Hi Everyone,
I recently saw an elderly patient who has been suffering from an anxiety condition for many years. This condition has progressed to a point where he is afraid to leave his house. He lives with his wife who does his shopping for him but otherwise he is independent inside the house with a WZF. He has had numerous falls and lost confidence in his balance which makes him even more fearful of leaving the house. I was seeing him at the hospital to assess and treat his balance and muscle strength in order to reduce his risk of falling.
During his assessment, he told me that even if he was able to overcome his anxiety and leave the front door, he wouldn’t be able to manage since the WZF would bump on the concrete and he wouldn’t feel safe. So I thought it would be useful for him to trial a 4WW to use outside. His wife was very excited about this, as she finds it difficult that he won’t go outside with her and felt that having the 4WW would enable him to accompany her outside.
As soon as he took the first step with the 4WW he said he felt unstable and that he did not want to use it. His wife told him to give it more of a try, so he did, but he kept saying that he did not want to try it. I was a bit confused about what to do. He was saying he didn’t want to keep walking with it, but he was doing so and managing quite well and very safely with it. I thought that if he gave it more of a go he would get used to it; however his words were clearly stating that he did not want to keep going. I asked him to stop walking and if he would like to sit down or if he would like to try to walk to a nearby chair and then sit down. He agreed to go to the chair and then sat down. I asked him to think about whether he would like to give it another try at his next appointment and he said he would think about it. The following week, he wanted to give it another try and did quite well, saying that maybe he could get used to it which I thought was huge progress.
This situation made me think about how we draw the line on when to stop a treatment if the patient is saying they don’t want to do something but is still actively doing it. If the patient says they don’t want to do something and either stops doing it or won’t do it to begin with, it’s obvious you can’t make them. But it’s not so obvious what to do if they say they don’t want to keep doing something but continue with it even though they don’t have to. It’s even harder when family members are there encouraging them to keep going and it seems they don't want to.
2 comments:
Hi Mel,
That is a very similar situation and consideration that I experienced regularly on my previous gerontology placemant at RPH WSC. One particular outstanding case was a 92yo woman who refused to ambulate with me everday that I saw her (she constantly lied about already walking that day, about feeling sick, feeling weak and unable to ambulate even if she wanted to). However, everday I strongly encouraged her to walk with me - crying and screaming and all. I continued to push her because I knew she had the physical capabilities to perform the exercise and that it was a confidence issue that was making her want to stop. By the time she was discharged from hospital, after I had pushed her to walk daily, she was eventually able to ambulate independently with a WZF and with much more confidence. I think that it is a clinical judgemnt that you have to make based on the individuals abilities. If I had not encouraged the patient to continue to ambulate she would have been happy to stay in bed for 3 weeks and then maybe never regain the strength to ambulate again. At the time, I think the patient resents us for pushing them too hard but in the end, when they are safe and steady on thier feet again, they really appreciate all of our hard work with them. Hope that you can relate to this and good luck with your patient!!!
Kate.
Throughout the placements i've been on, i found there are a lot of people not necessarily elderly, that refuse to do anything and just want to be left alone, primarily because they feel their incapable of doing it. My last placement was on the surgical ward at SCGH, and the protocol for day 1 post-op is to get the pt out of bed, but pt's intially refused because of pain, feeling unwell, and because they've just had a surgery, and believe the best thing for their body is to rest. What i learnt from that placement is that pt's need to be pushed (provided its safe and pt is medically stable) and need to be shown what they are capable off. Once the pt sees that they can get out of bed post op, and that they are physically capable, they become more compliant with treatment, and are more willing to try new things. So has much as they will resent you for it intially, once they see progress they definitely do have a lot more faith in you.
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