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Toni Talks about PT Today

Futile Care or Best Practice?

Published July 6, 2010 10:51 AM by Toni Patt

I worked with a patient this weekend that made me question some of the things I automatically do. He is a 16-year-old boy with a severe head injury. All of his physicians are in agreement that his prognosis is poor. I was consulted for family training and positioning. Prior to going into the room his nurse warned me. The mother has unrealistic expectations and believes her son will fully recover.

The PROM exercises were no problem. The problem was the request to replace one of his multipodus boots. The original had become soiled and was thrown away. I saw no problem with it. Proper positioning and pressure relief are necessary to prevent skin breakdown and the assorted problems that come with them. Just because someone has a poor prognosis doesn't mean he will die in the immediate future.

Not everyone agreed with me. The regular NICU therapist was shocked that he'd been issued the original pair. She doesn't issue them to patients with poor prognoses. She felt it was a waste of resources. She was upset the soiled one had been thrown away and didn't want me to replace it. There is some logic to that. Putting something on a patient who won't be ambulating and has a poor prognosis might not be the best use of resources. We only have so many available. Taking one might result in someone else not getting one in a timely fashion.

I replaced the boot. A pressure sore would only complicate an already-complicated hospital course. But the conversation made me think. When did we start deciding who deserved best practice versus adequate practice? When did cost become more important than outcome? Why should he be denied the boot because someone else might need one? I'm not advocating putting him on caseload and following the rest of his hospitalization. That wouldn't be the best use of resources. However, I see no problem with doing something to prevent further complications that we know he is at high risk for.

It really isn't our place to ration therapy based on subjective judgments. Part of our code of ethics is to provide the best reasonable care possible. To me that means every time with every patient. Unless patients are actively dying they deserve our best efforts appropriate for their condition. I can make a good case in this instance. If we start basing treatment decisions on things other than best practice and patient outcomes, our profession begins to suffer.

Unless instructed otherwise, doctors must do everything possible. Shouldn't that hold for us as well?



While this isn't the main theme of your post, I want to address a statement you made:

"Unless patients are actively dying they deserve our best efforts appropriate for their condition."

Patients who are actively dying are not exempt from our "best efforts appropriate for their condition."  While many aspects of physical therapy are not appropriate for the hospice population, especially those in final days, I have had the honor of using my "best efforts appropriate for their condition" to make their final days more comfortable.

ALL patients deserve our best efforts appropriate for their condition.

Janey Goude July 12, 2010 1:09 PM

Doctor Patt, I would like to present my case for why your decision was not only not best practice, it was irresponsible.

First, what evidence is there that the multipodus boot was necessary? Does this unit have insufficient staff that skin breakdown is a common occurrence? Are there no other ways of preventing skin breakdown? I do believe that evidence shows the most effective way to prevent skin breakdown is from diligent re-positioning, not application of appliances.

Second, given that evidence will not support the use of this appliance, will insurance companies reimburse your institution for its use? If not, did you really want to burden the family with the expense? Let us suppose the institution writes off the expense, how many decisions like that occur every day? Hospitals and other institutions are struggling to stay afloat, every dollar does matter.

Third, as professionals, we are the stewards of our resources. It is our responsibility to guard them and use them appropriately so that there will be enough for everyone. You said it yourself, giving it to this unfortunate young adult may deprive someone else of it. We are also the stewards of our institutions resources. If they have to foot the bill for items like this, it may prevent them from purchasing other equipment or making needed upgrades or repairs down the road.

Fourth, what steps did you take to ensure this one won't become soiled and thrown away as well? This cycle could go on and on further raising unnecessary expense. Did you instruct anyone on proper re-positioning? Did you instruct the family to ask for it every 2 hours or teach them how to position the feet themselves?

Fifth, It would seem to me that slapping a boot on somebody is actually the easy way out. You state that our job is to provide the best reasonable care possible and that means spending time with every patient. Did you spend time with this person's nurse or family to instruct them or was it simply more time efficient to apply a boot and be done with him?

Depending upon one's point of view, this issue could be seen as you stood up for a patient's right to equipment, or as you simply got caught wasting the hospital's money because it was you confusing adequate practice with best practice. Only you know the real rationale but I can see another side to the story.

In the NHS I have to defend EVERY piece of equipment I supply. If practice supports its use, no problem. I'm currently defending the purchase of flutter pipes for our difficult to manage COPD population. I have the research, I have a program plan, I have done my homework on costs and implementation and I am confident that this will pass, as is my business manager. I am pursuing best practice for my clients based upon clinical evidence, prognosis of the individual, and cost-benefit analysis. That is what makes adequate practice into best practice.

Dean Metz July 6, 2010 3:09 PM

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