Autonomy is defined as the patient has the right to make his or her own decisions about their life, in this case about their medical management (The Medical Protection Society, 2019). According to The Health Professional Council of South Africa (2008), the patient has the right to refuse health services, however they need to know or the health care professional needs to explain the implications, risks and obligations of such refusal. Physiotherapist are movement specialists, our main goal is to get the patient back to their optimal level of function (Bezner, 2015), therefore we as physiotherapist needs to work within pain-limits or we need to work through the pain to reach the optimal goal of the patient, which in an acute setting is to go home. The patient has the right to refuses treatment however, I personally feel patients have the responsibility to accept physiotherapy management and work through that pain in order to become better. I think patients have the right to refuse management but on a basis that they know the benefits of the treatment, they know why they have pain and they have been warned of the secondary complications. The unanswered question remains, when a patient refuses treatment because of pain, what do you do?
While on my orthopaedic rotation at Groot Schuur Hospital, I was involved in a case where a 15 year old patient had sustained a traumatic below the knee amputation, and he had a vac dressing on to drain wastage from the stump. The patient experienced an immense amount of pain and as a result did not want to participate in physiotherapy treatment for the day. I educated him surrounding the negative effects if physiotherapy treatment was not done. I explained to him if he was going to lie in bed whole day he would develop secondary problems, such as atelectasis, pressure sores, the stump will become stiff and most importantly he would be in hospital for a longer time. The patient decided to do the bed exercises with the unaffected limb, but when he needed to do the stump exercises the patient did not want to participate. Nevertheless, I continued my physiotherapy management.
When we needed to move out the bed, the patient refused and said, “You are not taking my pain into consideration”. However, I had been considering his pain. I was doing everything according to his degree of pain but this patient was demotivated to participate from the beginning. The patient refused to part-take in anymore physiotherapy management. My plan was to mobilize him to the bathroom and back so that he could independently gain independence in short distances, but he said I must leave him alone. After I explained to him the benefits of standing and mobilization he started to become frustrated and expressed this by shouting at me, while he was doing this one of my clinicians walked in. my clinician tried to encourage him but he still refused.
Patients often refuse physiotherapy intervention because they are afraid of pain, they also might have a fear of falling, not knowing less movement subsequently leads to more damage. Horgan & Maclachlsn, (2004), state that patients’ that have been involved in trauma-related amputations are more in denial in comparison to patients’ who have undergone amputation due to vascular-related amputations, they show more anger and hostility. Stump pain is another factor that could potentially play a role in patients refusing therapy. Stump pain has been associated with the psychological well-being of the patient. Stump pain can directly be associated with depression. Therefore, research has reported depression and pain occur simultaneously ( Horgan & MacLachlan, 2004). The above reason could potentially be the reason why my patient refused treatment. The patient was 15 years old and the trauma-related injury could have led to depression which subsequently led to him not wanting to participate in form of management.
Therefore, it is always beneficial to reassure your patient with the necessary information to help them understand why exercises would be important, if the the patient is not giving a clear reason for refusing the proposed treatment (The Medical Protection Society, 2019). Asking the patient about any fears and concerns before proceeding with management might also help you as the professional to establish a bond with the patient and your patient might respond better to you because you showing empathy towards the patient (The Medical Protection Society, 2019).
After lunch I needed to give feedback to the chief clinician. She asked me “why didn’t I mobilize him?”, I responded and said, “he refused treatment after encouragement, education and a senior therapist also encouraged him to move”. She responded, “No, we will go back and mobilize him, he consented to be here and if we do not move him he will not get better, so no we will mobilize him”. I headed up to the ward and she accompanied me and we mobilized the patient.
Patients’ often base their decisions on emotions, especially the feeling of being in pain and they do not always know what is good for them. However, your job as a physiotherapist is to make sure patients’ know the benefits, make sure that they feel reassured and to make sure that they do not develop secondary complications because of their decisions. Sometimes the line of authority also plays a role in the decisions of the patient. The patients sometimes take advantage of students; they use this as an opportunity to get out of physiotherapy. It is very important for students to gain the quality of becoming assertive, but in a respectful and empathetic manner. Students need to be emotionally strong when it comes to situations like this.
It is the 21st century, and the lifestyle is fast paced, the patient needs to be responsible for their own health care. Patients that are active participants in their rehabilitation, often present with better health outcomes. Therefore, it is important for students to “push” and motivate their patients to a point in order for them to see the results and for you to be effective. Being assertive will enable you to become a strong health professional. It will show the patient that you do care about their well-being and it will result in safe, and a good quality of care which all patients deserve (HEAL, 2013). However, with all the assertiveness and encouragement, we always need to keep in mind that the patient has a right and autonomy is more important than management.
References
Horgan, O., & MacLachlan, M. (2004). Psychosocial adjustment to lower-limb amputation: A review. Disability and Rehabilitation, 837-850.
HEAL. (2013, May 27). Retrieved September 4, 2019, from Assertive communication: Important for safe patient care: https://www.healconsultants.org/assertive-communication-important-for-safe-patient-care/
The Medical Protection Society. (2019). Retrieved September 3, 2019, from Refusing Consent: https://www.medicalprotection.org/southafrica/advice-booklets/consent-to-medical-treatment-in-south-africa-an-mps-guide/refusing-consent
Bezner, J. (2015). Promoting Health and Wellness:Implications for Physical Therapist Practice. Physical Therapy 95, 1433-1444.
HPCSA. (2008). GUIDELINES FOR GOOD PRACTICE FOR HEALTH CARE PROFESSIONALS. In HPCSA, SEEKING PATIENTS’ INFORMED CONSENT:THE ETHICAL CONSIDERATIONS (pp. 1-18). Pretoria: HPCSA.
