All good things must come to an end…or sometimes therapeutic relationships between patient and physiotherapist can be challenging from the start. Therapeutic relationships are complex in nature; there is an imbalance in power, feelings of trust may not build, mental or emotional crisis may be lurking in the background, the patient may not have even had a choice whether to enter a care episode. You as a physiotherapist might be struggling with workplace dynamics or with a crisis at home. But as professionals we pull it together, show up to work, and try to help people.
As we travel with our patients on their journey to health our goal is to get them to the end and make the journey as happy and successful as possible. Sadly, we don’t always reach the end of the journey together. Patients sometimes don’t improve under our care and sometimes need to be partnered with another provider, physiotherapist, clinic, or department. Therapeutic relationships can also sour and we either end those relationships or have them ended for us. Happily, most of our patients reach graduation day and are discharged home or out of our practice setting. We will take the time to examine the Standards of Practice and ethical guidelines we should review when dealing with more complex discharge scenarios.
Scenario #1: Ugh! Nothing I’m doing is working.
We have all been there; we all have had that patient that haunts us in our dreams. We tried so hard to help them. We threw everything at them but the kitchen sink. We approached them with CBT, and exercise in 13 different ways. We used manual therapy and motivational interviewing. We read every article on their condition, but nothing is seemingly changing their reported function or pain. We banged our head into wall for weeks with little progress made….
So, what do we do? What is our responsibility to our current patient as well as potential patients who also need access to limited resources? Some of the answers can be found in our Standards of Practice but hopefully you also have a trusted colleague, mentor, or manager to help you make these decisions.
Your first step should be to recognize your dilemma. You have reached the point in care that you must have an honest and up-front conversation with this patient about their treatment plan, lack of progress, and the findings of outcome measures to support this conclusion.
The patient most likely knows you have reached this point but maybe they still have faith in you, maybe they want you to be part of their team, or maybe they feel like if they move on, they have given up. These are challenging to disassociate from because it’s so easy to justify continuing care, but you know, based on your assessment and objective findings that it is time. So being the professional you are, it is your role to take the patient through the decision-making process and have a new plan of care set out. Do you refer to the family physician or specialist? Is there another provider in the practice setting or outside of it that has a different approach that might be useful? Do you need to refer to a mental health practitioner? Is it time for a meeting with family or the other members of their health-care team? Go Interdisciplinary Practice!
You have skills and resources to handle this situation and you have the Standards of Practice and Code of Ethical conduct to help guide you. Take the time to explore the Standards of Practice, you’ll find some pearls of wisdom and guidance to help navigate this challenge.
The Standards of Practice on Client-Centered Care and Client Assessment, Diagnosis, and Interventions are both useful when facing this situation. The most relevant performance expectations from the Standards are listed below, but if you are in this situation, it’s time to read through these Standards in their entirety.
- “Re-evaluates and monitors clients’ responses throughout the course of interventions, making adjustments and discontinuing services that are no longer required or effective.”
- “Makes appropriate referrals when clients’ needs are best addressed in collaboration with/or by another provider.”
- “Terminate the therapeutic relationship with clients making appropriate arrangements for transfer of care or discontinuation of services.”
- “Promotes continuity in service by collaborating and facilitating clients’ transition from one health sector or provider to another.”
- “Advocates within her/his capabilities and context of practice for clients to obtain the resources they require to meet their health goals.”
That may seem like a lot, but most of the answers to what you should do when patients are not improving in a reasonable amount of time are in there.
Scenario #2: Well, that went south fast!
At first, things are going great. Your patient is improving and life is rainbows and butterflies. Then something changes that therapeutic relationship. That change can come from poor communication between parties, changes in patient behaviour (e.g., inappropriate comments or frequently missed appointments), etc. We know these situations arise in all areas of practice both with generalists and clinical specialists alike and to physiotherapists will all levels of experience. So how do you discharge someone with whom you are no longer able to continue treatment?
