Ethical Dilemma

[AJ Lievre]

Hey everyone, I have been meaning to post this patient case for a while as we were discussing leveraging placebo. Sorry, it’s a long one.
I evaluated a 58-year female about a month ago who had a primary complaint of lower back and bilateral lateral hip pain. In addition, she reports bilateral lateral thigh and knee pain, left ankle pain and left shoulder pain. She has been diagnosed with fibromyalgia, Lymes disease, left RC tear. She states that over the years she has had multiple farm-related injuries (falling off a horse, getting kicked by a goat and being knocked over several times by cows). She has been on a downward spiral physically after being knocked over by a cow in late spring of this year. She has “dealt with pain” for many years, but her pain has gradually worsened over the last few months where she has become less and less ambulatory. She has no consistent pain patterns other than it “always hurts everywhere” and all movements and activities makes her pain worse. She is finding at this point that she can only tolerate 5-10 minutes of standing and 2-3 minutes of walking before she needs to sit down due to pain either in the ankle, knees, hips or back. She reports that she is convinced her Lymes disease is leading to whole-body inflammation making her pain worse and that it has led to trigger points in the muscles all over. She believes that if we can address the trigger points in the muscles, that she could walk better and be in less pain. She knows that she will have to “live with pain for the rest of her life due to the Lymes and the chronic inflammation”. She is not taking any pain medication or anti-inflammatories because she does not tolerate them. She is in a constant search of anti-inflammatory foods and supplements to help. (I could go on and on about this as I get a report each visit!).
Her goals are to be able to stand and walk longer and be able to work in her greenhouse with less pain.
After clearing all red flags following the subjective, it was clear that I am dealing with a severely debilitated centrally sensitize patient with strong beliefs about her pain. Following a small battery of functional outcome tests, we had a discussion of a plan of care. We talked about her previous experiences with physical therapy and other care to address her pain. 10 years ago she had a right RC tear that was “cured” in physical therapy by the use of ultrasound by “eliminating the trigger points and healing the tendon”. She talked about her combative experiences with previous PT’s over the last few years that have “not listened to her requests for treatment”. She said “I know you PT’s don’t think that US works, but it worked for me, and I don’t know why we can’t try it”.
So here is my ethical dilemma, it is clear that she wants to dictate her care with treatments that I’m not fond of particularly since it is very passive (which I think is really bad for this patient population). However, her main problems are beliefs about her condition and about her pain, and if I can leverage a placebo effect from something that she is convinced will help her, then why shouldn’t we try it. Although it is fairly clear from the evidence US has limited utility in the population, I am dealing with a patient and not a population (n=1, shout out to Roger Kerry).
In an attempt to make some shared decisions, I bargained with her, that if we did use passive treatment, then the 2nd half of each treatment session needs to be active. She was completely on board with that.
So I wheeled out the US cart for the first time in maybe a decade (I had to read the instructions to figure out how to use it again). I did my rows and circles with the US head wherever she felt needed it. And yes I did plug it in and turn it on, although I was tempted not to as the effect probably would have been the same. Each subsequent visit, I ask her what area she wants to work on today, and we hit it with an US, and then move on to exercise (aerobic conditioning, functional exercises)
Guess what, she still reports a lot of pain and is constantly in search of the next supplement or food that will manage her symptoms. But she states that she hasn’t felt this good in over a year, she is working in her greenhouse, stepping up on steps leading with the right leg, and is able to stand long enough to can vegetables and herbs from her greenhouse.
In my opinion, she is not ready to have the “pain talk” as she is entrenched (she is a sandstone for those of you familiar with Moseley) and my first attempt got deflected quickly.
Would love to hear your opinions about my dilemma, treatment decision and suggestions on where to go from here.
1. Does this case remind you of someone you have had in the past?
2. Is it wrong for our patients to dictate some of there care especially if we believe the requested passive treatment will not be valuable?

I attached a short article on making ethical decisions in healthcare.

Attachments:

You must be logged in to view attached files.

[Erik Lineberry]

Hello all, long time no post. My name is Erik Lineberry, I was a resident with VOMPTI a couple years ago. I was actually in the discussion board to make an entirely different post, but found this case interesting and decided to add my 2 cents.

