Rural Prac '09 Topic One - Communication

Situation
On Wednesday, I had an 82yo male patient on 'Ferns Ward', which is the orthopaedic ward, at SJOG Bunbury. He was 6 day post-op for a R TKR. Everyday, the new patients are seen in the morning once the bloods have come in and then the other patients who are day 2 onwards are seen in order of priority. Wednesday was a particularly busy day, and we hadn't yet been able to see this patient who was pretty standard except for not doing his exercises. On our way rushing down the corridor to see other patients with more pressing matters we overheard a nurse saying that this patient had decided to go home that afternoon. On hearing that, he very quickly found his way to the top of our priority list! Apparently the doctors tell the patients that from their point of view the patient is ready to go home, but they don't mention that the nurses, social workers, dieticians, physios, OT's etc. also have to clear them for discharge as well. As you can imagine, all that this patient heard was that he was going home. Unfortunately, his family didn't think it was a good idea because his day before had been rough in terms of obs and he was going home to a farm that they felt he wasn't ready to cope with. The nurses were also concerned about his obs. The OT and social worker we concerned about him returning to his remote farm where it was just him and his wife and there were no services available to them. As physios, we were mainly concerned with his lack of compliance with his exercises which had resulted in his inability to SLR which means no chance of going home and ambulating.

Task
Our task was to communicate to the patient that staying in the hospital for at least one night was going to benefit him in the long run even though he was very determined to go home and seemed very distressed at the prospect of staying another night.

Action
My supervisor and I attempted to discuss the matter with the patient and his family, but his family were afraid to verbalise how they really felt in case it upset him. We decided that the best course of action was to speak to the nurse who would have heard from the doctor. She told us that the doctor was only happy for the patient to be discharged when the entire team was happy. She also said that the nursing team was concerned with his obs and also his ability to cope on his own. After hearing this we took his family outside to hear how they really felt. It turned out that they felt very strongly about keeping him in the hospital for at least another night, and they were very distressed at the idea of him coming home. My supervisor decided that the best course of action was to tell the patient that when he could SLR he could go home.

Result
In the end, although the patient was unhappy with the prospect of staying another night I think it made him understand the importance of doing his excersices as well as having a clear goal to achieve in order to go home. The family and nursing staff were very happy with the outcome.

Evaluation
I believe that we dealh with the situation very well and did the right thing. I however don't like the fact that one member of the team can tell a patient they can be discharged without ensuring that the rest of the team is ok with it aswell. I am very happy to know that physios don't do this at all! I think the other staff and family were worrying too much about stepping on his toes and upsetting him instead of seeing the bigger picture and doing what was best for the patient. At no time were we cruel to him and he fully understood the logic, and we fully understood that hospitals are not the nicest places to stay.

Strategies
Without communication, this patient would have been sent home prematurely and probably would have ended up back in the hospital for even longer in a few weeks/months time. Team work was very important as well, to make sure that every aspect of the patients care was of the highest level . I only wish that I could have had the chance to go in and speak with him again today to really discuss and explain the situation again when he was no longer upset about the situation, and get him really appreciating and liking physios!