Difficult Patient

One of my patients was admitted to the ward following an infection of a deep partial thickness burn they sustained to their lower limb. The patient had gone to the ED following their burn however was not admitted as an inpatient. They were referred to the outpatient burns clinic which provides daily dressings (if needed), consultations with the Dr’s, physiotherapy and OT Rx. The patient did not attend the outpatient clinic the next morning as recommended, and a few days later presented to the ED once more, this time with increasing pain levels and an infection. To assist in the wound healing process the patient went to theatre and had a SSG and debridement (clearing away of all the dead tissue etc). Following their surgery they were NWB’ing for 5/7. Once this time frame was up they came to the gym twice a day where their Rx focussed upon stretches (active), mm strengthening exercises and high level balance skills. The patient’s pain was well controlled and they were very compliant for all sessions.

Following the ward round the doctor mentioned to the patient they may be D/C in 2/7 following a review of their SSG. The patient was eager to get home as due to the nature of their job they didn’t have sick leave pay, thus whilst in hospital weren’t able to earn any money. The doctor reviewed the patients SSG in 2/7 time and found a small area had not taken and had turned white. They informed the patient they would review the graft again in 2/7. Understandably the patient did not take the news very well as they had been hoping to go home that day. Following this I approached the patient to go to the gym. The patient stated that they were in a lot of pain and wasn’t able to go that day. I had looked at their chart and knew the patient had had adequate pain medication and suspected that the reason they didn’t want to go was they were disappointed they weren’t going home. I reflected on the reasons why the patient wasn’t keen to participate in physio. The major reason I thought was they had been doing everything the surgeon had asked of them – physio a major component of this –and yet the graft still hadn’t taken so what was the point. After reflecting on this I had a chat to the patient reiterating why it is important to keep exercising (as the rest of the graft wasn’t healed yet) and that by maintaining their fitness and strength they will be able to get back to work much faster. The patient then agreed to come to the gym and was compliant for the next two days.

Two days later the surgeon examined the graft and there had been no change – the rest of the graft was doing well except the small patch was now dead. The surgeon informed the patient that he should start fasting at midnight. The patient looked confused and asked why, to which the surgeon replied he needed to have surgery again and put another small SGG over the dead area. The patient looked very angry at this news and looked away from the surgeon. The surgeon then began to explain why the new SSG was needed however the patient was clearly ignoring him. The surgeon asked if the patient wanted to listen and the patient replied ‘nup’. The surgeon continued to explain why it was necessary and told the patient with the SSG it would taken approx 5 days to heal, otherwise it would take 1/12. I later went and spoke to the patient to see how they were, they informed me they were really angry and they wouldn’t be participating in physio again and there’s no point coming back to try and persuade them as their answer wouldn’t change. I left giving the patient an hour to think and then went back to again try and explain not only the importance of physio, but the reasons why the SSG is necessary – however thy refused to look at me and I left. I wrote in the notes the patient had refused physio that morning and left a note to the afternoon physiotherapist. The next day I was told by the nursing staff that the patient had refused to listen to anyone and had D/C themselves the afternoon before.

It made me realise that we can give the patients all the information/education/options and attempt to steer them towards the optimal Rx however in the end it is their own choice. We aren’t able to make the decision for them even though we know in the long run it is the best option for them. The patient above had already make a poor decision regarding their injury leading to an infection and surgery. Whilst they had not done anything wrong in the Mx of their SSG it still hadn’t taken and required further surgery – which they declined. Knowing that the chances of seeing this patient again on the ward is high due to associated pain and delayed healing of their burn is frustrating as it could have been prevented if the patient had taken our advice. However, it is ultimately up to the patient and the best we can do it attempt to guide them in the optimal direction and provide advice/education as best we can. If anyone has been in a similar situation and has any advice it would be much appreciated.