Communication is THE BIGGEST reason why things go wrong at this stage. Except in the most serious situations, the College of Physiotherapists of Alberta would expect that prior to the decision to discharge there would have been some conversations or warnings regarding the patient’s conduct. As well as discussions regarding the expectations for the patient’s interactions with the physiotherapist.
If those discussions don’t work and you’ve decided you need to discontinue treatment, you must answer all the patient’s questions and ensure they understand both the reason for discontinuing service and what they are to do next. In some cases, the transition might not be immediate, and it may be best to arrange bridging treatments if both parties agree to this strategy. If this is not acceptable then you can always inform them of their options for care within the community if available (sorry rural Albertans, that could be a 45’ drive). In rare situations of abusive or inappropriate behaviour where you as a physiotherapist do not feel safe, please have the clinic owner or your manager step in to assist you in explaining the plan in place to ensure there is continuity of care.
For more information you can access both Managing Challenging Situations and our Therapeutic Relationships Guides which will take you through several challenging scenarios and hopefully fill in some of the blanks. The Code of Ethical Conduct is another great resource for most difficult decisions we make in practice.
Scenario #3: We’re discharging you, right??
Sometimes we must examine what a successful discharge can mean for different types of patients. These can fall under three different discharge scenarios that we will cover below but the common theme continues to be communicating with your patients and helping them understand your reasoning for discharge.
Partial recovery and that’s perfectly ok: Sometimes with chronic pain, stroke or brain injury, patients have come as far as you can get them and that’s ok. It’s not a failure on your part or your patients, it’s a fact of life that the reasonable goal at the beginning of treatment was self-management with ongoing symptoms or concerns. They still graduate, the relationship hopefully ends on a positive note as they can manage without continued services and hopefully, they look back on their physiotherapy experience positively. Sometimes these patients will be your biggest fans because you were open and honest with them at the start, set reasonable goals and followed through with them. Feel good about discharging them!
Full Recovery, but why do they keep showing up in your schedule? You are so amazing they just can’t stop coming in for treatment! Congratulations, you have helped someone so much that they feel they cannot cope without you. While flattering, this is of concern in a healthy therapeutic relationship and makes discharge challenging. You need to talk to this person to set boundaries and review your reasoning for discharge. Hopefully they just didn’t fully understand the first time around. Make it a happy event and celebrate with them that they are graduating!
Financial Barriers: Sometimes you can run into scenarios where patients really want to keep coming but due to financial circumstances they can no longer attend. Generally, this speaks more to the private practice physiotherapists, but public practice physiotherapists may also need to discharge patients due to resource limitations. Both sectors still follow the same two Standards of Practice:
- “Promotes continuity in service by collaborating and facilitating clients’ transition from one health sector or provider to another.”
- “Advocates within her/his capabilities and context of practice for clients to obtain the resources they require to meet their health goals.”
The key message to any transition in service is communicating with all parties involved. This could be a sit-down discussion with the patient and their family followed by meeting or letters to the other members in their care team or to the new facility or health-care provider they are transitioning to. You could be the most trusted member of the care team and the one that the patient and family may look to for information so effective communication is key. This could also include discussions with a third-party provider and following reporting standards based on the situation.
Conclusion
Lets take the time to celebrate the many less challenging therapeutic relationships that make up most of our interactions. Life as a physiotherapist is hopefully mostly rainbows, butterflies, and macarons (challenging to make but totally worth it!) This Good Practice article focused on the patient discharges that, like macarons, require time, effort, and patience to get the outcome needed.
So, remember, poor communication results in patients feeling left out in the cold, frustrated, or unable to access the proper care they require. Our duty as physiotherapists is to ensure our patients receive the care they need. We need to act in their best interests while also acting ethically and responsibly. Physiotherapists make a positive difference in people’s lives every day and part of the effect we have in our communities is acting in the patient’s best interests and doing what we need to do to ensure they receive the appropriate care. Good luck if you find yourself in a situation that is challenging to navigate and remember you can always contact us to help guide you.
