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Death By Stubbornness: What’s A Doctor To Do?

Over the years that I’ve worked in acute inpatient rehab centers, I have been truly vexed by a particular type of patient. Namely, the stubborn patient (usually an elderly gentleman with a military or armed forces background). I know that it’s not completely fair to generalize about personality types, but it seems that the very nature of their work has either developed in them a steely resolve, or they were attracted to their profession because they possessed the right temperament for it. Either way, when they arrive in the rehab unit after some type of acute illness or traumatic event, it is very challenging to cajole them into health. I suspect that I am failing quite miserably at it, frankly.

Nothing is more depressing for a rehab physician than to see a patient decline because they refuse to participate in activities that are bound to improve their condition. Prolonged immobility is a recipe for disaster, especially in the frail elderly. Refusal to eat and get out of bed regularly can make the difference between life and death within a matter of days as leg clots begin to form, and infectious diseases take hold of a body in a weakened state. The downward spiral of illness and debility is familiar to all physicians, but is particularly disappointing when the underlying cause appears to be patient stubbornness.

Of course, the patient may not be well enough to grasp the “big picture” consequences of their decisions. And I certainly do not pretend to understand what it feels like to be elderly and at the end of my rope in regards to prolonged hospital stays. Maybe I’d want to give up and be left alone too. But it’s my job to get them through the tough recovery period so they can go home and enjoy the highest quality of life possible. When faced with a patient in the “wet cat” phase of recovery (I say “wet cat” because they appear to be as pleased to be on the rehab unit as a cat is to being doused against their will), these are the usual stages that I go through:

1. I explain the factual reasons for their admission to rehab and what our goals are. I further describe the risks of not participating in therapies, eating/drinking, or learning the skills they need to care for themselves with their new impairments.

2. I let them know that I’m on their side. I understand that they don’t want to be here, and that I will work with them to get them home as soon as possible, but that I can’t in good conscience send them home until it’s safe to do so.

3. I give them a projected discharge date to strive towards, with specific tasks that need to be mastered. I try my best to give the patient as much control in his care as possible.

4. I ally with the family (especially their wives) to determine what motivates them, and request their presence at therapy sessions if that seems fruitful rather than distracting. (Helpful spouse input: “Mike only wants to walk with me by his side, not the therapist.”)

5. I ask loved ones how they think the patient is doing/feeling and if there is anything else I can do to make his stay more pleasant. (Helpful input: “John loves ice cream. He hates eggs” or “John usually goes to bed at 9pm and gets up at 4am every day.”)

6. I meet with nursing and therapy staff to discuss behavioral challenges and discuss approaches that are more effective in obtaining desired results. (For example, some patients will always opt out of a task if you give them a choice. However, they perform the task if you state with certainty that you are going to do it – such as getting out of bed. “Would you like to get out of bed now, Mr. Smith?” will almost certainly result in a resounding “No.” Followed perhaps by a dismissive hand wave. However, approaching with a “It’s time to get out of bed now, I’m helping you scoot to the edge of the bed and we’re going to stand up on 3. One, two, three!” Is much more effective.)

7. If all else fails and the patient is not responding to staff, loved ones, or doctors, I may ask for a psychiatric consult to determine whether or not the patient is clinically depressed or could benefit from a medication adjustment. Typically, these patients are vehemently opposed to psychiatric evaluation so this is almost the “nuclear” option. Psychiatrists can be very insightful regarding a patient’s mindset or barriers to participation, and can also help to tease out whether delirium versus dementia may be involved, and whether the patient lacks capacity to make decisions for himself.

8. If the patient still does not respond to further tweaks to our approach to therapy or medication regimen, then I begin looking for alternate discharge plans. Would he be happier in a skilled nursing home environment where he can recover at a slower rate? Would he be amenable to an assisted living or long term care facility? (The answer is almost always a resounding “no!”) Is the patient well enough to go home with home care services and round-the-clock supervision? Does the family have enough support and can they afford this option?

9. At this point, after exhausting all other avenues, if the patient is still declining to move or eat or be transferred elsewhere, some sort of infection might set in. A urinary tract infection, a pneumonia, or bowel infection perhaps. Then the patient becomes febrile, is started on antibiotics, becomes weaker and less responsive, and is transferred to the medicine floor or higher level of care. Alternatively at this phase (if he is lucky enough not to become infected) the patient might have a cardiac event, stroke, blood clot with pulmonary embolus (especially if he is a large man), kidney failure, or develop infected pressure ulcers. Any of which can be cause for transfer to medicine. In short, if you stay in the hospital long enough, you can find a way to die there.

10. After much hand-wringing, angst, and generalized feelings of helplessness the wives and I review the course of events and ask ourselves if we could have done anything differently. “If I had acted like a drill sergeant, do you think he would have responded better?” I might ask. “No dear, that would only have made things worse.” She’ll reply. I’ll see how disappointed she is in his deterioration, staring off towards pending widowhood, engaging in self-blame and what-ifs (E.g. “If we had only had more money perhaps we could have taken him home with 24 hour nursing care until he was better…” “If I had cooked all his meals, maybe he would have gained enough strength to avoid the infection…” etc.) I try to be reassuring that none of this would have made a difference, myself reeling from the failure to get the patient home.

