ethical problem

I’m writing about an ethical problem, that occured while working as a physitherapist.

My patient is suffering from a severe pulmonary disease (COPD) and is an incomplete paraplegic. He denied the standing training together with the nursing staff and would only like physiotherapeutic support. In addition, he refused to carry out a home program. Because of this, I decided to stop the therapy because he shows too little self-initiative. I made this decision after an enlightening conversation with my patient by explain the situation to him. Now, however, I feel a discomfort. Perhaps I have not decided correctly. If I analyze this situation on the basis of ethical principles, I have acted only in the sense of justice (society and other patients), but not justice of my acutal patient. I think that’s not enough. I feel like i have not done the best for my patient.
Can someone help me? What do you think, did I act fairly? Do you have any further analysis possibility?
Thank you very much for your help!

 

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6 Replies to “ethical problem”

  1. Hi there
    What I think was really good that you had I honest conversation with your patient concerning his difficulties with commitment in the processes of therapy. I understand your thoughts and feelings and often the situation is quite komplex.
    Is there also a interdisciplinary exchange with the nurses as well? I think this could help not feeling alone with your decisions and feelings.
    The discomfort you feel, I think, could be due to a moral conflict you were in and the unhappy feeling by blaming yourself for not meeting obligations concerning the patient. During work, I have this moral conflict as well wether I don’t meet the obligations of the patient or/nor by not meeting the professional ethics. I hope you understand what I mean. It is not that easy to explain.

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    1. Thx very much for your comment! Yes, there was an interdisciplinary exchange with the nurses and the doctor. They all had the same problem with malcompliance of the patient. They have supported me in my decision to stop the therapy. Maybe I paid too little attention to it, but as you said, this helps me to feel better. Thank you for your input!

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  2. Hi Hegglle

    I have been reading your post and I have been finding it difficult to form a coherent thought about it, as I have some questions about your post (that I hope you can help me with to understand a few things better).

    I understand that you decided to stop your treatment after your patient refused to carry out a home programme and you felt that he shows little self-initiative, was it a home exercise programme that you gave him?

    You also mentioned that he denied standing training and nursing staff and he would only like physiotherapeutic support. Did the standing training form part of the physiotherapy treatment? And by nursing staff, do you mean that your patient did not want nursing care?

    Overall I think that you have made the right decision by discontinuing physiotherapy treatment, based on the fact that you have explained to your patient why you decided to stop the physiotherapy treatment and as you mentioned it was an “enlightening” conversation, telling me that the patient understood the situation. I would just like to know how your patient reacted when you informed him that you will be discontinuing physiotherapy treatment? As you mentioned at the beginning of your post that your patient only wanted physiotherapeutic support.

    I would just like to find out whether you included the patient’s goals in your treatment. Did you ask him what he wanted to achieve during your sessions with him? His lack of compliance may be due to the fact that the goals you set for him may not be what he wanted to achieve with physiotherapy. And did you explain the importance of the home program?

    Perhaps you can answer these few questions that I have and I will be able to form a better understanding of the situation.

    Regards
    Elgene

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  3. Hey Elgene

    thanks a lot for sharing your thoughts with me!
    Yes, it was a home exercise programm with exercises for movements and strengthening. I also told him that he needs more training than pyhsiotherapie twice a week and therefore the home program is so important.
    No, sorry for this confusion. He refused no nursing care, but an additional standing training with the nursing staff (he lives in a nursing home).

    To your question about his goals. His goal is to be able to walk again. I explained to him that this goal is too big and is currently inaccessible because he can not even stand alone. For this reason, we decided to define first the goal to stand without any additional support. We discussed this together and he agreed. Nevertheless, he did not want to cooperate later on..
    Maybe it was too early for him. He was freshly a paraplegic and was not yet psychically stable. One day he agreed to our goals and the therapy, another day he refused it. At the moment, i think that the decision of stopping the therapy was probably good, so that he can get a good grip on his new situation. Later, the therapy can still be taken up again. What do you think about it?

    Have a nice day!

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  4. Hi Hegglle
    I enjoyed reading your post. Often health professionals are faced with the challenge of continuation of therapy with unmotivated patients, and too often we make hasty decisions concerning continuation of treatment.
    When making these decisions do we only focus on the fact that patients are uninterested in the therapy or do we also take into consideration how much the patient needs physiotherapy treatment and how the patient will ultimately benefit from physiotherapy treatment?

    Very often patients are not interested in the treatment we provide as they feel like they are not involved in the treatment. Many a times we fail to ask patients what they want to achieve from the treatment. Imagine being in the situation of this patient, would you not like to have an active role in your treatment?

    With patients, especially those similar to your patient, we often need to take into consideration the psychological factors affecting them. if your patient was a newly diagnosed paraplegic, do you not think that he was likely grieving about his situation? Do you not think that he might have been in the stage of denial? Do you not think that a referral to the psychologist would have been appropriate?

    As physiotherapist sometimes we really need to to push our patients in order for them to fully understand the ultimate goals. Also because we are just human, we have to empathize with our patients and take it one day at a time. The fact that you feel that you have not done enough for your patient shows that you still care about him and his well being.

    From a personal point of view i would not have discontinued physiotherapy treatment. my opinion is solely based on the fact that if the patient received sufficient support from family members, nurses, etc. he would have been very motivated during physiotherapy treatment. Also if the patient was really in the denial stage, understanding that he really needs extra support is of vital importance when treating him. another factor to take into consideration that when someone is in denial they will have up and down days, and as the therapist you need to just continue motivating the patient to do their best.

    On the other hand i feel that you have made the right decision from the point of view that you have done justice to society and other patients. but how will this justice benefit the specific patient whose treatment you discontinued?

    I hope that you found this comment helpful.

    Regards.
    Wafeeqah.

    Liked by 1 person

  5. Hi Hegglle! ๐Ÿ™‚

    Thank you so much for answering my questions! ๐Ÿ™‚ I really appreciate the time and effort.

    I understand that your patient was a newly diagnosed paraplegic. Is he using a wheelchair? I am not sure about the neurological level of his spinal cord injury but say for example he is a T1-T5 he should be able to be independent with all transfers and bed mobility such as rolling and lying to sitting and therefore I agree with you that his goal to walk again is “too big” like you say. I am sure you’ve educated him on his condition and what goals you can work towards in order for him to become functional as far as possible. I also agree with Wafeeqah, maybe in this case a psychologist would have been helpful, as it is clear by your patients reaction towards you and the treatment that he has been dealing with
    some issues of his own. I know that patients can sometimes be rude and refuse be treated. What I usually do is explain the importance of the treatment to the patient and if they still refuse, I ask my clinician to talk to the patient.That also works sometimes.

    In your case, I think that maybe you should have pushed your patient a bit more before you’ve decided to discontinue your treatment and he was a newly diagnosed paraplegic who really could benefit from physiotherapy if he received rehab in the beginning stages. Maybe the exercise programme was to difficult for him and he decided not to do it. I also think education and motivation would have played a big role in your treatment sessions with him and just getting him to push himself to achieve the goals that you guys set together, therefore I think you could have treated him.

    Hope this helps! ๐Ÿ™‚

    Regards
    Elgene

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