I’m in a dilemma

 

Help! What shall I do? I’m in a dilemma between a medical prescrition with clear instructions and my patient’s  needs. The physicians want the 14 year old girl with CP to wear ortheses to avoid foot deformities, but she doesn’t want to. Without ortheses she manages to go on the toilette on her own. Shall I support the girl in her needs or just do want the physicians wants me do do? Help!

Bests, flomes

 
 
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7 Replies to “I’m in a dilemma”

  1. Hi flomes

    That’s a difficult question!
    What do you think about the foot deformities? Do you think that she really needs the support in order not to have pain in her feet and toes? Or do you think it might be a solution to wear a device only during the night so she is not limited in her possibilities?

    Best wishes for your decision!

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  2. Hi Flomes. I think that it’s a useful suggestion to consider a variety of options, rather than taking a Yes / No approach. Are there other alternatives to the decision that you may not have considered?

    In addition, I wonder how useful it would ever be to “force” a patient or client to do something they’re against. I would begin by trying to understand why the patient doesn’t want to wear the orthoses. She may have a very good reason for saying No. Bear in mind that you may not agree with her reason but it may still be logical from her point of view. If you are able to understand WHY she refuses then that gives you a place to work from in your discussion with her.

    All the best,
    Michael

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    1. Hi Michael,
      Thanks a lot for your comment. You’re absolutely right, there is no sense in forcing a patient. To understand the situation more precisely I’d like to share some more information. The teenager girl doens’t like to wear the ortheses, one the one hand because they feel heavy on her legs and look “handicaped”, one the other hand because wearing the stiff ortheses, she can not use her foot muscles to balance standing position and therfore is much more dependant on support and assistance from another person. Without the ortheses she manages to go on the toilette and to transfer from wheel chair into her bed on her own. For her it means independence and a liitle bit of autonomy. At that age a very important fact.
      The precription from the specialized physicians are very clear. They want her to wear the ortheses. Without ortheses she risks to develop foot deformities and increasing kneecontractions. Discussions haven’t been fruitful until now.
      Is it more clear, why this situation is difficult to me?
      Bests, flomes

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      1. Hi Flomes. You’re right, this is a challenging situation. From my point of view, the client has a good reason not to want to wear the orthoses. She doesn’t like the way they look and feel. I know that I would feel the same way as her. In these situations, presenting evidence and facts in the form of “education” will most likely have little value because her reasons are not affected by the facts.

        In South Africa, physiotherapists are first line practitioners, which means that we are not forced to carry out prescriptions from other health professionals. Physicians may refer a patient to the physio, but the physio makes the decision about when, if and how to carry out treatment. Is it different in Switzerland?

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  3. Well, it seams that in South Africa you are very advanced. Until now in Switzerland health insurances only pay physiotherapy with a medical prescription. And the more presice the prescription is, the more I’m forced to carry it out in the requored way. In the present case the prescription is very clear and I actually have to carry it out, even if it’s against my professional ethos. That’s the origin of my dilemma and that is why it is quite difficult for me to handle.

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    1. Are you able to contact the referring physician and discuss the situation? If medical doctors in Switzerland are anything like those in South Africa, they often make referrals for very specific physiotherapy interventions, even though those interventions may not be appropriate. In such cases, we try not to simply ignore the referral, but contact the physician and discuss the patient with them. In many cases they are happy to defer to the therapists judgement. Is that something you could try?

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  4. Yes, I tried indeed several times to discuss the topic with the referrng physcians. It seems to be difficult also for them to decide between prevention of foot deformation and supporting daily activities without wearing foot ortheses.
    They do have a dilemma too! Next Tuesday I’ve got another meeting with the physician who contacted the chief physicians of University Hospital. I’m very curious about their decisions!
    My problem is, when they insist on their therapeutical approach with ortheses I’ve got a hard time to stand their deiscion which is against my personal professional ethos. That’s not part of my strengths! Well, at a certain moment I probably have to trust their experience and professional competence.

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