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Toni Talks about PT Today

Under Pressure

Published April 19, 2011 12:07 PM by Toni Patt

I have been working with a brain injury patient who has been designated a VIP. Everyone who cares for him knows his status. It has followed him to more than one unit. Being a VIP has not been as helpful as the title suggests. My facility is quick to point out that all patients are treated equally unless the patient is willing to pay to be in the luxury area. The same physicians and staff care for these patients but the circumstances are nicer.

I've worked with VIP patients in the past. The same things happened then as are happening now. The patient receives extra attention, be it nursing, medical or therapeutic. One therapist from each discipline is usually designated to work with the patient at a specific time that is blocked off for therapy. If therapy is missed, it is expected to be made up. When prioritizing is required, the VIP patient automatically goes to the top of the list. I am beginning to resent the situation I have been placed in. Each day an hour of my time along with that of support staff is dedicated to this patient. The time is blocked out and unchangeable. There is no cutting back his time to accommodate something else.

The pressure for him to improve is becoming overwhelming. His family admitted him with the expectation he would improve functionally. Someone is there for every treatment. Every day I'm pressed to describe some improvement from the previous day. Every time I go into the room I feel the pressure to make him better. It radiates off his family. It radiates off his physicians. Meanwhile he continues to plod along at his own pace, which is nowhere near as rapid.

There are days I dread entering the room. No matter what I'm able to facilitate, it won't be enough. Neuro patients fluctuate. It's the nature of the process. Days of downward fluctuation are more stressful. Days of upward fluctuation are worrisome because a new expectation develops. I can't make him do something his brain isn't ready for. I can't even get him to be consistent from one day to the next.

I'm running out of ideas. I've made progress with what I've been doing but it hasn't been enough. The underlying expectation is more. Get him to do more. I've been rethinking my techniques and trying to see where I can make changes. I keep asking myself what else I can do. What else I can change. I can't find an answer. Every time I go into that room, I feel the pressure to come up with that answer.

It's too bad my VIP isn't an average, everyday patient. There would be no pressure on him or me to make improvements. His family would be happy with the little changes I regularly make. His care could focus on him, not the surrounding issues. We could just keep plodding along and slowly get better.


I smiled when I read this.  I experienced this in a variety of settings in Palm Springs and at a local hospital in Las Vegas.  We could bump some of the "non-essential" patients but never the VIPs.  Why? I would ask.  They pay the bills and established the foundations where we work of course.  

I am no longer at those places.  And you know, D. Reinke has a good point.

Jason April 20, 2011 10:24 PM

Toni, I can appreciate your frustration in this situation. When I worked in an inpatient facility, the patients were often celebrities in movies, theatre or more often, in business and were treated very differently by administration and we had to follow suit. That was one of the reasons I eventually went into home care in the projects of NYC. I wanted to give people what they needed, not a pampering.

It is unfortunate that health care is a capitalistic business where patients are customers and the big spenders or donors get preferential treatment and those with a huge need but a small purse sometimes get less (although I suspect that is not the case with you treating them).  

I've been reading about how you have trusted your instincts and did well with them for almost 2 years. Now is NOT the time to stop that practice! Good luck with this case.


Dean Metz April 20, 2011 1:35 PM

From reading your post I can't tell if your facility doesn't have a stroke team meeting with clients where a prognosis is set out and expectations are discussed with the family, or if the family is in denial or just so used to getting their way that they assume they are above the prognosis.  If you live your entire life getting what you want, that is what you would expect in this situation, too.  It is unrealistic, but they have been living in their own reality.  That isn't on you.  That is on them. If they have not been given a comprehensive picture by the team, that is on the practitioners.  With this type of family, you are going to have to present a united front, most likely in a team meeting type of atmosphere.  If you haven't had that type of meeting, then for all you know they are being presented with different pictures from different team members.  In which case they are likely taking the best scenarios from each practitioner and weaving them together to make a rosy picture. In previous posts, I get the impression you work on a rehab unit within an acute care facility.  If that is wrong, the rest of this may be mute.  When I worked in that setting, we had a physiatrist who coordinated care.  Each patient had a therapist of each discipline, a social worker, and a nurse assigned to their care.  We held weekly meetings where we discussed each patient, their progress, and their discharge.  We held a family meeting once a month where the patient and family member(s) attended and were informed on the patient's progress and what future expectations were.  That way everyone was in the same room, hearing the same information at the same time.  So, the family was getting the same message reinforced by everyone at every session.  If your facility doesn't have that, perhaps you could suggest having one meeting like this with the physician of record to help set expectations.  We all know clients who defy expectations (for better or worse), and families/clients who live in denial of expectations.  All you can do is provide education and skilled intervention.  I have no doubts this man could not be in better therapeutic hands.  It just occurred to me that my post from April 13 deals with this:  Clients' Rights (  Clients and their families have the right to make bad decisions, including living in denial.  You have to embrace that reality and come to grips with the fact that there are some things over which you have no control.  Do your best with what is in your control, then walk away and enjoy your life.

Janey Goude April 20, 2011 12:21 PM

Toni, I am just a stroke addled survivor but from my reading thousands of stroke forum posts. The first problem is that the doctors involved don't provide a damage diagnosis, for example, this area was in the bleed drainage area or penumbra and thus is only partially damaged and with lots of hard work and neuroplasticity can be recovered. This would require mapping damage to humunculouses and standard functions. The same with the dead area. With no diagnosis you are being asked to provide a miracle of dead brain  function recovery in an impossible amount of time. somehow you have to get away from the prescription that the doctor wrote of ET, evaluate and treat. This whole issue really falls on the doctor not setting proper expectations.

The whole stroke rehab mindset is wrong


dean reinke, recovery - survivor, do-it-yourself April 20, 2011 1:58 AM
minneapolis MN

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