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Toni Talks about PT Today

Mortality is a Topic for Discussion

Published June 21, 2011 4:18 PM by Toni Patt

Throughout my career, the focus has always been on the positive. How the patient will improve. Identifying what goals can be achieved. Negatives were discussed only as barriers to positive outcomes. Death is only discussed in terms of someone having died, not having the potential to die. I've heard death discussed as a possible outcome when talking about critically ill patients. It doesn't seem to come up as a topic in relation to physical therapy.

It should. I realized this last week when discussing a new admission to the rehabilitation unit. She is elderly with orthopedic injuries to both legs. She will be non-weight bearing through either leg for at least eight weeks. I was talking with another therapist about potential goals and mentioned it might not matter. The injuries could end up being fatal. Unilateral hip fractures in the elderly are associated with a 15-25 percent mortality rate in the first year and this woman injured both legs.

You could have heard a pin drop. I don't think I could have caused more shock if I started cursing. Apparently I uttered the unspeakable. There seems to be an unspoken taboo preventing discussion of mortality about physical therapy patients. You just don't say someone might die. I never said I thought the woman would die. Nor did I say she would die from her injuries. I said given her injuries, age and co-morbidities, there was chance she could die within a year.

I don't think it was wrong to say that. Before writing this blog, I found 10 articles dating from 2000 to 2010 that support my statement about hip fracture and death in the elderly. Our patients are getting sicker. The odds of someone dying after an injury or illness requiring physical therapy are increasing. That needs to be acknowledged when we're talking about our patients.

There is nothing wrong with saying someone is at a higher risk due to an injury. There is something wrong with deliberately avoiding the topic. If I know someone is high risk, I can shape a treatment plan to counteract the immobility. There's a lot to be said for positive thinking but reality can't be ignored. As professionals we need to at least acknowledge the possibility of death. We don't have to like it. It doesn't have to be lunch conversation. We just have to admit it could happen.

3 comments

I worked counselling patients who were potentially being tested for fatal genetic disorders where they had a 50% chance of inheriting the disorder. The difficulties in discussing the topic are huge and need to be handled so carefully.

There are many people who want to know what will be happening in the future and wish to make plans accordingly, but there are also many people who would state to our team that the quality of their remaining days would be better if they could just live the rest of their days in hope rather than dealing with the grief and depression of themselves and their families with the negative outcome of our predictive testing.

Discussion of statistical outcomes can quickly alter peoples life choices and the decision making by patients, their loved ones and by their health care staff, and not always in a way that is beneficial to the situation.

I am not saying patients should not be informed, and that health care workers should not be cognizant of risk but  I am saying that there is a right way to do it and staff needs to be careful how even their attitudes and body language communicate any assumptions they might have.

Linda Cooper June 23, 2011 3:03 PM

Also, on the main home page of the APTA website is a news feed about the transition and new emphasis of the role of PTs in hospice and palliative care sites.  Toni, you are totally right.  Not only do we need to bring up these discussions, we also need to be able to stop our therapy interventions when the realistic outcomes and quality of life are not impacted by our skills.  

Lisa West June 21, 2011 10:32 PM

Brilliant post for all the reasons you describe, but also for one other reason. It gives someone the opportunity to start thinking about advance directives. Advance directives are not simply the domain of social work, it is up to all health care professionals to be willing to talk to patients about this subject. I worked in Florida right after the Terry Schiavo case was in the news. It was our legal responsibility when we opened cases to have these discussions with patients.

From what I can recall, your statistics are spot on. There is a good likelihood that this unfortunate person will not make another year. To ignore that, takes away her autonomy, becomes very paternalistic, and may result in a treatment course that raises false hopes, causes more harms than benefits and may not be what the patient wants in the long term anyway. Yes, we should work for the most optimistic outcomes but as you said, we shouldn't lose sight of reality.

Dean Metz June 21, 2011 6:17 PM

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