I know as a physio one of our aims is to get people to become as independent as possible. A recent encounter with a difficult patient made me view independence at a new level and realise that each individual’s home situation plays a huge role in determining when they are appropriate for DC.
This particular patient had a TKR with a few post op complications. Unfortunately there was a large haematoma around the knee and massive swelling. We were seeing this patient 2 x daily for mobility and swelling Mx, and felt like we had good rapport with him. On a Friday, the doctor doing his morning rounds Ax the pt and told him he was allowed to go home. The doctor told him this without talking to either the OT or PT and determining his functional status or home situation.
From a PT point of view, we were not happy with his ROM he had were worried about the amount of swelling still evident. The OT had also not yet done a home review. This pt lived on his own, on a farm, about 1 hour out of the country town where the hospital was. He lived in a movable home (like caravan), with 4 steep steps up to the front. He also had family and grandkids in nearby country towns who he told us he was going to visit in the next week. So from our point of view, this pt was going home alone, would have to get up 4 steep steps, and was going to be driving in the next few days.
Both the senior OT, my supervisor and I went to see this pt and strongly advised that he live with his daughter (which was a possibility) upon DC just for a little while until he the swelling decreased. We were polite and tried to use reasons that he would relate to and understand. The pt (who had previously been polite back to us) became very adamant and quite rude, saying that he ‘had lived on his own for 15 years on the farm and who did we think we were trying to tell him that he shouldn’t go back there.’ We made it clear that he could go back there, but informed him of the effects of surgery and that some people like to have other people around when they get out of hospital. He said we could advise all we wanted ‘but he was going to do what he wanted to do.’
Furthermore, after asking if he could attend the OP clinic for follow up Rx, he told us “well if you see my feet walking through the door, you know I’ll be coming in.’
So… I guess we just have to wait and see what happens next week.
This patient also packed up all his things, sifted through the papers he had next to his bed, packed them up, and the only one he left on his bed were his Physio exercises!
It got me thinking about being independent and how people view it. This patient it seemed was very rude and bluntly refused our advice or further help. At the time I was a bit put out as I thought we had been helping him every day and he had always been grateful. I then thought that maybe his behaviour came from the fact that he wanted so badly to be independent.
I learnt how to be tactful and give strong advice without sounding forceful, however I also learnt that no matter how hard you try, some people just don’t want to listen for whatever reason.
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2 comments:
I like what you sai, about advising strongly but not forcefully. Sometimes it's all you can do to be as clear and as unbiased as you can be with your information, even though you know what will happen and the patient cannot seem to see the light. It's their life, and sometimes that is their only independence is making the choice to do that thing, even though it's a "bad" health choice, according to us. We can provide the very best information and highest evidence, but you can't "make the horse drink" to put it in a proverb. I'm sure the dentist and the computer technician have similar problems with trying to get us to understand the best option. Sometimes it is a matter of priority too. Doctor's information can be given priority over ours, as in that situation you faced, and the patient's priority will nearly always come over our health priorities for them. We must subject our treatment to them, it seems.
Independence and the need for it can be very strong hence the felling of losing it as you said can be too much for some. I have found that it is peoples’ feeling of losing control of their life or they feel that they are is actually the issue. You are right about the importance of being tactful but also firm in your advice. If one was able to see this patient again from the beginning is there anything one could change or say at the start of his admission to enable this patient to have a greater understanding of how much a TKR can effect your daily life?
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