Psychosocial Aspects in Discharging Decision in Physical Therapy - Research Paper Example

Psychosocial Aspects in Discharging Decision in Physical Therapy 0 Introduction and background: Physical therapists (PTs) are health care workers who are tasked to care for individuals, regardless of age, sex and degree of illness, that have medical problems and other health care issues that limit their ability to move and perform various functional activities for daily living (ADLs). PTs are tasked to examine each patient and develop a treatment plan utilising various therapeutic methods that enable the patient to reduce pain and immobility, restore function and prevent and retard disability (APTA, 2009). In addition, it is the PT’s job to help patients improve their life by adapting fitness-and-wellness programs promoting healthier and more active lifestyles. Physical therapists can work in hospitals, private clinics, out-patient clinics, home-based therapies, educational institutions, sports and fitness facilities, work/office settings and nursing homes (APTA, 2009).The physical therapist has a place everywhere in the medical system. Performing a variety of functions and activities, the physical therapist is considered a vital member of the rehabilitation team. The physical therapist is portrayed as having evolved from being only a treatment provider to being a patient’s evaluator, and developer of treatment programmes (Singleton 1987, p. 54). Since the 1970s, physical therapists have progressed in terms of professional independence in the sense that they were given more liberty when it comes to formulating and executing professional judgements (Babeu, Born & Ozar, 1993). Thus, physical therapists have asked for more independence concerning their role in the clinical decision-making, although many physical therapy leaders believe that this increased autonomy can lead to a more complex ethical dilemma and responsibility for the physical therapist (Swisher 2002, p.693). The APTA (please spell this out first) recently developed a vision statement in support of direct access to physical therapy services: “By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, functional limitations, and disabilities related to movement, function, and health” (Jette, et al., 2006, p.1620). Realising the significant role that a physical therapist plays in the care of their patients, a physical therapist has to realise the importance of decision-making; part of it is discharging a patient based on the right physical, social and moral parameters. Ethical decision-making and moral virtue are portions of clinical expertise rather than detached steps in the course of providing just physical therapy to patients (Swisher 2002, p.693). However, it is also imperative that one must realise that attention is given to the ethical dilemmas that are exclusive to physical therapists, and that there is a need to recognise these ethical issues that are often encountered by a physical therapist in the course of providing care for their own patients (Purtilo, 1978). It must be recognised that physical therapists play a unique role in patient care. More often than not, they are the ones who handle patients directly and have the difficult task of ensuring that the patients, as much as possible, regain full use of their body in doing activities of daily living. As such, many physical therapists are faced with the patients’ expectations of their recovery from the interventions that the PT recommends. However, there are instances when these expectations are not met, and the PT has to make the patient and their families understand the reasons for the failed expectations. These psychological expectations put the PT in a difficult position, especially when it comes to discharging issues when patients fail to meet their goals. Due to this, many institutions have developed their own discharging criteria, making it easier for the therapist to make a decision, regardless whether the patient achieved his/her expectations goals, or not. 2.0 Discharging Criteria Although PTs are well equipped to evaluate a patient, and can decide on the discharge, still the discharging process can be difficult for them. The difficulty lies in the identification of patients that can be discharged after major surgeries or illnesses, and patients that are still at risk to develop major disabilities and morbidities, and thus, may still be in need of therapy. However, but a major physical criterion for discharge from PT care is a patient reaching the maximum potential functional level, whether this is the normal functional level for them, or an adjusted level where the patient is able to do ADLs. There is a variety of reasons why a patient is discharged from a physical therapy program. It can be secondary to a physical therapy aspect like when all or most PT goals based on the initial evaluation have been met, or if the patient’s maximum rehabilitation potential has been reached. The reason can also be secondary to a non-physical therapy aspect, like patient or patient family request, and even a non-compliant patient. Anything that is out of the control of the patient the therapist can also be cause for discharge; among these are moving out of the service area, end of the certification period, or other health conditions that prevent the therapy from continuing. Sometimes, financial difficulties for patients with long-time illnesses can be secondary reasons for discharge. Whatever case there is, the patient is discharged from the care of the physical therapist (Magistro, 1989). Although discharging the patient from PT care sounds easy, in actuality it is a difficult ask more so in the case of chronic illness, or in situations where the patient failed to return to pre-illness status. ). A rational and logical decision is required when it comes to accepting and discharging a patient to and from rehab