The power of perception is real and I think the way you handled allowing this patient to dictate their care was appropriate. The way I see it the US is being used to improve the patient’s outlook on their condition and allowing you to add exercise and education that will help. The US time can even allow for a positive conversation about the patient’s condition and care. Healthcare should be collaborative and a patient is part of it. In this situation I guess I am okay with providing the treatment because, even though the physiologic value of US is little to nothing, it is valuable to this patient in other ways. I always feel like while I am not necessarily lying to patients like this, I am not being entirely truthful and it does sit a little weird with me.

Also, I attached a fun article in relation to how perception shapes care and the use of US. I’m interested to know if your patient has experienced the positive benefits of using US with clockwise circles.

Attachments:

You must be logged in to view attached files.

[Katie Long]

Hey AJ,

It sounds like this is the patient that you and I had discussed a while ago when I was still in Woodstock? Sounds like she is seeing improvements! Great!

This actually reminds me a lot of a patient of yours that I was treating at WRF a while back. He came in for low back pain and while I was seeing objective improvements throughout his POC, he kept reporting to me subjectively that he did not feel like he was making improvements. He kept telling me about how you had “cured” him and how amazing his PT was with you. I remember how frustrated I was because you and I had spoken about his case and I knew I was on the right track with his treatment. However, I decided to put him on mentorship with you just so he could see you and get the “placebo” of seeing you. Sure enough, I only saw him 3 visits after that because he made “leaps and bounds” of improvements according to his subjective reports. We really did nothing different, but because he had the placebo of seeing you and getting your confidence, he did so much better with therapy.

This was so incredibly frustrating for me, because I was trying to assert my competence as his treating therapist, but also be sensitive to what he believed would help, which was seeing you. So to answer your second question: no, I don’t think it is “wrong” perse to “allow” patients to dictate parts of their plan of care as long as it is used in attempts to continue their progress towards active, evidence based, meaningful treatment. I think we find it very frustrating because we are trying to help our patients in the best way we know how. But in the end, I think we must consider that this patient is taking time out of their day, paying a co-pay (or insurance, or out of pocket), taking time off work, etc. to come to us in attempts to help them feel better. So to bring up a point in your question: “…if we believe the requested passive treatment will not be valuable?” valuable to whom? Them or us? in the end, it is their [shoulder, knee, ankle, etc.], not ours. There are three tiers of evidence-based practice: current literature, clinician experience and patient values/expectations. And I think that I need to remind myself of the third component in these situations. It is just as important and should be considered just as critically and with as much merit.

Thanks for the post, it is always a good reminder to reflect on these types of scenarios.

[Matt Fung]

AJ thanks for sharing this case with us.

While your patients presentation is unlike any I have come across this early in my practice it reminds of someone that Kristin and I have seen during my mentoring hours. The patient is coming in for plantar fascia pain and is responding well to therapy. However the referring doctor insists on his patient receiving US as a part of his POC. In this case we have the ethical dilemma providing what we believe may be the best treatment approach to the patient, while at the same time not upsetting our referral source by going against their treatment recommendations. We have decided to incorporate US into some follow up visits to appease the referring physician despite its lack of evidence in the research.

In regards to the case you posted I believe it is ethical to allow patients to dictate a portion of their care even if their request lack evidence, if it will improve patient buy in and compliance. Typically during my evaluation I will as patients if they have been to PT before and if so what they felt worked best for them. Based on their response I try to work with them to utilize different exercises or techniques they believed worked best for them while prefacing it with, “we might try a couple of different things here because everyone practices a little differently.” If a patient is adamant about receiving passive modalities during their treatment session I would like to think I would handle it similarly to you where we try and find a way to keep both parties happy, working together to make them feel better.

[jeffpeckins]

I had a patient who was seen by Katie for many weeks for posterior knee pain and severely limited flexion ROM. Katie was unable to make many significant gains, so she referred him back to the physician for more diagnostic imaging. Fast-forward about one month, and I am evaluating him for a “quad tendon rupture.” He has absolutely no pain or weakness with knee extension, and all of his pain continues to be in his posterior knee. I was very confused about this, so I called the referring physician and spoke to her. She said that imaging showed a quad tendon rupture, and that he has decreased knee flexion ROM due to “bone on bone arthritis” (side note: she tells ALL of my patients this and it is incredibly frustrating). I told her about how my clinical findings show no evidence of a rupture. The conversation concluded with her telling me I should treat his rupture so that she can give him a shot in his knee to help decrease his posterior knee pain. I ended up seeing him two more times, the first to give him an HEP to improve quad strength and promote quad tendon healing, and the second to make sure his HEP was being followed and he was doing his exercises correctly.

