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Toni Talks about PT Today

A Dangerous Patient

Published July 10, 2012 3:05 PM by Toni Patt

Sooner or later, everyone comes in contact with a patient who swings at her, attempts to bite or scratch or spits. It goes with the territory, especially if you work with patients who have brain injury or Alzheimer's disease. We console ourselves with the thought that the patient doesn't really mean to do it. It's simply a reaction to fear or pain.

What if that isn't the case? What if the patient is doing it deliberately and with family encouragement? We have one like that. She is an older woman with moderate dementia. She doesn't want to be in a SNF. Her family doesn't want to take care of her at home. She is obese, manipulative and capable of more than she lets on. She constantly complaints to anyone, including her family, that she is being forced to do things she doesn't want to do.

Instead of encouraging her to cooperate, a daughter told her it was okay to fight back. She was overheard telling the patient that hitting and scratching were acceptable if the staff did something she didn't like. Things the patient doesn't like include being rolled in bed, getting up for meals, taking medicines and bathing. Yes, patients have the right to refuse. They have the right to say no to all of the above. They don't have the right to injure another person in the process.

Thus we have a gray area. On one hand, rolling, eating and bathing are necessary for good health. Medicines are necessary to combat her multiple co-morbidities. On the other hand, she has the right to not want them. The problem is she may not understand what she is refusing or the complications of those refusals. Is a demented person capable of making those decisions?

Now the problem has become how to care for this patient safely. Fortunately she isn't on therapy caseload. Had she behaved that way with me, I would have discharged after two warnings and notifying the family. She is coherent enough to understand her daughter's instructions. She is coherent enough to know better.


I had an intentionally malicious patient in home health: a young man in his twenties with AIDS. The incident occurred in the eighties, when AIDS was fairly new on the scene and transmission was not yet well understood. At that time, saliva was thought to be a ready mode of transference.

This young man was feeble, bordering on wheelchair-bound, and on dialysis. His reputation with the nurses at the dialysis facility preceded him. The nurses scattered when they saw him because he went in spitting. He spat on any health care worker who came near him.

I was the only PT on staff at the fledgling home health agency. My supervisor explained the situation and told me I didn't have to see this patient. We could refuse based on his history of threatening behavior. I knew I could use PPE to protect myself from spit, so off I went.

I set clear expectations from the beginning. Since dementia wasn't a factor, I knew he comprehended them. I laid out my expectations of him: he wouldn't spit, not once. There would be no second chances. I shared what he could expect of me: I would treat him with respect and do everything in my power to help him achieve his goals.

He never spat at me. He just wanted someone to treat him with dignity, which sadly was a rare commodity for AIDS patients in the early years of the disease.

Granted, this is different from your scenario, but unfortunately, deliberate attacks also happen in the absence of dementia. Some people are just mean. Some have been so emotionally wounded, the only thing they can think of to make themselves feel better is to hurt someone else. Some people, like the patient and family you mention, have a skewed perspective of acceptable behavior.

Interestingly, you may have a case of both: a demented patient and a family without dementia who are equally inappropriate. That scenario makes is doubly difficult to determine when the patient is not longer cognitively able to understand the consequences of her behavior/decisions.

Jane Goude July 11, 2012 2:55 PM

When the patient is of sound mind, boundaries should be clearly explained. At the point the patient's actions endanger the health care professional, treatment is denied.

When the patient is not of sound mind, the family is consulted. The family may know how to orchestrate encounters to enhance patient cooperation. The same well-defined boundaries are explained to the patient and the family. At the point where the patient endangers the health care worker, the treatment is denied.

In either case, instead of categorically denying treatment, it may be possible to alter treatment to a level where the provider is safe: an alternate treatment, a different delivery system, a different provider.

For me the gray area lies in figuring out when to call in the family. Determining when a patient crosses the line from understanding the implications of his refusal to not comprehending the consequences of declining therapy is often a hard call.

There is no gray area for me regarding when to withhold treatment. Safety is always preeminent, be it the patient's or the clinician's. A patient's dementia does not negate the right of the health care provider to work in a safe environment. The criteria is simple, though our compassion makes it difficult to execute.  

Jane Goude July 11, 2012 2:11 PM

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