Delivering our patients from well-meaning care

"From inability to let well enough alone; 

From too much zeal for the new and contempt for what is old; 

From putting knowledge before wisdom, science before art, and cleverness before common sense; 

From treating patients as cases, and from making the cure of the disease more grievous than the endurance of the same, Good Lord, deliver us."

—Sir Robert Hutchinson 

The London Hospital, England 

He was a big man with yellow eyes. Yellow skin, yellow teeth and a scream that curled my neck muscles up into fat, bulging sausages. He was already almost clinically insane from liver failure, but the enzymes kept rising and the yellow spread. 

The heat from the whirlpool water loosed a curl and the tips scraped across my eye, but I couldn't sweep it back as was my custom, or I'd ruin my sterile field. I got angry as I pulled him nearer for he was a prize fighter that day. Nurses had bustled his hands up in mitts, curiously like children's mittens, to keep him from scratching and pulling. 

We lowered the stretcher into the water and he hit me again as his amputated stump struck the water's surface, and it bled until the water foamed. He cursed my God and my family and my very breath. I played it simpler and cried. I was 24 years old and this was my first year as a PT. 

I am older now, but not beyond a good cry at a hopeless situation. That man was on death's doorstep because of liver failure. He and his family had decided to forgo dialysis. Save for a miracle, liver failure was going to kill him. 

And yet I had orders to immerse him twice daily in a 103 degree whirlpool to clean his amputated leg wound. Within minutes of immersion, his stools would loosen and the water would become contaminated. "What are you doing?" I yelled at myself. He died pretty soon after that, but I haven't forgotten him.

Perhaps one day I will, but I have my doubts. 

The Paradox of Well-meaning Care 

There is a time, I think, when PT is a harm and not a good. Wound care has evolved greatly over the last 10 years. My story, perhaps, is inconceivable to today's graduates. But there are still times when I feel the health care system traps people into participating in therapy when dignity would ask that they be left alone. 

Perhaps the situation I see most often is this: A Medicare patient is discharged from a three-plus day hospital stay into a skilled nursing facility. At that point, Medicare A will pay for up to a 100-day stay, as long as a patient meets certain "skilled care" criteria. Participation in a skilled therapy (e.g., PT, OT, speech) is one of the benchmark tests for skilled care that Medicare accepts. 

Thus, the patient—and his family—are placed in an interesting position. By far, most patients desire as much therapy as they can get. Many patients are only in the skilled nursing facility in order to gain that extra therapy to get back to pre-hospitalization status. For these people, when PT discharges them for meeting their goals or perhaps for plateauing, there is often a sense of disappointment and frustration. Don't you think I need another week or two, they ask? 

But there are many patients who have neither the will nor the capacity to work towards "getting better." They are tired and weary. Perhaps they have cancer or emphysema. To them, PT is a cross to bear, nothing more. And yet, they do it. Why? Because, they know that the moment they stop participating in therapy, the bills for the nursing home revert to private pay. Those who have a secondary insurer, such as long-term care insurance, don't have this worry. But many contemplate the financial burden they are about to become—and quiver. 

Approach these patients with a cheerful, "Ready to paint the town red with me, Elmer" and you'll see a slumping about the shoulders, perhaps an audible sigh. 

"Not today, please," they'll whisper. "Could we just wait a bit? Today's not a good day. I'll see you tomorrow. Yes, make it tomorrow?"

If you push, very often you'll get concession. They are a genteel generation, not given to public fuss. But you read fatigue across their brow and in the stoop of their shoulders—a stoop that seems to become more pronounced with therapy, not better. 

What am I doing? you yell to yourself. A voice inside answers, Leave him alone. 

And perhaps we should.

The Definitive Aquatic Precautions and Contraindictions List (1 hr)

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