Creating a feeling of “we” in the client-physiotherapist relationship is integral to achieving positive therapeutic results.1 There are many steps involved to gain a client’s trust as a physiotherapist and depending on the client’s lived experiences it can become even more challenging.
One of the main roles a physiotherapist has with a client is creating and discussing the client’s plan of care. The physiotherapist helps the client understand their condition and how physiotherapy may be able to help the client achieve their goals. There needs to be an explanation of the risks and benefits of the proposed plan of care and together the physiotherapist and the client engage in a discussion of how to proceed in a way that is consistent with the client’s goals and values.
However, as in many relationships, there can be friction and disagreement. This article sets out to explore the physiotherapist’s role and responsibilities when the client chooses an option which differs from what the physiotherapist is recommending.
In the Managing Therapeutic Relationships Guide physiotherapists can find direction on how to build trust and respect with a client as well as how to create a safe and sensitive practice for those who physiotherapists interact with. However, this article will go a bit beyond the guide to explore what happens when a client is choosing a risky path of care or ignoring advice from the physiotherapist. There are potentially more risky behaviours that exist outside the scope of practice of physiotherapy, such as a client refusing to accept medical interventions for cancer treatment. However, within physiotherapy scope of practice we still see clients returning to sport or work much too early after surgery or those that return home too soon after a stroke without the proper supports in place.
Risk is weighed by both the physiotherapist and the client and each may have different perceptions regarding the weight of that risk. There may also be discussions between the client and the physiotherapist regarding the perceived benefits of the proposed plan of care. However, when differences occur between the physiotherapist and the client, the physiotherapist should remember three things.
1.Consent must be informed.
The client bases their decisions on the information they have been provided coupled with their own values and goals. The client’s background or lifestyle will affect the decisions that they will make so even though the physiotherapist may present very similar information to two different clients the physiotherapist may see drastically different choices. It is the physiotherapist’s responsibility to inform the client of the available options for care and the risks, benefits, and likely outcomes associated with each option. A client cannot properly consent to something if they aren’t informed of all the potential risks associated with a proposed plan of care.
2. Communication flows both ways.
The physiotherapist must ensure the client receives relevant information related to their condition and it must be presented in a way the client can understand. If there is risk involved with the client’s choices for their plan of care then the physiotherapist should be outlining the potential negative outcomes and utilizing their education, experience, and research findings to communicate the risk to the client. This information should be meaningful and relevant to the client and make it clear what the potential consequences are to their choices and actions. When a physiotherapist is describing risk to the client, it is important that they know that the format with which risk is presented has significant impacts on the client’s understanding of that risk.2 As it is a key component of physiotherapy practice to do this with clients it should be a skill that is honed like any other technical or non-technical skill physiotherapists use.
The client will hopefully feel that they can trust the physiotherapist and feel comfortable disclosing reasons as to why they are choosing a different care pathway from the one the physiotherapist has recommended. The client could be rushing back to work for financial reasons or not using a recommended brace due to poor knowledge of how to use it. The physiotherapist should be trying to discover the reasoning behind the decision making so that they can address the client’s concerns and problem solve with the client to come up with a solution that could avoid unintended consequences.
If the client brings up a pathway that wasn’t presented due to the risks associated, the physiotherapist most likely would recommend they not choose that option. It is very important to recognize that clients are autonomous and may decide to participate in risky behaviour against professional advice, which brings us to our next point.
3. Where does a physiotherapist’s duty of care end?
It is important to understand that there are limitations on a physiotherapist’s ability to provide safe care. The physiotherapist has both a duty of care to the patient and a duty to provide safe care and sometimes those duties can be in conflict.
Physiotherapists should recognize that clients have the right to make informed decisions about their own care, even when this decision may put the client’s health at risk. That doesn’t mean that the physiotherapist provides treatments that are contraindicated. The physiotherapist has direct control over their practice and has to practice safely.
In other situations, a physiotherapist may be in the position of needing to provide the best or safest option in a risky situation. Consider a stroke patient who is planning to discharge themselves from hospital against medical advice. Perhaps the physiotherapist’s assessment is that the patient requires a certain level of assistance or equipment that the patient is not willing to accept. The physiotherapist needs to educate the client, advise them of their concerns and recommendations, document the conversation, and provide the client with options for treatment or service. The physiotherapist may potentially provide the client with the safest option the client will accept, making the situation as safe as the physiotherapist can make it. The client then has the choice to either accept the physiotherapist’s recommendations or not. The physiotherapist is responsible for their recommendations but not for how the patient acts on those recommendations.
The following scenarios will hopefully shed some light on a physiotherapist’s role in working with a client who makes a decision that the physiotherapist considers risky or ill-advised.