I made the decision that it was unethical for me to treat a patient for a diagnosis that I did not find any evidence for with my objective testing. Yes, an US may have diagnosed him with a rupture, and even if he has one somehow, it is not why the patient is seeking PT treatment. He wants to decrease his posterior knee pain and increase his ROM. I’m not sure if this was the correct decision to make, but I felt uneasy about using his time and money to treat him for something that was not going to help him achieve his goals.

[jeffpeckins]

AJ,
First of all, Laura (another PT who works at the clinic) told me that you were using US on that patient and she got a kick out of that!

Similar to what others stated, if the patient specifically requests a modality and believes it will heal her trigger points and tendons, then I think it should be incorporated. I would personally use it for as short of durations as possible, just enough to satisfy her. If you had used US for 30 min and then had her go home afterwards, I believe that would be less-ethically sound decision. But you used the US to gain rapport with the patient and for buy-in to do other more research-backed treatments.

I like what you said about you treating a patient, not a population. That is something that is easy to forget, especially when trying to apply research into practice

Katie,
I am glad I’m not the only one who suffers from all of my patients wanting to see AJ! I like your point about patient values/expectations being as critical in their care as the other two tiers. That is something that is east to lose sight of, especially now as I am focusing more-so on improving with gaining clinical experience and using current literature in my practice.

Matt,
Your scenario is also very interesting, because not only does it effect the patient’s care, but it effects the success of the business. I’m surprised that the physician is so adamant about the patient receiving US. I’m wondering if it would be rude to send him a research article or two to update him on the current evidence. Is it common in your setting to have physicians as involved as that one is in your care and treatment of your patients?

[Erik Kreil]

I’ve treated an otherwise healthy 13yo boy who c/o mid-TS pain when sitting for an extended period of time at school (homeschool). His mother (and homeschool teacher) exclusively came to my clinic because we were the only clinic in the area that still had an US machine… She would define his pain for him, and even when he would answer me she would follow up with her own answer that often contradicted his response. Ultimately, I had a private meeting with the mom and explained that her son’s responses were more valuable to guiding my treatment than her own. Fortunately, she responded well enough to a brief demonstration and explanation of the current research to settle down at least long enough for me to show improvements if we did treatment my way.

[Myra Pumphrey]

A.J. Thanks for the post! Have I ever seen a pt. like this before? Ha! :-) First, I would say, by retrospective reassessment, you definitely made the right choice since the patient is so much better! I believe your skills in paralleling with the patient by listening to her intuition/values/beliefs were a positive factor in her progress.

Having said that, I hate it when this happens and find the situation very difficult to navigate. #1, there is always that terrible feeling that you get when you physically are the one rolling that U.S. down the hall to a room. Secondly, these patients are such a project, I hate spending time with them doing something that I would not have even considered in their treatment plan w/o their insistence.

I like that you made the deal with the patient, ultrasound AND active treatment. Also, when in this situation, besides discussing the questionable benefit of ultrasound, I also discuss that when you have pain in multiple places, you want to put emphasis on strategies that benefit you more globally….that is one of several arguments I would make for exercise. I might have even picked out something else that she believes in that has a benefit for her whole body and give her positive reinforcement for that, like the anti-inflammatory diet (I would not go down the supplement road with her), while nudging her away from the ultrasound.

I would not use ultrasound unless there is a specific finding that I am treating (ex:
hypertonicity in a specific muscle, or other pertinent finding – I am sure she has plenty to offer). The other thing I do is use assess/reassess to help to compare the benefit of ultrasound versus other treatments. Often, the patient will ‘discover’ that other treatments are more beneficial from the reassess if I don’t directly tell them that I am rechecking a movement or test to test the benefit of the ultrasound. In other words, I reassess a movement after ultrasound, then after exercise, then discuss/compare the results, trying to avoid the placebo influence. I love it when you can turn these patients to trust your clinical reasoning by discussing your examination findings related to their complaints and using assess/reassess, rather than continuing to try to tell you what will make them better. Lastly, I do state my limit on the first or second visit. I tell them that I phase out ultrasound after 3-4 visits, stating whatever reason that I think will make the most sense to the patient.

[Kyle Feldman]

AJ and Myra

I love hearing your clinical experience with this patient population. As newer grads it is hard to know what to do without multiple experiences with this population.

I am starting to learn better strategies with lots of trial and error.

The best part of residency is learning from mentors and learning from your own mistakes and patient experiences.

Thanks for the post!

Kyle

[Author]

Posts