Discharge Planning is a Responsibility
For the better part of last week I was the bad guy. I made several decisions that weren't popular with both patients and physicians. That sounds strange on the surface. The decisions were made in the best interest of the patients. In one case I recommended SNF placement instead of rehab because I knew the patient wouldn't tolerate three hours of therapy. The doctor wasn't y happy because she felt the patient wouldn't get adequate care at a SNF. A few days later I wouldn't okay a cane for discharge home. The patient was a dense left hemiplegic. He required a lot of assist to walk with me and even then wasn't safe to use the cane.
I think PTs always try to think of the best interests of their patients. I would never deliberately recommend SNF over rehab if I thought the patient would benefit from rehab. If the patient can't tolerate three hours of therapy daily, he is wasting both his insurance and precious recovery time. He won't get any benefit from therapy if he is too tired to participate. The same applies to my man with the quad cane. He is able to walk with total assist of me to advance the leg and help him balance. It would require extensive training to teach a family member to do that. Even then safety might still be an issue. The question became which is better: keeping him from walking or preventing a serious fall?
I divide my time between an acute stroke unit and inpatient rehab. On the stroke unit I assess patients and make discharge recommendations such as SNF, rehab, home with home health or no needs. The stroke physician, who is a neurologist, has the final say on disposition but usually listens to me. The reason for that is simple. A neurologist knows neurology while a PT knows recovery potential and realistic goals. On the rehab unit the PTs help decide if someone goes home as planned or requires placement. Sometimes that means being the bad guy. I'd rather be the bad guy with good intentions than recommending rehab for everyone just to keep the unit full.
No one becomes a PT in order to prevent patients from improving. We become PTs to help people get better. In the process many decisions are made. All are made with the best intentions. Sometimes I'm wrong. Sometimes a patient does much better than I expected. I like being wrong like that. Sometimes a patient doesn't do as well as I hoped. I was wrong because I wanted the patient to do well. Anyone PT will agree patients are unpredictable. No matter how hard we try the end result depends upon the patient.
It wasn't until I started working on the stroke unit that I realized how much responsibility I have for my patients. The unit is small with high turnover. Nonetheless, I think of every patient on that unit as being on my caseload and thus my responsibility. Whenever I'm in doubt or unsure I make it a point to see the patient the next day to reassess my original impression. I don't want to make a mistake about someone else's future. Life is much simpler on rehab. Not only are the OTs and STs involved in the decisions, but we see the patients for more than one or two visits. We have a lot more information to work with when discharge planning rounds come around.
If I ever stop and really think about what I do each day I'm not sure I would be able to be as effective. I try to be as objective as possible. I base my decisions on my experience, knowledge and what I reasonably believe is possible. I have to remind myself that I'm only involved in one part of the patient's recovery and my job is to make decisions to facilitate that. I've never ask any of my co-workers how they interpret discharge planning. I'm sure many would say it is another part of what we do. As professionals it is our responsibility to make the decisions in the best interest of the patient. I agree. Sometimes, though, those decisions make me feel like the bad guy.