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Toni Talks about PT Today

Treating a Difficult Patient

Published May 20, 2015 4:11 PM by Toni Patt

"I'm paying to be here and be taken care of. You will do what I tell you."

It's bad enough we struggle for respect from physicians and occasionally other disciplines. I would say the majority of the population doesn't know what we do or the amount of education required to be a therapist. Usually if we work hard and prove ourselves, the respect follows. Or we generate recognition that what we do requires skill and training.

That wasn't true of a woman I attempted to work with last weekend. She had just arrived to the SNF and wanted to go to the bathroom. When I arrived, she was still on the gurney demanding a RW be given to her so she could walk to the bathroom. When I told her I wouldn't do that, I got the response quoted above. She seemed to think I was a servant, not a trained and skilled therapist.

At that point, I knew nothing about her because I'd been called to the room without explanation of what was needed. The only information in the old chart was her diagnosis of THR and ambulation of 15 feet with moderate assist. That's not a lot of information, certainly not enough for me to plop a RW in front of her and let her be off to the bathroom.

I tried to explain the process to her. This resulted in being told I was rude by both her and her son. Her son pulled me into the hall and threatened to have me fired on the spot as well as have my license removed. He actually behaved worse than that. Meanwhile his mother was still demanding to go to the bathroom very loudly. They both believed I should just deliver the RW and let her be.

The EMT person made things worse by saying the patient did it at the hospital. Yes, but did she do it correctly? The EMT had no way of knowing.

I was the bad guy because I wouldn't simply put the RW in front of the patient, but actually wanted to do an assessment and make sure everything was done safely and properly. The patient, her family, the EMT and nursing didn't seem to think any of that was necessary. The woman said she could do it. That was enough for them.

No one seemed to understand that PT is a skilled service. A PT can't just deliver a RW because the patient wants one; much less leave it in the room without assessing the patient. I made everyone angry because I wanted to do things the right way. The patient's demand was more important than using clinical judgment and making sure everything was safe.

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I certainly empathize  with the need to go to the bathroom, BUT if something were to happen, (or maybe even nothing would happen) breaches of protocol are usually nothing to laugh at. I'm thinking if it were me get a nurse to help with a bedpan for the patient.

Scott, PT - PT/ Owner, Out patient clinic June 3, 2015 8:21 PM
McHenry IL

We cannot "control the actions and reactions" of patients and healthcare workers.  However, we can, with much certainty take a moment to mindfully and thoughtfully decide how we will act and respond in ALL patient based experiences and interactions. The example Toni gives..."the difficulty patient". Maybe we should change our thoughts and words first because right off the bat in calling her the "difficult patient" we have set the scene and the tone for the experience. How you think and view the patient will always affect the treatment, the outcomes, and the overall experience they may or may not have. Yes, we do need to be safe. Yes, we do need to be in compliance...but we also have a need to be compassionate. There may have been many other "successful" responses and ways to address the patients immediate need to use the bathroom.  Older adults are a unique population and maybe the patient came across as "entitled" but I am sure that as a DPT your "ego" is strong enough to handle any client in distress no matter what the reason or the circumstance:).

Linda Rizzo, , Therapy Clinic Coordinator Magee Rehab June 3, 2015 3:37 PM
Phila PA

Was there even a PT order in the chart at this time? Not sure what the laws in TX are however in all of the states that I've practiced (I'm a traveler), we aren't supposed to touch the patient until an order is there. And we should definitely clear certain things prior to touching the patient. At the end of the day, PTs must protect their license at all times...and that means follow the laws. If the patient was being brought in by the EMTs, it's a good chance that the admission process had not been completed. Nursing should be assisting this patient until he/she is properly admitted and assessed. It seems simple to just walk with the patient to the bathroom, but it's not skilled and if there was an incident (fall, pt faints, etc), that PT would be held totally responsible because she is a skilled PT and should've known better. Unfortunately in SNFs, PTs are treated like human hoyer lifts and glorified clothing changer rather than the skilled clinicians that we are

Lynnette June 3, 2015 3:22 PM

None of us are clear on how this patients experience was in the acute care hospital, she could have had a bad experience with meds, nurses, Drs. who knows.... Yes, we have limited time, sometimes limited info, we need to protect our licenses and provide the best possible care while trying to have compassion for this person we are trying to help.  I have had so many patients who have soiled /wet themselves because they were unable to get the assistance they needed.  If we are in these types of facilities, we need to be ready for these situations.  I have had many unruly, rude patients that have thanked me after I have helped them in the immediate situation.  