This 10 step process happens far more often than I’d like, and I certainly wish there were a way to head off the downward spiral with some kind of effective intervention. Would it help to have a volunteer unit of ex-military peer counselors in the hospital who could visit with my patients and help to motivate them to get better? (Operation “wet cat” perhaps?) Should I change my approach and put on my drill sergeant hat at the earliest stages of recovery to force these guys out of bed? Can educating younger law enforcement and military workers about illness help to prepare them to be more compliant patients one day?

I don’t know the cure for stubbornness, but it sure leaves a lot of widows in its wake.

It’s Important To Discuss Side Effects With Your Health Care Providers

Prepared Patient Publication Logo Talking About Side Effects With Your Health Care Team

Side effects may occur with any new treatment, including new medications, placement of a new medical device, surgery, or even physical or occupational therapy. We usually think of side effects when we begin to experience bad changes —when the treatment introduces new worrisome symptoms or problems. Most treatments have some sort of side effect associated with them, and many of us may wonder if side effects are simply the price we must pay for a necessary treatment.

But side effects shouldn’t be taken lightly, for a number of reasons. At their most extreme, side effects raise the alarm when you are having harmful and even potentially fatal treatment reactions. Even somewhat mild side effects like a dry mouth, sleepiness, or minor muscle aches may still interfere with your daily life. Sometimes side effects bother some people so much that they skip doses or give up a treatment altogether, which can derail care and put them at risk for both short- and long-term complications.

Before treatment begins, here are a few questions you can discuss with your health care team: Read more »

*This blog post was originally published at Prepared Patient Forum: What It Takes Blog*

Considering Your Options When The Insurance Company Stops Paying

Blue Cross just advised a twenty-six-year old woman I know that it will cut off payments for the physical therapy that was making it possible for her to sit at a keyboard for eleven hours a day.  Her thirty sessions were up.

The young woman has an overuse injury to both of her arms that causes so much pain she can’t even mix up a salad dressing.  “I am not getting any better,” she said.  “To do that I would have to stop working or scale back the number of hours required by my job.”  Those physical therapy sessions offer strengthening exercises that reduce swelling and inflammation and make it possible for her to keep working.

Shifting Medical Costs to Patients

One cannot entirely fault insurance companies for trying to clamp down on medical costs, but rather than actually lowering the underlying costs of medical services, their solution is to Read more »

*This blog post was originally published at Prepared Patient Forum: What It Takes Blog*

The Right And Wrong Ways To Strengthen Your Core Muscles

What do slouching, back pain, and a middling forehand or weak shot off the tee have in common? Often it’s a weak core—the girdle of muscles, bones, and joints that links your upper and lower body. Your core gives you stability and helps power the moves you make every day. Whether it’s bending to pick up a laundry basket, swinging a golf club, paddling a kayak, or reaching to pull a vase from the top shelf of a cabinet, a strong and flexible core makes the move more fluid, efficient, and robust. Strong, well-balanced core muscles can also improve your posture and help prevent back injuries. And if back pain does strike, core exercises are usually part of the rehab regimen.

Core Muscles

Click image to enlarge.

Your core is composed of many different muscles in the abdomen, back, sides, pelvis, and buttocks. These muscles work together to allow you to bend, twist, rotate, and stand upright.

For all these reasons, more and more people are incorporating core exercises into their fitness routines. If you’re among them, or planning to be, it’s critical to pay attention to proper form. Read more »

*This blog post was originally published at Harvard Health Blog*

What To Do About Runner’s Knee (Patellofemoral Pain Syndrome)


My left knee hurts. When I put weight on it with my leg bent, like when I get out of the car, I feel a dull pain in my knee. My doctor and physical therapist have given me a diagnosis of patellofemoral pain syndrome, also known as “runner’s knee” or patellar knee-tracking syndrome. Simply put, my kneecap doesn’t run smoothly up and down its track—a groove called the trochlea.

Anyone can get patellofemoral pain syndrome, but for some reason it is more common in women than men—especially in mid-life women who’ve been running for many years. The problem, say researchers who just published a study in the journal Gait and Posture, is that lots of “mature” women develop alignment problems with their knees. The researchers compared younger female runners to older female runners and found misalignment of the knee to be much more common in the older women. Some knees sagged inward, others bowed outward or were rotated.

When the alignment is off, the kneecap can’t smoothly follow its vertical track as the knee bends and extends. This causes wear and tear on the joint. That leads to overuse injuries like runner’s knee and, down the line, osteoarthritis, which can really put a cramp in a runner’s career.

My physical therapist recommended that I Read more »

*This blog post was originally published at Harvard Health Blog*

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