Pressure to Continue Daily Therapy for a Patient Who Has Plateaued
You are the only physiotherapist in a 60-bed skilled nursing facility operated by a company that circulates a quarterly 'therapy utilisation' target to its directors. Mrs. Okafor is 84 and is in week nine after a left middle cerebral artery stroke. She now walks 15 m with a quad stick and one assist, transfers with one assist, and needs help with lower-body dressing. Her Berg Balance Scale score has been 26, 27 and 26 over the last three weeks, and her 10-metre walk time has not changed. She receives physical therapy five days a week. At a care conference this morning she says she is 'tired of all this' and wants to stop therapy, though she would like to go home. Her daughter insists that more therapy is the only thing that will get her mother walking again and has told the administrator she will complain if the sessions stop. The administrator tells you to keep treating her daily because the facility 'cannot afford to lose the days'. Medicare Part A day 62.
1. Identify the competing obligations in this situation and explain which course of action you can defend.
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The obligations pulling in different directions
- To Mrs. Okafor: autonomy and informed choice, and a duty to offer treatment that has a realistic chance of benefit rather than therapy that fills a schedule.
- To the payer and the public purse: services billed must be skilled, reasonable and necessary, and documented truthfully. Knowingly providing or billing for care that is not medically necessary exposes the clinician and the facility to false-claims and civil-monetary-penalty liability, and it breaches professional codes on integrity and billing.
- To the daughter and family: empathy and realistic information, but not a duty to provide futile treatment.
- To the employer: legitimate operational needs, which do not override clinical judgement.
- To yourself and the profession: your licence attaches to what you sign, not to what you were told to do.
The defensible course Neither blind compliance nor abrupt withdrawal. Three findings have to be separated: (1) Is she refusing? An adult with capacity may refuse, and that refusal must be respected; capacity and reversible contributors (depression, pain, delirium) must be assessed first. (2) Is the current programme still effective? Three weeks of unchanged Berg and walk times is a signal to change the plan or stop, not evidence that more of the same will work. (3) Is daily skilled therapy necessary? After Jimmo, maintenance care can be skilled, but the decision must rest on clinical need, not on census.
So: reassess, redesign or discharge on clinical grounds, honour her wishes, inform the family, document the reasoning - and decline to let utilisation targets determine the frequency in the record.
2. Set out, step by step, what you would do and say over the next 72 hours.
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Step 1 - see her alone today. Ask what 'tired of all this' means: pain, exhaustion, low mood, hopelessness, feeling unheard. Screen mood and cognition, check for untreated pain, constipation, poor sleep and medication effects. Confirm she understands what stopping means and what continuing would involve, and record her decision and your assessment of capacity.
Step 2 - test the plateau properly. Repeat outcome measures on the same day and time. Ask whether the programme is the problem: is it intense enough, task-specific enough, and directed at what she actually needs to go home (steps, bathroom transfers, stairs, endurance rather than more of the same)? Offer a short, time-limited trial of a redesigned plan with a measurable goal and a stop date, so the decision is data-driven.
Step 3 - family meeting with social work and the physician. Tell the daughter plainly what therapy can and cannot now achieve, give the numbers, and ask what her mother wants. Present the real options: a restorative nursing programme for ongoing practice with nursing staff, discharge home with home health and caregiver training, outpatient therapy after discharge, equipment and home modifications. Make clear that continuing daily skilled therapy is not the only route to walking.
Step 4 - handle the administrator. State that you will treat according to assessed need and will not document or bill care you do not believe is indicated. Put the request and your response in writing. If the instruction persists, use the compliance or ethics channel; a pressure to keep patients on caseload is exactly what those channels exist for.
Step 5 - close the loop. Document, plan discharge or a new plan with dates, and ensure nothing is left implicit.
3. Draft the substance of what belongs in your progress note, and list what must not appear.
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What belongs in the note
- Dated objective measures with the trend, e.g. 'Berg 26 (26, 27, 26 over three weeks); 10-metre walk 0.32 m/s, unchanged; walking 15 m quad stick, one assist.'
- Her statement in quotation marks with the date and who was present, and your assessment that she has capacity and understands the consequences of refusing.
- The clinical reasoning: goals met or plateaued, what was considered and tried, why a change or discharge is proposed.
- Education given to her and to her daughter, what they said in response, and the family meeting attendees.
- The plan and who owns each part: restorative nursing referral, home health referral, equipment ordered, physician notified, review date.
- The fact that therapy frequency was reduced for clinical reasons, with the reason stated.
What must not appear
- 'Patient non-compliant' or 'family difficult' as substitutes for an explanation.
- Skilled-need language with no objective support, or goals copied forward unchanged.
- Minutes, units or visits that did not happen, or entries written days later as if contemporaneous.
- Any reference to utilisation targets as a justification for frequency, and any hint that the daughter's complaint influenced the plan.
- Treatment described as delivered when it was refused; refusal is documented as refusal, not as a completed session.