When Neil Sedaka wrote the words “Breaking up is hard to do” he clearly wasn’t referring to physiotherapist/patient therapeutic relationships, but rather to the end of a romantic relationship. However, I believe many of us would agree that “breaking up” with a patient who has not successfully achieved their physiotherapy goals is also hard to do. These discharges can be some of the more challenging situations faced by physiotherapists.
As Practice Advisor, I have been asked by members to provide guidance on when or how to discharge a patient. I also receive calls and emails from patients, family members and third-party insurers asking why an individual has been receiving the same treatment for weeks, months, or (in extreme cases) even years with no apparent improvement or change in their condition.
As physiotherapists, we are required to meet specific expectations when providing client-centered care to our patients. Performance expectations specific to discontinuing treatment that is no longer appropriate, effective or clinically warranted are found in the following documents.
Delivers only services that are clinically indicated for clients and that he/she is competently able to provide.
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.
Collaborates with clients and other providers as appropriate to plan and implement discharge plans.
Provides client education to enable and optimize clients’ transition to self-management.
There are four common themes in these documents.
The expectation that we only treat a patient when it is clinically warranted, effective and appropriate.
The first action we need to take when a patient requests or is referred for physiotherapy treatment is to complete a thorough intake interview and assessment. The purpose of the assessment is to identify a physiotherapy diagnosis, clarify the patient’s goals and determine the proposed plan of action. Although as physiotherapists we want to help everyone, we are not always the right provider nor is physiotherapy always the right option for addressing the patient’s problem.
Sometimes there is pressure from the patient, employers (the patient’s or the physiotherapist’s) or a funder to initiate treatment despite our determination that it is not appropriate. We have an ethical and professional obligation to only provide evidence-based care that is safe, effective and clinically appropriate. We may have to decline to provide the requested treatment when we know it is not in the best interest of the patient.
The expectation that we continually monitor a patient’s response to the intervention and modify, change or discontinue treatment when it is no longer effective or appropriate.
An initial treatment plan is simply the starting point in the process. When physiotherapists identify a physiotherapy diagnosis and make a determination about the potential prognosis for the patient this is our “best guess” based on our training and experience with similar cases. Each patient is unique and will respond differently to our treatment interventions.
The patient’s response to the proposed treatment plan must be continually monitored by the primary physiotherapist. This is especially important if the implementation of the treatment plan has been assigned to a physiotherapist assistant. It is the responsibility of the physiotherapist to ensure the treatment is resulting in ongoing improvement and moving the patient closer to achieving their functional goals. If it is not and, after trying different approaches, it becomes apparent that the patient has progressed as far as they are able, it is time to look at discharge. The use of objective outcome measures at the outset of the plan and re-applied throughout the course of treatment can provide evidence of either improvement or when a plateau has been reached. This can greatly assist with determining the need to discontinue treatment and discussing this with the patient.4
There is an expectation that we recognize our own skills and competence and collaborate with/facilitate a referral to another colleague/professional who is better able to address the patient’s needs and goals.
As physiotherapists we are not expected to be the expert in all things. Each physiotherapist will have developed their own set of competencies, skills and knowledge based on their education and experience. An expectation of patient-centered care is that the patient receives the appropriate intervention from the most appropriate provider. If that is not you, you have the responsibility to transfer the patient’s care to a provider who can better meet the needs of the patient, whether that’s another physiotherapist or a member of another health profession.
The expectation that all these discussions and decisions are made with the patient to ensure their understanding of and consent to the ongoing plan including when and why treatment will be discontinued.
Once we have agreed to a plan of treatment, we need to have a clear discussion with the patient regarding the proposed timelines we estimate will be required to meet their goals, our prognosis as to what the eventual outcome will be, and start identifying the criteria we will use to determine when it is appropriate to decrease or discontinue physiotherapy. This conversation needs to start early, and we must be confident that the patient understands and is onboard. Having the conversations at the onset of the relationship allows the physiotherapist and the patient to identify and address possible barriers or fears about discharge and to develop the skills and confidence required to facilitate achievement of the expected outcome.4
This all sounds simple. However, it is not. A study completed by Emilie Pashley et al4 asked several physiotherapists to discuss challenges faced and strategies utilized when discharging outpatients. A common theme emerged in the conversations. A clinician’s experience greatly influences their ability to make treatment decisions and to formulate and implement discharge planning. The more experience a physiotherapist has with a specific patient population or condition, the more accurate and confident they are when making treatment plans, formulating a prognosis and setting expectations around goal achievement and discharge.4
We have all been novice physiotherapists and have felt unsure that we were doing the right thing for our patients. As new physiotherapists, we are often focused on providing the treatments we have spent years learning and, on our desire to fix patients.4 It may take years of experience to switch our focus from providing treatment to helping patients achieve independence to self-manage their health.4 When we intentionally provide patient-centered care, initiate discharge planning early and facilitate and encourage self-management, the discharge discussions will become easier and more natural.4
The Good Practice article from 2014, Managing Therapeutic Relationships: Time to Say Goodbye, looked at your right to discharge abusive patients who may still require ongoing treatment.1 Although physiotherapists may occasionally need to discharge difficult patients, there are many other reasons that we may need to consider discharging a patient before achieving a successful outcome or before the patient feels ready to discontinue treatment.
Some examples include:
Patients who are not responding as expected or are just not able to achieve their goals. Unfortunately, our patients do not always achieve the functional goals they have set. There may be a multitude of reasons for this that are outside either the patients or the physiotherapist’s control at the time.
