Family Issues

I recently treated a patient who was admitted to hospital following a fall and sustaining a hairline fracture of the pubic ramus and ischium. This patient had a history of falls and in the past had been given a 4WW to use at home when ambulating with the hope of preventing/reducing the chance of them falling again. Unfortunately this patient ‘only occasionally’ used the 4WW, as they did not feel they required it. Additionally this patient had had a previous neurological event leaving them with a fairly significant long standing ataxic gait pattern which contributed to their impaired standing balance (which we could not address). Once the patient’s pain was Mx by the medical team we were asked to assess the patient’s mobility and determine whether they were safe to D/C. Following this Ax it was clear that the patient was still a falls risk – however this would not change with a couple more days as an inpatient receiving physiotherapy. After educating the patient on the importance of using their 4WW we referred to the patient to the falls clinic and wrote in the notes that the patient despite a falls risk was safe to be D/C. This was when the family issues began.

Prior to the medical team stating the patient was to be D/C the patient’s family had had no involvement nor voiced any concerns about the patient returning home. The day the patient was to be D/C their son announced that they (patient) could not go home as they were at risk of falling etc. Modifications were already in place at the home, services/assistance organised and the patient ambulated safely with a 4WW. Despite this the family maintained that the patient was not going to be safe at home, however the family had not made any alternative living arrangements or suggestions. Simply put the family wanted the hospital staff to organise these alterative arrangements and not take any responsibility. However, the medical team did not agree with the families concerns thus were not prepared (or couldn’t) arrange for these new ‘living arrangements’. Thus a ‘stand off’ occurred on the ward with the family refusing to take the patient home, and the medical team not providing any alternatives. While I had little involvement in this scenario it made me see the importance of a family meeting prior to D/C a patient. No such meeting had occurred in this scenario and what I found particularly difficult with this case was that the family didn’t appear to want to be involved in the process they just wanted ‘the problem’ sorted out for them.

If a family meeting had occurred all these issues could have been discussed with each of the medical team and allied health team present. From a physio POV there was no reason why the patient couldn’t return home as they could ambulate safely – should they chose to use their 4WW and they were part of a falls program. For these reasons (and that they were independent for all ADL’s) the medical team could not refer them for a rehabilitation program or in a nursing home/hostel etc, despite the family wishes. Unfortunately it was a tricky situation which I’m sure occurs all the time as although the patient may still be a falls risk, the reasons for them being at risk of falling is with the patient not complying with medical advice. In the end what the team had to do was explain to the family that this patient wasn’t going to ‘get better’ and by putting them in care (apart from them not meeting the criteria) it doesn’t mean that will not fall. In the end the family accepted this and took the patient home but it was a very awkward situation, especially for the patient who just wanted to get home. On reflection it would have been better to have got the family involved sooner, but as they had voiced no concerns (and had been spoken to by the staff) there had been no indication that this would happen. What I learnt from this situation was to always involve the family in the decision making process or at the very least keep them informed along the way in order to avoided such conflicts.