Entry 3 - Intervention (25/04/2010)

Situation: I had been treating a very elderly woman for about a week and a half, when out of no-where she refused physio treatment 2 days in a row. I thought this to be very strange as she was a very pleasant woman who had previously been so enthusiastic and always enjoyed her rehab physio sessions with me. The woman was at Osborne Park Hospital for ongoing rehabilitation following a left hemiarthroplasty, performed because of a fractured neck of femur (NOF) suffered from a fall outside her home. The first 2 days that the woman refused treatment I didn’t really think too much of it. On those days she reported feeling very tired which I didn’t feel was unreasonable as she’d had multiple investigations such as CT’s and X-rays on each of the days and told me she had slept poorly on each of the previous nights. After the second day I did have a quick chat with one of the members of the medical team regarding the investigations that were being performed, his response was that some of the patient’s symptoms such as her abdominal pain could have been linked to cancer, so they were investigating this further.
When I went to continue with the rehab the following day and the patient refused again, I wanted to look into this more, so asked some additional questions to ones from the previous days. During a lengthy discussion with the patient I discovered that the she had basically had enough, did not want any further treatment and just wanted to go home. She told me that she felt her “time was up,” referring to her life, suggesting that she didn’t feel she had much longer to live. She told me multiple times that she had “lived a good life” and as such was “happy to go.” She also explained to me that she felt she may go unconscious soon and if she did, she did not wish to be resuscitated. After the events of this conversation I knew I had to relay my findings back to the medical team.

Task: My ongoing task for this patient was to provide rehabilitation for her hemiarthroplasty to get her a point where she would be able and safe for discharge home from the hospital. She was living with her son at home and this was to be her planned discharge destination, so I had to get her to a state where she was independent with transfers and mobility so she could go home.

Action: After becoming aware of my patient’s thoughts and feelings, I was quick to assure her that the doctors and the whole team were doing their best to try and help with her pain and recovery. I explained that the tests that had been performed were necessary to try and ascertain what was causing her problems. I also reminded the patient of her sons and all the stories she had told me about them and asked her if they knew about her current state of mind and if so what they thought about it. She responded by saying that they were fully supportive of her decision, a response that I was not utterly convinced about, but nonetheless took on board. Apart from what I had already said and explained to the woman, I felt that I was out of my depth to say much more on the subject to her, so I headed straight to the doctor’s office to let them know about my conversation.
I explained to the team that was present all the events that had occurred prior to the conversation and exactly what was said during the conversation itself. The registrar said that they were aware of the patient’s low mood over the previous few days, but were not aware that the patient did not wish to be resuscitated in the event of an emergency. They thanked me for my findings and went straight in to have a further discussion with the patient about the matter.
When they had finished with the woman, they came back to me, thanked me again for my efforts and we had another lengthy discussion concerning the patient. In summary, the patient informed the team that she’d decided not to have any further investigations performed and that she wanted it officially put on the record that she was not to be resuscitated if it came down to it. They explained to me that their goal was to get the patient medically stable to enable her to be discharged home as she wished. Until then she was to remain in the hospital and I would still continue to be her treating physiotherapist. I was told, that I could try my absolute best to get her to do some rehabilitation exercises, but if she refused, then I had to respect this decision and there was nothing that they or I could do about it. I made sure that I documented precisely and thoroughly the events that had transpired, so that there was clear records of exactly what had happened over the previous few days.

Result: In my final week, I managed to get the woman to go for a short walk on just 2 occasions, but there was no additional rehabilitative therapy to go with these. She was still in a fair bit of pain and having bowel problems on my final day at the hospital and it had not been confirmed as to exactly why her symptoms were present. During the week I was trying most mornings and afternoons to get her to go for a walk or do some exercises and tried many different approaches, most to no avail. I tried saying that she may feel better after a walk, referred to the doctors saying they felt she may feel better, said that she could relax for the rest of the day after a walk or that she could sleep better if she does a bit of exercise. When it did come time for me to finish at the hospital she was still medically unstable and consequently was waiting to be discharged home.

Evaluation: I feel I did really good, learnt the importance of liasing with the whole team, although in this incidence it wasn’t the best outcome, I still learnt that its good to do it, coz u don’t know what u might get out of it, I strongly encouraged her to at least go for a walk with me if she wouldn’t go to the gym, but at the end of the day it was her decision and there wasn’t much that I could do about it
On reflection, I feel I acted appropriately under the circumstances and actually performed pretty well. The unfortunate part of the situation was that I couldn’t get the patient to attend physio treatment sessions as often as I would have hoped, but I feel that I did as well as I could to try and make this goal of rehab a reality. I learnt the importance of effective liaison with other members of the multidisciplinary team, which in this case were the doctors. I felt I showed I could be a responsible member of the team who had vital information to present and this was fully understood and acted upon by the doctors. I also felt that by going to them after the second day, to try get an understanding of the situation was a wise move as it prepared me well for the conversation that I had with the patient the following day, that resulted in me being able to abstract so much important information from the patient for the first time. By attending to the patient twice a day where possible it gave her every opportunity to come with me for her physical rehabilitation, which is why she was initially transferred to Osborne Park Hospital. At the end of the day, I left it up to the patient to decide if she wanted to participate or not, as per the medical team’s advice, however I felt I did all that I personally could to make this achievable. I was pleased with my performance, despite a less than desirable outcome for the patient personally.

Strategies: Above all, this situation taught me that I personally can contribute and be a valuable member of the multidisciplinary team, despite my status as a relatively inexperienced student therapist. I realise that I should have known I still play an important role in the team despite being a student, but this experience just proved to me more than anything that I do belong and do have worth in that environment, which was encouraging. By liaising with other members of the team so much, it also showed that I can learn a lot of important information from others, which will help me when treating my patients, but also that I can in turn provide information that can help others. In the future I will definitely be trying harder to get more out of the others members of the team, plus contribute by passing on what I know. I was also reminded of the fact that you can’t force a patient to engage in the treatment routine. It’s ultimately their choice and if they are refusing treatment, then you have to respect this decision and move on. I feel that giving my patient two opportunities per day was appropriate as it was important that she try to participate in rehab, however, spending any more time than this probably would have been a waste of my time. It really is important not to dwell on a patient who has refused treatment because you invariably have plenty of others who would appreciate your time and efforts much more. Finally, I discovered some new ways of trying to get a difficult patient to agree to treatment, both from my own accord and from my supervisor. These include the ones mentioned previously such as feeling better, doctors, sleeping better plus movement helping if needing to go to the toilet and multiple attempts in a day. None of which were particularly successful with this patient, but were on others that I treated during this placement and that I could see myself using in the future when encountering difficult patients.