When is PT Inappropriate?
A friend of mine works as a nurse in a hospice setting and she mentioned to me a few days ago that many of the patients she admits into their facility come with orders for physical therapy. I've seen articles and research about the effectiveness of physical therapy for patients in a hospice setting, but the idea that many of them have PT orders is something to discuss.
Nearly all of the patients admitted to hospice will expire within six months of admission. Some will improve and transfer out, but most will not. I don't remember exactly what the statistics were, but I vaguely remember President Obama mentioning that most healthcare expenses are compiled during the last year of a person's life. Where does physical therapy fit into that?
I haven't ever worked in a setting like hospice before, although the ICU setting probably has some similarities. When I worked with patients within the unit, my role was often second to life-saving measures; like when a patient's blood pressure needed to stabilize, or if his breathing pattern diminished and needed assistance. I would take a step back and wait until the patient was stable and able to participate. Do those same concepts apply to hospice? I'm not trying to imply that we shouldn't "waste" money on our patients in a hospice setting; I'm just trying to understand that setting and our role as physical therapists better.
Aside from hospice, there are plenty of times that a patient has been given orders for physical therapy that are clearly inappropriate, even dangerous in some situations. Patients who are total assist for bed mobility and transfers, non-ambulatory at baseline, and morbidly obese with orders to ambulate three times daily. Patients with orders for modalities who have clear contraindications against their use. Patients with lower endurance who fatigue in the first rehab session of the day but have orders for hours of rehab daily.
In most of these cases, I'd send a note back to the ordering provider explaining why the order was either inappropriate or not achievable, and I'd also include a short statement about the current plan of care. Most of the time the provider was in agreement with me. This kind of goes along with a piece my fellow ADVANCE blogger Toni wrote this week -- that time-based expectations for some patients for therapy participation are completely inappropriate.
What do you think? Have you ever worked in hospice? Is physical therapy a priority in that setting? I'd like to learn more about our profession in that role. Have you ever spoken with a patient or provider to discuss their orders and if they are appropriate for the patient?