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Toni Talks about PT Today

My Patient Doesn’t Want to Work With Me

Published October 15, 2009 10:32 AM by Toni Patt
Last week I inherited an interesting patient from a therapist who went on vacation. The patient is an 87-year-old Chinese female admitted with a diagnosis of right MCA infarct.  She has a history of undiagnosed dementia. She lives with her husband and two caregivers 24/7. Prior to admission she was ambulatory household distances with assist and a RW. Except for her adamant refusal to participate in therapy, she isn't very noteworthy. What's interesting are the questions raised by the refusals.

The first question I asked was why she was on a rehab unit in the first place. The most she's done so far is 1.5 hours in one day of PT and OT combined. That was with me giving her no other option. She clearly doesn't want to do therapy. She obviously isn't meeting criteria. We've had patients who did very little previously. Her stay will be as brief as those were.

I also want to know what I'm expected to work on with her.  She doesn't want to do anything. Even with a translator to explain things she refuses to do anything. Ethically I can't physically pull her out of bed and drag her down the hall.  Passive exercise is the only thing possible if she won't work with me. This isn't a completed confused and disoriented patient. Her dementia prevents her from understanding what has happened and why therapy is important. It doesn't impair her ability to know what she will and won't do.

What's really frustrating is that her impaired functional status is completely effort dependent. She can transfer and ambulate with CGA if she wants to. I did it with her. Based on that treatment I have no goals for her.  She needs CGA for safety. Yes, her endurance isn't very good but she wasn't doing much of anything before she came to the hospital.

I'm back to the original question. What am I supposed to do with her? I know there is a cultural element to this. That doesn't change the situation. She is on rehab and I am supposed to provide therapy.  What is left to work on when the patient won't participate and I can't physically do it for her? Ethically I know I can't force her to do something she doesn't want to do. Therapeutically I know she can't stay in bed. 

I've run into this when I've worked in acute care.  It's much easier to handle. If the patient doesn't want to work with me, I move on to the next one. I document lack of participation and assess the patient as a poor rehab candidate. I'm not sure what happens to those patients but I would guess either they return to a setting where they are taken care of or find their way to custodial care via an SNF.

I'm ready to pull my hair out. I have to drink a cup of coffee just to work up the energy to go into the room and make an attempt. Today I completed 15 minutes of therapy. Tomorrow won't be much different. She will discharge on Thursday to an SNF. I understand she isn't going to do much with me. Nonetheless, I keep thinking there is something more I can do to change that. 

3 comments

Jane said exactly what I was thinking.  My first thought was "who is letting this person come to rehab in the first place."  Although I no longer work on the rehab unit, I've been on both sides of the coin: med/surg and acute rehab.  It wasn't until I worked in med/surg that I realized that no matter what I may document, there would always be one physiatrist who would admit just about anyone as long as they were not on public aid (and sometime denying perfectly appropriate patients who were on public aid). In the end, it's like a slap in the face to us as therapists....no respect for our opinions.  

Christie ,, October 18, 2009 9:04 AM

Dean's suggestions are good ones.  I think this situation falls under the well known 12-step mantra he mentioned in his blog a few weeks ago, "Give me peace to accept the things I cannot change, courage to change the things I can and wisdom to know the difference."

Something you said brought a question to mind:

"She obviously isn't meeting criteria. We've had patients who did very little previously. Her stay will be as brief as those were."

From that statement one can only assume this isn't an isolated event.  So the question is, Who is responsible for the admission process and how are these inappropriate admits getting through?

Your facility has a bigger problem than this client.  I'd speak to your supervisor - air your concerns and ask for her assistance in addressing the issue.  When all else fails, talk finances.  Nothing gets the attention of big business like the "bottom line".  The facility is losing money on these clients.  That isn't to say that is the main issue, but it is probably the component that will get you the most expedient results from admin to deal with the situation.

Best,

Janey Goude October 17, 2009 11:07 PM

You have options. 1. Let it go, there could be many reasons she doesn't want to participate, cultural, depression, the cognitive impairment, or something else that has nothing to do with you or your intended interventions. 2. Chat with the family member to try and gain insight into what is going on or gain an ally in your attempts or simply gain understanding of this woman's actions. 3. Call in for a Psych or Social Work evaluation to see if there is depression that clouds the issue.

The truth is though, if you can set no goals for her, you need to discharge her and move on.  

Dean Metz October 16, 2009 9:07 AM

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