Wendy, PTA June 2, 2015 12:59 PM

I have to agree with Toni on this. It appears she was called to help out with the bathroom issue. Nursing could have assisted her to go to the bathroom. The PT should have been called to do first an evaluation instead of helping the patient with the bathroom. Granted some PTs might say that taking her to the bathroom will constitute an evaluation. But one thing everybody is forgetting is that there is barely any prior medical information on this patient's chart. We don't know if there are any other issues with this patient that may come up during a physical therapy assessment that could prevent Toni from issuing a RW. Then we are in big trouble.

Raphael, PT May 30, 2015 4:02 PM
San Antonio TX

Although there was no excuse for the patient's arrogant remark, I'm with  he is on this. Elderly people (and often younger ones too) can have an urgent need to urinate. This is not the time for presentation of rules and regs, much less an evaluation. I understand,  under the circumstances,   not just sending the patient off unsupervised with a walker, but I would have accompanied her to the bathroom immediately,  with contact guard if necessary. Lecture and evaluation can come afterwards. There is something dehumanizing in being told by a stranger they you cannot go to the bathroom when you need to.5

Katharine, PTA May 29, 2015 10:25 AM

The question raised by Toni is of respectfully performing a skilled job.

In most SNFs there is minimal to none repect by admin/ nursing staff.

The admitting. Nurse could have educated the patient/family of policy of using assistive device upon admission.

If the patient was admitted as a patient who could use RW independently, then it could have been provided by nursing staff.

As the patient needed moderate assist PTA, the request or rather DEMAND for RW should have been denied by admitting staff. The patient is admitted for rehab and without a formal evaluation, provision of RW for BADLs defeats the purpose of rehab admission.

Then we can just start using devices at whim of patient and all the functional testing can rest in peace.

Deb Smith May 28, 2015 10:38 PM

I don't know the situation you were in but I would have done bathroom training with her right there with a RW and a gait belt. But maybe that was not possible to do.. Yeah companies are out of control with their point of service crap. Very unethical.

Jerry, PTA May 28, 2015 9:13 PM
Sarasota FL

Perhaps information is missing, but maybe the patient really needed to go to the bathroom, now, not 30 minutes or an hour from now. As we get older, control can become a big issue. Were you able to offer her an alternative (i.e. bed pan?) It is difficult to concentrate on an evaluation when "you gotta GO". Granted, her approach was not the best, but there is no value in "talking it out" when there is an overwhelming need. Hope there wasn't a flood.

Chris, , P.T. Greene Rehab Services May 28, 2015 5:56 PM
Venice FL

I have been a PT for 31 years and my patience with my profession as well as my ethics seems to get more and more challenged. No one seems to respect our profession and I am sure we are at fault to some extent but it seems my mind is quickly tiring...especially when all I want to do is do REAL therapy with REAL patients and help people.

As an "well aged therapist" the rules and regulations continue to seem to work against just that. I currently work part time for one of the huge rehab companies and I carry a tablet that must be on my person constantly. The upper echelon initially said that we had to start/stop our patient within 15 mins of eachother, than it was 10 and now it is less than 5 minutes. At the end of the month all is totaled and if it doesn't average less than 5 there is an "action plan".  So frustrating and does not sound ethical at all....the reasoning is told to us in CMS and the company, but cannot always happen and yet we are now told "there are no excuses". Help???

Donna, geriatrics - PT, snf May 22, 2015 4:28 PM
Delray Beach FL

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