The condition itself has progressed to the point where the patient’s initial or desired goals are no longer achievable, or they have reached a plateau and are no longer responding to the interventions. Negotiating with the patient early on to develop realistic, achievable goals is an important strategy to assist with treatment and discharge planning.4 Clear indication as to how to progress towards the goal achievement will be measured and a plan to deal with goals not being met is a necessary part of the process. This pre-planning can open the door for the discharge discussion if it becomes necessary.
The patient may want rehabilitation, but they may not be emotionally or mentally “ready” to start on their journey. There are many reasons for a patient to not be in the best space psychologically to actively embrace treatment so physiotherapy may need to be postponed until the patient is in a place where rehabilitation has a greater potential to be successful. If this is the case, referral to a professional that can help manage the emotional or mental health issues may be the most appropriate treatment choice.
The patient is encountering physical, social or economic barriers to attending sessions, adhering with ongoing treatment or being actively involved in the plan. These barriers may be related to transportation challenges when the individual requires special transport vehicles, the financial burden of paying for transportation over several visits, family/friends able to provide limited or no support or other personal issues making attendance and adherence with the treatment plan difficult. Sometimes the barrier is related to who is driving the rehabilitation plan – is the patient actually motivated to attend therapy or is it driven by a well-meaning family member in spite of the patient’s wishes. It may be necessary to discontinue physiotherapy if these barriers cannot be overcome.
The patient’s treatment is being directly affected by external financial factors such as caseload and bed management in a facility, a third-party who has set a pre-determined number of treatments or treatment dollars or the individual’s inability to personally pay for private care. This situation often results in a physiotherapist having to discontinue treatment before the optimal outcomes have been achieved. Becoming aware of these potential limitations as soon as possible will give the patient and the physiotherapist time to adjust the treatment plan and goals and ensure the patient is as prepared as possible for the impending discharge.4
The patient who simply will not follow treatment recommendations. There can be many reasons for this. Some, as noted above may be beyond the patient’s immediate control. However, sometimes the patient is looking for someone to “fix” them through passive treatments and or is not able to put in the work required in a collaborative, active treatment plan. Physiotherapy is not intended to be a passive treatment option and if the patient cannot or will not become an active part of the team, it may be necessary to discontinue treatment.
The patient has been told they are authorized or have access to “X” number of treatments or dollars and feel they have the right to use up the entire amount regardless of when they achieve their functional goals or the appropriateness of ongoing therapy. The ongoing provision of physiotherapy can never be based on financial benefits or gain for either the patient or the provider/clinic. If treatment is no longer clinically warranted, physiotherapists must discontinue services.
The patient is not responding to the current interventions and may be better served by another clinician who can address the patient’s needs from a different perspective or skill set. As physiotherapists we would like to be able to fix everyone. However, sometimes the patient’s specific needs may be more appropriately addressed by another physiotherapist or other health-care provider with different skills, expertise or knowledge base. We must know when it is appropriate and in the best interest of the patient to collaborate with a colleague or to make a referral to another provider.
The patient who has become dependent on the therapeutic relationship.4 Some patients refuse to be discharged when they have reached their functional goals because they do not have the confidence that they will be able to stay well without help or guidance from their physiotherapist. Some patients expect to be “pain-free” and wish to continue physiotherapy because they still have pain even though they have achieved their functional goals. Sometimes, with elderly or isolated patients, the therapeutic relationship offers the only real contact for the individual and they become very reluctant to let go. These can be very difficult and emotional conversations for both the provider and the patient but continuing treatment that is no longer clinically warranted just because the patient wants it is ethically and professionally inappropriate. Clearly identifying functional, realistic treatment goals, having a way to objectively measure progress, as well as educating the patient on ways to self-manage their condition and ongoing therapy needs will make these discussions and discharge easier.
If you are finding these conversations challenging, the participants in the study4 recommended that working with a mentor or colleague who can add their expertise and experience may be a good place to start building your confidence and comfort to plan for and initiate discharge conversations regardless of the reasons for discontinuing treatment.4 Regardless of your experience level, seek out support from a colleague or look for a mentor who can guide you. The Managing Challenging Situations Guide also provides some tips for how to plan these difficult conversations.
You can also contact Physiotherapy Alberta’s Practice Advisor at firstname.lastname@example.org or 780-702-5390 to discuss the situation you’re encountering. You are not alone.
Physiotherapy Alberta College + Association (2014). Good Practice: Managing therapeutic relationships – Time to say goodbye? Available at: https://www.physiotherapyalberta.ca/physiotherapists/news/good_practice_managing_therapeutic_relationships_time_to_say_goodbye
Physiotherapy Alberta College + Association (2017). Code of Ethical Conduct for Alberta Physiotherapists. Available at: https://www.physiotherapyalberta.ca/files/code_of_ethical_conduct.pdf
Physiotherapy Alberta College + Association (2017). Standards of Practice: Client Assessment, Diagnosis, Interventions. Available at: https://www.physiotherapyalberta.ca/files/practice_standard_client_assessment_diagnosis_interventions.pdf
Pashley E, Powers A, McNamee N, Buivids R, Piccinin J, Gibson BE. Discharge from outpatient orthopaedic physiotherapy: a qualitative descriptive study of physiotherapists' practices. Physiother Can. 2010;62(3):224–234. doi:10.3138/physio.62.3.224. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2909870/ Accessed July 15, 2019.
Patient Safety. Every Person. Every Time.
Regulating Alberta's physiotherapy profession and acting as an association by providing member services.