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Toni Talks about PT Today

Don't Lie to Patients

Published March 31, 2010 4:41 PM by Toni Patt

Once again we have a disposition issue on the rehab unit.  A gentleman who lived alone was admitted following a stroke.  While on the unit his stroke has continued to evolve resulting in impaired judgment and making it impossible for him to live alone.  To make matters worse he has a history of psych problems for which he hasn't been taking his medicines.  The result is someone with frequent mood swings and poor insight.

From the moment of his admission he has been talking about going home.  To him there is no other option.   During weekly rounds it was decided a SNF would be a good alternative disposition.  He would be in a safe environment while providing his son with more time to make more permanent arrangements.   This seems very simple except for one thing.  No one has told him there has been a change in plans.

As early as this morning our PA, who is responsible for addressing this was, and was present when the decision was made, told him he was going home.  She encouraged him to participate in therapy by telling him he needed to get stronger so he could go home this week. Not only was that unnecessary it was so wrong in so many ways.  He will be upset, angry and difficult to manage.  He may become combative or verbally abusive.  He has every right to be mad.  He was lied to.

There is a special relationship between patient and caregiver.  Patients trust us to have their best interests in mind.  Patients and family members make decisions based on the information we give them. They assume the information is accurate and provided in good faith.  There is unspoken trust that whatever we tell them is true.  When our PA told this patient he was going home he had every reason to believe her.  Caregivers can't go around misleading patients.  She was wrong to tell him he was going home when that wasn't the case.  Avoiding the situation has made it worse. 

When I was working on my DPT we looked at the ethics of healthcare as well as the professional rules that guide us.  Both clearly state that it is our obligation as PTs (healthcare providers) to provide true and accurate information to patients.  I assume other disciplines have similar statements.  There is a reason for that.  It is to ensure patients really do receive accurate and truthful information upon which to make informed decisions.  That statement can be found in the Patient Bill of Rights.

Now we have two problems.  One involves the patient in question and his eventual disposition.  The other involves the PA lying to the patient by reinforcing his belief he is going home when she knew that wasn't the case.   This is an example of what I assume were good intentions going horribly wrong.  I would hate to think there was some other reason to mislead the patient.  To me this is a reminder of how carefully we must choose our words.

posted by Toni Patt

1 comments

I am 100% for telling the truth 100% of the time.  I've had doctors scold me for being honest with my children about a procedure, saying I made it worse on them.  My perspective is that if I am always honest with them, they can always trust me.  If I tell them when a procedure or medicine is going to be unpleasant, they can trust me when I tell them a different procedure or medicine isn't a big deal.  If I lie to them about the unpleasant procedure, then it will be easier on the doctor adminstering the procedure for a few moments, but it will be more fretful for my child for a lifetime, never knowing whether I am telling the truth or not.  To me, the doctor's few moments of displeasure (which my child will be concurrently enduring to a much larger degree) is well worth my child trusting me for a lifetime.

Now, I'm going to play devil's advocate.  The scenario I've presented is one that involves an intact cognition and an ability to reason that is representative of developmental age.  Your scenario doesn't have that.  You said that the reason the ethics of healthcare and the professional rule mandate truthfulness in dealing with patients " is to ensure patients really do receive accurate and truthful information upon which to make informed decisions."  But you described your patient as someone who, because of medical incidents, has impaired judgement and poor insight.  Even if he had all of the truthful information, he couldn't make an informed decision that would be in his best interest.  In fact, you have indicated someone else has already made the decision without his consent.  Where was the truthfulness for informed decision when that was going on?

The patient you described will likely be angry, combative, and verbally abusive no matter WHEN you tell him he is going to the nursing home.  Stereotypically a patient will receive superior care in a rehab unit than in a nursing home.  In addition, rehab is typically most effective the earlier it is done - the closer to the insult, the more effective the therapy.  From the PAs perspective, he may be maximizing the time the patient has on the rehab unit by giving him incentive to work hard and get the most out of the time he is there.  If the patient is going to be mad anyway, he might as well be mad at the nursing home.  No point in him wasting the last few days of rehab.  If this man is incapable of making an informed decision - someone else decided where he is going, the decision has already been taken out of his hands - then you might as well capitalize on the time he has before he HAS to find out.

Seems the real question here is "At the point where the decision-making has been removed from the patient, how important is truthfulness?"  Once someone else is making decisions, is it okay to fabricate reality in order to increase patient compliance?  I'll admit, I've done it with dementia patients.  I've entered their alternative reality to get them to cooperate with therapy.  But if you get down to brass tax, what I was saying/representing was a lie.  I did it in the patients best interest and on the advice of a nationally reknowned physical therapy expert.  

How different is your scenario, really?  You have a patient incapable of making his own decisions, a patient incapable of reasoning in his own best interest, so you are manipulating the truth to maximize compliance in order to get him in a position of maximum physical independence for him to live out his days with the highest degree of quality.

Like I said, playing devil's advocate here.  Another thought.  Perhaps the family asked the PA to lie...or asked him not to tell the patient he was going to a nursing home.  It would still be the PAs decision to lie - noone can force him to do that.  Just wondering if there could be other factors at work here that you aren't aware of.

Good topic here.  Thanks for the opportunity to share.

Janey

Janey Goude April 1, 2010 10:54 AM

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