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PTA Blog Talk

Coddling Patients

Published April 21, 2010 5:45 PM by Jason Marketti

The other day I was at work talking to a patient about therapy when he expressed his desire not to participate. He then called over a nurse and said I need to check with her before I see him. The nurse came over and said the patient has a right to refuse therapy and we should leave him alone if he does not want it.

Two things here. The patient has already declined therapy and the nurse is not backing up a basic foundation of good health, movement of the body. Movement of the body prevents bed sores, edema, pneumonia, and promotes strength and independence.

I wonder if the patient would have participated if the nurse simply stated it was up to him whether he wanted to go or not, and then encouraged him to try to move around more to "clear the lungs." I am seeing some coddling going on with the patients I am currently seeing and I do not understand it.

The gentleman patient was cognitive and able to make his needs known without difficulty. He stated clearly he did not want to participate in therapy and this was reinforced by the nurse. Why? And how often does this really occur?

Perhaps it is a mindset that needs a gentle persuasion that physical therapy is a good thing. It's just that I have not yet encountered a setting like this (until now) that is so overprotective of patients. Even the pediatrics wards were not this bad.


I read "coddling patients" with great interest.  I work in a SNF, where daily there are those patients I dread trying to get to attend therapy.  Every time I have to go into great explanation why they should attend therapy, eventually most will agree to come down to the therapy gym and admit they are glad they attended.  I am fine with those.  But then there are the few, who understand they will not get better without therapy, eventually getting angry that no one will leave them alone and it gets to the point where you can't entire their room without them immediately getting angry that you're there to try and convice them to come to therapy.  I have seen our COTA bring in a patient that had just refused therapy with me, be dropped off at the therapy gym (COTA will say she did ADL's and was through with them) for me to "work with" only having that patient stated they didn't realize this was where they were going (the COTA told them they were going to the beauty shop or get coffee) and they still weren't going to do therapy and by now they were really upset.  Needless to say this makes them NOT want to participate even more.  This has happened several times and is not an isolated incident.  There has to be a point where we are violating patient rights, morally, ethically and legally!  I have begun discharging these patients "due to lack of progress" while OT keeps them on them on caseload.  Management has not made an issue of this yet, I know we aren't meeting those Ultra-High RUGS, but I can't deal with those sleepless nights wondering if more harm than good is coming out of this.

T., Rehab - PTA, SNF June 26, 2010 12:44 AM

I agree that the PT is suposed to "sell" the therapy plan to patient. I also believe in working as a team. It has been my experience as a PTA, for 25 years, that if an MD orders therapy the first thing the PT should be able to assess is if the patient truly needs treatment. My issue is when the whole plan goes in the trash because a nurse is more interested in keeping the patient "happy"in bed, instead of encouraging the patient to work on getting the active part of their recovery going. As health care providers, we should be supportive and respectful of our specific fields of training and work together for the patient's benefit.

Lucy, , PTA SNF May 11, 2010 7:04 PM


The nurse did her job.  She is supposed to be the patient's advocate.  That includes backing up the patient when he refuses treatment.  You don't have to like it.  You don't have to agree with it.  But you do have to respect it.

That said, you still may have a bone to pick.  It would be with your PT.  You didn't mention the PT at all.  I'm assuming there was one in the picture who did the evaluation?  As a PT, I'd place the onus on the evaluating PT, not the nurse.  

If the PT had done the selling part of the job (yes, every PT "sells"), then the deal would have been closed one way or the other.  Either the patient would have bought in, or the PT wouldn't have known it was a "no sale" and you would have never seen the patient.  It would have been an "eval only" scenario.  The nurse should not have had to explain the advantages of PT to the patient.  Your evaluating PT should have done that.  

A patient came to mind in just the last few days that is a real life example.  I was doing home health so I had the additional hurdle of being on the patient's turf.

I showed up at the patient's home and he wouldn't let me in.  I'm not sure why he scheduled the appointment!  But there I was, standing outside, trying to negotiate entry through a closed door - literally and figuratively.

I listened to the patient and why he didn't want PT:  He didn't need it.  Of course!  That is probably as oft repeated a phrase in PT as "I didn't do it" is in the prisons.  In the patient's opinion, his daughter had badgered the doctor into writing the order.  

Eventually I convinced him that it was in his best interest to let me in the house to do the eval.  After all, if I didn't, the daughter would likely just get another order written and he'd just have to repeat this standoff.  I reasoned with him that if he let me in, I could determine he was safe at home, send the doctor the report, and then the doctor would have ammunition to send the overbearing daughter away.  

If, on the other hand, I found he would benefit from therapy, but he still didn't want it, I would honor that.  I could send that report to the doctor also, along with documentation that the patient appeared to be competent to make that decision.  In other words, I was on his side.  Doing this evaluation could only help neutralize the interfering relative.

Turned out he was as functional as he needed to be.  He was old had worked hard his whole life.  Now, in his twilight years, he just wanted to be left alone with his TV and a cold coke.  His daughter wanted him walking laps in the mall.  The therapy was meant attain her goals, not the patient's.  

As therapists we have to be careful not to let our enthusaism ursurp our patient's goals.  We are also the patient's advocate, which sometimes requires delicately balancing the patient's best health interests with the patient's own interests.  We can't cram physical health down patients' throats.  We offer an avenue for them to pursue their goals.  It's an amazing day when the patient's goals and maximum health benefits are one in the same.

Back to my elderly coke-drinking, TV-watching home health patient.  Turns out this gentleman did need some safety training to keep from ending up back in the hospital.  By the time I got around to explaining that, he knew I was on his side and he graciously allowed me to return for a few visits to accomplish HIS goals.  Nobody wants to end up with a broken hip because they tripped on a throw rug on their way to fetch a coke that was only 10 feet away.

So it was a win-win.  The patient got the therapy he needed to be safe in his home.  The doctor got the ammunition he needed to back down the daughter.  The patient knew who to contact if he ever decided he wanted to take up mall-walking.  He was left with a pleasant PT taste in his mouth so he might be less resistant to rehab in the future should he ever need it.

If the gentleman had declined safety training, I would have documented that and left the door open for him to change his mind.  I'd prefer to be able to give him the tools to be safe, but he has the right to decline those and put himself at risk for falls.  My respecting those rights will only make it easier for caregivers in the future.  

Janey Goude May 4, 2010 1:11 AM

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About this Blog

    Jason J. Marketti
    Occupation: Physical Therapist Assistant
    Setting: San Jacinto, CA
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