Returning Too Early
Most physiotherapists have encountered the scenario where the client returns to sport or work too early. We recognize that there are many factors that alter the timing of these decisions such as pressure to play or finish out a season that may come from the client, a coach, or the parents if the client is a minor. These interactions can be challenging with minors as there are more people associated with their return to sport. Parents, coaches, teammates, etc. all may be influencing the younger athlete in their decision making. It is important to focus on the client and ensure that the information presented to them is clear and they are aware of the potential long-term effects of their decision now. It is challenging for athletes to see past the next season or for younger people to envision life in their 40’s or 50’s so it must be clearly laid out for them. Having a positive relationship with the parents and coaches of younger athletes will help in the shared decision-making process.
In the world of work, physiotherapists sometimes get clients that return too early due to financial pressure, or pressure coming from the workplace. There are also those on work visas who are hoping to be sponsored by their employer to become permanent residents of Canada and who don’t want to create any negative perceptions that may influence the employer’s willingness to sponsor them. In more stressful economic times, many people suffer from increases in financial pressures, and this may result in riskier decision making from the client.
Although the reasoning may vary as to why the client is rushing back from their injury, the physiotherapist’s responsibility is to provide information to the client and discuss with them the risks of returning too early. The more obvious risk of re-injury or creating new injuries or impairments are on top of that list but depending on the client there may be an added risk to others. If someone returning to operate a crane still has trouble moving their neck or shoulder, impairing their ability to safely operate the crane, those around them could also be at risk and should be considered when talking to the client.
So, if there is a potential safety concern what does the physiotherapist do? Generally, for a client’s return to work there are requirements that must be satisfied before they are allowed to return to work. If it is a work-related injury the physiotherapist has a responsibility to provide accurate information to the case manager or the employer as to the client’s current status and what they are capable of and more importantly what they are not yet capable of doing at the workplace. The client may not be happy with the report or recommendation, but it is the physiotherapist’s responsibility to be honest and accurate in their assessment of the client.
Poor Capacity to Make Decisions
Let’s go back and once again consider the stroke patient who is in the process of self-discharging against the advice of their health-care team. One of the questions that may come up is whether the client has the capacity to make decisions regarding their health and well-being. Capacity assessment is a formal assessment process and not something that a physiotherapist can decide or judge on their own. Capacity to make decisions is assumed for those over the age of 18 unless proven otherwise.3 The physiotherapist should first establish if the client has already had a capacity assessment.
If a client appears to lack capacity, ask if a Personal Directive, Supported Decision-Making Authorization, or Guardianship exists and if there is nothing like that in place the physiotherapist may want to advocate for a capacity assessment. Going down the road of questioning a client’s capacity is a very tricky road to manage. For a hospitalized stroke patient, the Health Information Act allows the physiotherapist to consult with the rest of the health-care team regarding the patient’s capacity and structures should be in place to begin the formal process of a capacity assessment.
What changes in the scenario where the client didn’t have their capacity assessed, was discharged, and is now attending a private clinic? Since they are in a private facility the privacy legislation changes from the Health Information Act to the Personal Information Protection Act. With that change the physiotherapist now needs the patient’s consent to talk to their family doctor or family regarding their concerns. There is quite a bit of context to this situation as bringing up the subject of the patient’s cognitive ability could undermine the trust that has been built in the client-physiotherapist relationship. The client must consent to go through a capacity assessment. The physiotherapist has a responsibility to act in the client’s best interests and must not ignore the fact that the patient may have impaired capacity to make decisions. The physiotherapist should discuss their concerns with the client in a sensitive and compassionate way.
The Client Still Chooses to Go Against the Physiotherapist’s Recommendations
There are many clients that recognize the risks and have the capacity to make informed choices but still make choices that confuse the physiotherapist. An example may be a client recovering from a stroke or amputation who requires a two-wheeled walker but only wants to use a four-wheeled walker. They recognize they are unsafe to use the 4WW, but they also know that using the 4WW makes some aspects of their life easier. Another example is the client who has been advised to remain in their cervical collar or clamshell brace, but they refuse to wear it.
Should a physiotherapist provide the first client with the 4WW even though they know the client could be at risk of injury? Should the physiotherapist discharge the other client knowing that they aren’t going to listen to the physiotherapist’s advice, or work with the client while they opt not to wear the required brace? All of these scenarios require context to properly answer but there are a few key things that physiotherapists can abide by.
Contraindications exist for a reason. The physiotherapist’s job is to make the client as safe as possible and to accept that competent adults get to make decisions that affect their lives - whether the physiotherapist thinks it's a good decision or not.
The client may choose to remove their clamshell brace but that means that their physiotherapy sessions would be limited to what can be done safely with the client when they are out of their brace. Or the physiotherapist may provide a 2WW to the client who wants a 4WW and if the client switches to a 4WW after they are discharged there is only so much the physiotherapist can do. The physiotherapist has educated the client of the risks, provided recommendations, and made the situation as safe as possible. The client’s choices may be informed by any number of values and beliefs. In the end the physiotherapist’s responsibility is to provide as much support and education as possible to positively influence their decision, but the client ultimately gets to make the decisions that affect their life.
- Ahmed H, Naik G, Willoughby H, Edwards A G K. Communicating risk BMJ 2012; 344 :e3996 doi:10.1136/bmj.e3996