When Rehab Expectations Disagree
Last week I went to a continuing education course on degenerative neurological diseases. I had a "doh" moment when the speaker touched on expectations and therapy. She said all patients expect to get better. No matter what the neurological deficit, they think it is temporary and will be better in a short period of time. Until they accept they've had a loss they won't make significant progress in therapy.
I experience that on a regular basis but didn't know how to describe it. No matter how hard I try to explain, I always run into one patient who just doesn't get he's had a stroke and isn't the same as before. Today I ran into a family who feels that way. The patient is a large man with a huge right MCA infarct and dense hemiparesis. He is over six-feet tall, weighs more than 350 pounds, is globally aphasia and pretty much dead weight to mobilize.
Before I even initiated the examination, his wife began asking about rehab. I finally had to ask them to step out because they answered all of my questions before he had a chance to respond. Assessing a global aphasic is difficult at best and next to impossible with distractions.
This was one of those times I actually had a tech with me. By the time we finished, I was very thankful he liked to go to the gym. Although he didn't resist, the patient couldn't help us. It took all we had just to get him to the edge of the bed. I couldn't stand him because I didn't think I could control his weight or adequately block his knee. Getting to a chair is out of the question unless I find a bariatric neuro chair somewhere in the hospital.
When I spoke with his family, I tried to spin things as positively as possible. That turned out to be a mistake. No matter what I said, his family only seemed to hear what they wanted to. Every question they asked revolved around his getting rehab as soon as possible. I did everything but flat-out tell them it will never happen.
I said he needs months of therapy before being ready to return home. I told them I saw positive signs like trying to vocalize and mimicking but he didn't really work with me. I might as well have kept my mouth shut. We were having two different conversations.
His family doesn't seem to realize he's had a severe stroke and will not return to the way he was, which will make therapy challenging. His son has already gotten into an argument with a neuro rehab doc who came when the patient was asleep. Everything I say will be taken out of context.
My unit isn't set up to handle someone like this. We can do big. We can do global aphasic. We can do dense hemiplegia. We can't do all three on the same patient. Even if I wanted to, I have no way of standing him. He just isn't going to make much progress until he reaches a SNF and the family is going to fight that every step of the way.
Some patients learn by trial and error, others by explanation. Often I need to put a mirror in front for them to get it. I don't know how to get this family to understand their expectations for this man aren't reasonable right now. They aren't seeing the same things I am. And until they acknowledge the severity of this stroke, they won't see it.
Sooner or later, I'll have to explain why we won't be standing. They'll probably see everything as an excuse. I can visualize his son trying to do it anyway. I can see I'll be walking on very thin ice for a while.