3 thoughts on “Drawing a fine-line between “yes” and “no”
Dear Saschia
Thank you for sharing your piece and allowing me to comment on your writing.
This experience is highly topical with us as physiotherapists. I have experienced similar situations, as you have described, many times and this is a dilemma that we get faced with daily.
Your argument is clear from the beginning of your writing, I like how you have used the definition of autonomy in your introduction. I would suggest that you separate paragraph 1 into two separate paragraphs at the end of line 6 as it is quite long as an introductory paragraph. Continue to reference autonomy throughout your writing and in your conclusion.
Again paragraph 2 is quite long, I suggest you separate this paragraph into two sections after line 12, before you start “The patient refused to part-take in anymore physiotherapy management…”
I like how you substantiate your reasoning for wanting to do treatment with the patient despite their pain and for stating benefits of treatment etc. However the argument could be stronger if you use literature to substantiate some of the reasons why this patient may not have wanted to partake in physiotherapy. Consider how the patient was feeling after just loosing part of his leg and his independence. Consider looking at literature that focuses on the psychological implications following an amputation and how these factors may influence motivation and willingness to participate in physiotherapy treatment.
Corrections
Paragraph 1, Line 3: “on a base of…” change to “on a basis that….”
Paragraph 2, line 3: change to “…and that he would not be doing…”
“After lunch I needed to give feedback to by the chief clinician…” remove the word “by”
Final paragraph, 3rd last line, change “form” to “for”
Consider adding an image or form of media to strengthen your writing piece and its overall message.
Good work, I hope these comments can help you for your final submission.
Kind regards
Emma-Leigh Tanner
Hello Saschia, thank you for sharing your story and views on this issues. Refusal of treatment is always a sensitive issue, as you explained it is necessary to educate and to show empathy. It’s sometimes even more difficult as students to know when refusal of treatment can be accepted and when to push harder.
Content: Your writing was good, everything was a smooth read and it all linked to your heading. I understood your story and why you chose your facts and references. Just a comment on your chose of picture, I don’t really understand the link between your argument, your heading and the picture? Possibly consider an other picture or even trying to refer to the picture in your argument so that the reader can understand your connection?
Argument: You stated quite a few claims and you where able to support them with relevant references. Your structure is good and I was able to follow the flow of your argument without having to reread a few times. I enjoyed reading your piece, it is of much relevance to a lot of students daily ethical issues. Personally I think you handled the situation correct. You asked permission, you educated the patient, you lowered your goals for the treatment session and you showed empathy. I understand your head clinicians point that they agreed to the operation and the secondary complications there after but sometimes its impossible to understand what you agreed to until you are placed in the situation.
References: Strong references used. Correctly formatted in text and in the reference list. Possible consider adding in links to your references so the reader could have direct access to your sources?
Writing: Grammatically correct. Good sentence structures. Paragraph lengths are correct, not to long. As mentioned in your first comment, there are a few incorrect sentence structures and some typos. Please just reread your work again before submitting the final.
Once again, great piece to read and relatable. I do hope you can use the feedback for some good.
Wiana Muller
Comments from email to WordPress:
Hi Saschia,
Content: I would suggest that you start your piece different. I would start with the definition at autonomy as well as where you discuss what physiotherapist do (essentially switch around your first paragraph). I have highlighted in yellow what I believe you should start with and there after give the part where you discuss your own opinion . You could then add the question at the end of your first paragraph.
“I had an incident where my..”- I was involved in a case where the patient sustained a traumatic BKA…
“vac”- i would refer to it as a vac dressing
“The patient was complaining of being in too much pain and he will not be doing any physiotherapy”- The patient experienced an immense amount of pain and as a result did not want to participate in physiotherapy treatment for the day
“I educated him and told him if he lies in bed whole day he will develop secondary problems, such as atelectasis, pressure sores, the stump will become stiff and most importantly he will be in hospital for a longer time.” -I educated him surrounding the negative effects if physiotherapy treatment was not done…and the continue with the examples that you state.
“After I explained to him the benefits of blood flow in standing to the stump, how mobilisation helps decrease pain he was shouting and me, so one of my clinicians walked in and also tried to encourage him but he still refused”-I would not give specific examples again as you stated these above. I would just say educated on the negative effects of not receiving treatment.
“Sometimes they take advantage of students, they use this as an opportunity to get out of physiotherapy, and therefore it is very important for students to gain the quality of becoming assertive, but in a respectful and empathetic manner and emotionally strong when it comes to situations like this”-Sentence is too long. You need to add full stops.
Grammer:
“You not taking my pain into consideration”-
When….I was doing everything according to his degree of pain but this patient was demotivated to participate from the beginning.
“however I have been taking his pain into consideration, I was doing everything according to his degree of pain but this patient was demotivated to participate from the beginning.” – However I had been considering his pain. I
The patient refused to part-take in anymore physiotherapy management.
“After I explained to him the benefits of blood flow in standing to the stump, how mobilisation helps decrease pain he was shouting and me, so one of my clinicians walked in and also tried to encourage him but he still refused”- My plan was to mobilize him to the bathroom and back so that he could gain independence for short distances, but he said I must leave him alone.”
The patient refused to part-take in anymore physiotherapy management-“Patients often refuse physiotherapy intervention”
Patients make-“Patients’ make decisions based on emotions”
“, however your job as a physiotherapist is to make sure patients’ know the benefits, make sure that they feel reassured and to make sure that they do not develop secondary complications because of their decisions”-“However your job as a physiotherapist is to make sure patients’ know the benefits, make sure that they feel reassured and to make sure that they do not develop secondary complications because of their decisions.”
Kind regards
Michele Keyser.