care. The physical therapist is tasked to evaluate and assess the patient as to their functional capabilities including those of a psychosocial nature. While a few have suggested that intuition is a key part in decision-making in the clinics, the intuition should be based on theoretical knowledge and practical experiences that will aid a clinician in making an intelligent and logical course of action. Without knowledge and experience, a rational and logical decision will not arise (Magistro, 1989). A patient is discharged or his treatment’s plan is halted when the patient’s condition is deemed permanent, or when there is the likelihood that any treatment protocol given to the patient will have little or no significant positive effect on the patient’s condition, and to the eventual patient prognosis. Most patients or their families will exert pressure for treatment to continue despite the reality of the circumstances, and some may even insist by paying for their own treatment sessions if insurance will not cover payment anymore. Some degree of compromise must be achieved, but great discretion and a full perception of the entire situation by all the involved parties must be shown (Magistro, 1989). It is also understood that institutions, as well as the government, should have a stringent policy concerning the discharge of patients even when they are not totally psychosocially ready. In the case of malingering of patients, and those with actual disabilities, it is essential to evaluate them carefully and thoroughly. Thus, the patients passing the criteria are discharged in order to make room for other patients that are in authentic need of treatment (Brooks et al 2002, p.492). Although giving the physical therapist this chance at decision-making in discharging the patient, it is still a much-argued issue in the clinical practice. An investigation on the psychological effects resulting from early discharge of patients concluded that the said patients did not suffer psychologically (van der Vlugt, et al. 2001). A psychological questionnaire was completed by 645 patients with acute myocardial infarction on day 5 of being hospitalized and 3 months after being admitted (is this admitted or discharged??). The model was developed in two groups of patients with similar profiles in age, gender, history, risk factors, localization of infarction and in-hospital mortality. Patients were grouped as in the Registration Phase (RP) and in the Validation Phase (VP). The grouping validated the results. The daily new event rates were recorded, which was the proportion of patients with complications during a specific day in the hospital, and those patients that did not show complications until that same date. The complications were categorized in order of severity for cardiac disease major events like recurrent infarction, unstable angina, ventricular fibrillation and tachycardia, and atrioventricular block, among others. Patients, who had no complications with a daily major event rate close to zero, and for minor events below 2%, were eligible for early discharge 5 days after hospitalization. During the VP, patients without complications were discharged earlier by three days compared to patients in RP with similar clinical profiles. During registration and validation phases, the patients were asked to fill in the HPPQ (spell out please) on day 5 in the hospital, and three months after the date of admission. Under conditions of confidentiality and privacy, a medical doctor (MJV) handed out the questionnaires. Instructions on completing the questionnaires were given to the patients. They were requested to personally fill in the questionnaires by themselves, without the help of family or friends. Reminders were sent by mail to patients who did not respond. The analysis of variance of the results showed that the psychological outcomes at three months did not differ between patients discharged earlier and those who stayed longer in the hospital. Data that were corrected for baseline characteristics gave the same results. The psychological profiles of patients in the registration and validation phases also were not significantly different. No differences were found between an uncomplicated versus complicated clinical course when measured at baseline and at three months by the four subscales of the HPPQ. No significant relationships were also observed when baseline differences were corrected between RP versus VP, complicated versus uncomplicated clinical course and the baseline psychological status. However, the feelings of being disabled significantly differed among registration phase patients with a complicated versus an uncomplicated clinical course at three months. The data for this set was corrected for baseline characteristics. Men had better psychological outcome than men, showing that gender was related independently to all HPPQ subscales. Age may also be used as a predictor for three of the subscales. Although older patients scored higher on well-being and feelings of being disabled, they scored lower on despondency. A history of AMI (please put the complete name) was related to decreased well-being, and consequently, increased feelings of being disabled. Social inhibition was more common in diabetic patients, while increased social inhibition was associated with angina pectoris. It should, however, be noted that the variance of shown by the predictor variables is low, and that only 6% of the variance was explained. This study was able to qualify the factors that could affect the discharge decision, and thus predictions can be made on the effects of discharge on certain patients. Brooks et al (2002) studied the effectiveness of manual techniques, incentive spirometry, breathing exercises, and other techniques used in a patient population. Objective PT discharge criteria were not incorporated in studies that examined the effectiveness