As therapists, we are respecting the right to refuse the higher setting if it is too painful. The point of developing the list of patient rights was to prevent health care providers from forcing them to do things against their will. If I'm working bedside and a patient doesn't want to get up, I can't drag the patient out of bed. It works the same way with CPMs. If the patient doesn't tolerate 120 degrees, I can't force it.
Dr. L suggested setting the CPMs at 120 degrees and keeping the control away from the patient. Obviously we can't do that. I'm not sure how many patient rights that would violate. As a result, the PT department is caught in the middle. We can't follow Dr. L's orders if the patient won't let us set the CPM that high. This isn't a new problem. It has happened before. It will happen again.
I'm using Dr. L as an example. In reality, patients refuse all kinds of things. As a rule, doctors don't like that. This isn't the dark ages when whatever the doctor said was law. Patients have become more knowledgeable and aware about their treatments. This problem isn't whether the PTs are following the doctor's orders. The problem is that the patients are refusing to follow the orders. Dr. L needs to realize that. Maybe he should be mad at himself for not educating his patients on what to expect post-operatively. Or, maybe he should be mad at the patients who are refusing the settings. There's nothing like an ortho doc yelling to inspire compliance. The people he shouldn't be mad are the PTs who are trying to walk a thin line between patient desires and doctor orders.
I don't have a solution to this problem. As a department we can make a greater effort to get those CPMs to 120 degrees the first day. We now call the department manager as soon as we have a problem with a CPM. He, in turn, calls Dr. L. Maybe Dr. L needs to put a few CPMs and try getting 120 degrees right away. Maybe he needs to experience patients refusing to follow his orders. That might help, but it won't happen.