of perioperative PT. Most studies also examined postoperative PT treatment for one to nine days, which is increased to an unspecified length of time deemed proper by the physical therapist. Independent mobilization/ambulation, normal breathing, and an effective cough were the expected proper responses, so with normal temperature, baseline values of outcome measures; a normal chest radiograph; vital signs that are stable; normal pulmonary function (oxygen saturation by pulse oximetry) and normal mental status. Thus, Brooke et al. (2002) conducted a multi-cantered study to develop the postoperative physiotherapy discharge scoring tool (POP-DST), a tool for the assessment of patient’s readiness for postoperative PT care discharge. The content and validity in predicting readiness of this tool was determined so with its interrater reliability. The validity of the contents was evaluated through focus groups and mail surveys with structured questions aimed at experts in the field. Based on the results of the study, POP-DST demonstrated acceptable interrater reliability and interobserver agreement. The predictive validity of the tool was verified because it was able to identify patients at low risk for respiratory complications at post-PT discharge. The POP-DST is a suitable tool for removing subjective bias in interpreting readiness for discharge, since it makes use of a scoring system. Steiner, et al. (2002) utilised the International Classification of Functioning, Disability, and Health, or ICF, and made use of a rehab-CYCLE tool as a structured approach to rehabilitation that assists in methodically reviewing various disease processes and consequences. This is to classify therapeutic goals and direct such to the right professionals, and to provide the best treatment for the patient by linking treatments to the results during the rehab process. In this regard, this tool guides the health care worker, particularly the physical therapist, towards providing the patient with the best care. The healthcare worker is directed through the use of a rational set of activities, while also relying on the patients to express their problems, and the healthcare worker to devise hypothesis that can be evaluated and tested. Steineer et al. (2002) believed that their approach is more patient-centred and offers a biopsychosocial point of view, which can be used as an evaluator for the readiness of a patient to be discharged in all aspects of living including physical, psychological and social aspects. Clearly, the tool described above can be effective as it takes into consideration many of the aspects of the patient’s life including psychosocial readiness to be discharged. During the treatment sessions, the psychosocial integration can be done in order to ensure that a patient will ready to be discharged on time. The study also hypothesized that even when patients are discharged from the PT’s care, a good home care plan for the patient is also an essential for the patient to realise his maximum potential even as he is released from care. This is an aspect that is not provided by the tool used by Steiner et al, 2002. In this case, the role of the physical therapist is to ensure that the patient, his family, and caregivers are made aware of the proper protocols that are necessary to ensure home care instructions are properly followed. In determining if discharge for patient is a recommended move, a physical therapist is tasked to examine the patient, and gather data regarding their function and their disabilities, their wants and their needs, their ability to participate in daily activities including mobility, self-care and any other context to which they live their lives. These data are combined together with the physical therapist’s experiences to arrive at an initial impression as to what the recommendation should be based on their evaluation (Jette, et al., 2003). The therapist then considers the effects of such recommendations on the regulations imposed by the healthcare system, and together with the other members of the rehab team, arrive at a final recommendation. For the rehab team involved in the acute care environment, it is imperative that they come to a recommendation that takes into consideration the patient’s ability to function in their natural environment, including recommendations for adaptation to the said environment if necessary, and recommend the correct level of care for the patient after discharge (Jette et al, 2003). 3.0 Psychosocial Considerations of Discharge In psychosocial theory, value is a very important concept that should be included in the discharge decision. Value is that aspect of the human personality that leads an individual in their preferences to certain alternatives that they encounter in their day to day activities including their own perception of time, human commotion, interpersonal relationships and the basic human nature (Dorfman, Meyer & Morgan, 2004). In many illnesses, especially for chronic or major illnesses, the modifications of the patient’s psychosocial behaviour are always considered when developing therapy protocols, including those for home care treatment. The patient’s beliefs, goals, interests, loved ones, way of life and even their finances should be taken into consideration when making any decision for the patient (McGillivray 1973, p.63). In this sense, one should also be aware that a patient’s psychosocial behaviour can, and does influence the patient’s treatment and their outcomes, and recognise the difficulty any healthcare professional encounters in order to provide effective treatments to patients who manifest difficult behaviours. An awareness of these behavioural patterns is of great significance to physical therapists since many patients that require their services exhibit such behaviours (Magistro 1989 p.529). As such it is important to properly identify and deal with these risks since failure on the part of the physical therapist to do so can lead to major consequences to the physical therapy treatment given, the expected effects of the therapy/treatment provided, and the patients themselves. Heine et al. (2004) maintain that persuading patients and their carers that they are ready to be discharged is time consuming for healthcare staff, who may find it difficult to understand why patients who are physically able are unwilling to return home. Factors other than physical status may therefore play a role. Referring to Fenwick’s (1979) idea of readiness for discharge that included a blend of physiological, psychological, and social factors, Heine et al. (2002) state that a number of factors need to be taken into account, including the patients’ cognitive, affective, and psychological abilities and limitations, in addition to available support from the family and community. Heine et al.’s study concerned patients with total hip replacements. The authors state that health professionals’ knowledge of issues which affect readiness for discharge will enable the formulation of suitable strategies to overcome unwillingness to be discharged. Every participant in their study expressed reluctance to return home without the support of family or friends, fearing that they would not be able to cope and that in the event of a problem, they would have no one to assist them. This contrasted with the fact that, while in hospital, the presence of staff led to patients feeling safe and secure. The concept of ‘feeling safe’ can be separated into physical and psychological, with the former being much less prominent than the latter. As participants became more confident, they became more willing to return home, and this was enhanced by post-discharge arrangements being made for them: follow-up visits by health professionals apparently assisted the participants to feel ready for discharge. Moreover, confidence levels were increased by hospital staff being perceived to be ‘experienced, capable and knowledgeable’ ( direct quote, Author?? ). In cases where nursing staff express opinions which differ to those of other staff, confidence levels drop. This study thus points up the need for ‘accurate, adequate and appropriate’ (author?) discharge information to be provided, although no mention is made of consistency, which would seem to be crucial given the preceding statement. Findings from Heine et al.’s study also demonstrate the necessity for health professionals to assess readiness for discharge from the point of view of the patient. Health professional should ask patients to give information about the support they have at home, and how safe they feel about discharge. A feeling of safety is clearly affected by a patient’s feelings, as well as community and physical factors. Furthermore, it is pointed out that the tendency to shorten the length of stay for patients, in order to lower costs, impacts upon the patient’s feeling of safety. Heine et al thus conclude that such other issues must be resolved if there is to be quality patient care. Research by Magistro (1989) focused on the major psychosocial behaviour of fear: fear of the patients about everything unknown, including their future, events that will follow after the discharge, the personalities of those who will take care of them, misconceptions about the disease, especially coming from family members and caregivers. Patients also fear loss of independence: that they may not be able to even brush their teeth or eat alone can be very distressing psychologically. A further fear is abandonment, more so for the geriatric patients who will most likely be sent to nursing homes or some other institution. Some patients also fear morbidity and mortality including further injuries like falls, and the fear that their disease will return. Further research is warranted in order to test the hypothesis suggested by the study of Jette et al (2003) regarding the effect of decision-making by physical therapists and occupational therapists, and the difference in perception between the two in their view of a patient’s functionality and disability. Clearly, the difference of opinion about a patient’s readiness for discharge will negatively affect the patient. It also warrants that further studies have to be conducted to assess if a therapist’s recommendations actually play a part in the placement of the patient right after discharge and if a variety of decision making schematics utilised when the decision is known to impact discharge destination (Jette et al 2003). The discharge decision is a simple social process which involves both the therapist and the patient. The therapist makes use of clinical analysis to come to a conclusion as to when and where the patient will be at the best possible place after discharge. This includes being able to assess the patients psychosocial capacity since if the patient is unable to cope with his illness then it becomes a problem not only for the physical therapist but for every other healthcare provider for the patient. According to Powell (1999), decision-making has to be less rigid in order to improve. Several suggestions were given as to how a less rigid decision-making can be achieved: oral, not just written, evidence can be accepted; families can be allowed to make decisions jointly without adversely affecting the patient; and families of patients who have chosen a proxy can be heard when they attempt to inform health care professionals who that person is. In the acute care setting, this is important since it implies that there is a rapid decision from among decision makers to arrive at a discharge destination. This recommendation is shared with other decision makers including patients, their families and of course the other members of the healthcare team. Recommendations are implemented with the assumption that the discharge decision is compatible with everyone involved including the actuality imposed by the healthcare system. This clinical deduction as described demands that collection and synthesis of various data from every aspect of the patient’s well being, including that of the patient’s situation in life, are utilised to formulate scenarios that will benefit the patient the most. This preliminary impression may be coloured by the physical therapist’s clinical expertise and experiences but may be refocused upon re-evaluation with other healthcare professionals and additional knowledge of the restrictions that may have been placed in institutions, private and government regulations (Jette et al, 2003). 4.0 As a Physical Therapist As a physical therapist, the author has had experiences when the patient can no longer benefit from any treatment that can be provided by the physical therapist (PT Licensing Board 2009) and thus the patient is discharged from care. Despite this, some patients insist on returning to the clinic, seeking therapy, sometimes mainly due to the influence of family or other caregivers, who usually have a huge impact on patients. For instance, the family members may convince the patient that he can get better if they go back to the rehabilitation clinics, even if the therapist had clearly pointed out that the patient will not get any better if he stays any longer in rehabilitation facilities. This may lead to an obsession for patients to be around a physical therapist all the time because psychologically he is convinced with this fact (Effgen 2000 p.125). In this case it is the duty of the physical therapist to inform the patient of the development of their therapy and their concomitant discharge from the treatment sessions. However, there are times when the patients expect more from the therapy sessions than what was achieved and thus, their persistence to return to treatment. This is the case even if the achieved status is already the maximum potential for the patient, or even if the full functional capacity of the limb could not be utilised (Robinson 2005). This maximum threshold may be due to a variety of reasons including unavoidable complications of the disease they suffered, the patient’s failure to follow the instructions of their therapists with regards to home care, or sometimes, failure of the physical therapist to provide the maximum treatment protocols which can be used for the patients’ case. However, such decision may have been reached to protect the patient from complications and side effects of a rigorous physical therapy session. Whatever the cause may be, discharging a patient who has ‘issues’ may prove to be difficult, although in most cases the reason for such behaviour is fear. Many patients fear that they are not ready to be discharged from the PT program, some fear falling (instability of their limbs to support them) even if they have been walking and supporting themselves for some time already, while other patients fear being unable to do their ADLs without the support and aid of their physical therapists. It can be a variety of reasons but all ultimately end in a single factor, and this is fear. In clinical practice, many patients have exhibited this symptom and maybe adjustment can be made by lessening the visits of the patient to physical therapy sessions until they become ready to ultimately let go. Some patients also develop a bond with their physical therapists, especially for patients who have to endure prolonged physical therapy sessions like patients with CVA (spell out), TBI (spell out) and those on cardiac rehabilitation. When discharging time comes, many patients are hesitant to leave their ‘only friend’ behind (Jensen et al 2000). A good physical therapist is someone who can include within their practice the four dimensions in therapy including a dynamic and multidimensional knowledge that is patient centred and has evolved through the PT’s experiences, a clinical reasoning progression that includes patient views and opinions, a focus which centres on the patient functioning, and consistent virtue that cares and commits to the patient and their needs in entirety (Jensen et al 2000). 5.0 Conclusion In conclusion, some studies have made an impact on this author who has come to realise that discharging a patient requires more than the physical nature of the patient to be stable. This author now understands that the patients’ psychological needs and their readiness to return to normal lives should be considered. The author believes that it is the role of physical therapists to integrate psychosocial treatment with physical rehabilitation treatment in order to ensure patients’ readiness to be discharged when the time comes. The ultimate discharge decision done by rehab professionals for their patients, especially for those patients who will still need care after discharge, shows consideration of patients as persons and the environment in which they reside including family, friends and the environment in itself (Jette et al, 2003). Although physical therapists are usually confined to a patient’s bulk movements like walking, it would not hurt to be able to integrate some form of psychosocial treatment in the physical setting to aid the patient. This will ultimately prove to be beneficial to the physical therapist in the end when the patient ends up being problem-free upon discharge. This aspect of treatment and discharge will be addressed in the author’s future practice. Although studies have shown the need for the psychological and social point of views in discharge decision-making, further research into assessment of psychological readiness for discharge is deemed necessary, considering that there are only a few significant aspects studied previously. The role of the physical therapist towards this decision making and in readying the patient needs to be underscored. Read More