Patients refusing their occupational therapy can be one of the most challenging aspects of being an OT or COTA. We are constantly under pressure from the higher-ups to get our units in and maintain productivity.
As a new OT, you may not be sure exactly how to make a call when you’re in this situation. At what level of refusal is the patient just being tentative vs. when should you accept that it’s not going to happen?
So how do you manage this?
First, we have to find out why the person is refusing. Oftentimes it’s because they are legitimately sick, exhausted from multiple appointments before you, or they’re in pain and just not feeling rehab today.
In these cases, who can blame them for not feeling up to it? While you might be pressured to, it would be unethical to try to “force” them (or any patient for that matter) to participate in rehab. Rather, we should help by notifying nursing, their physician, and other therapists if there is something medical they may be unaware of.
Even the smallest of symptoms can be an indicator of something bigger, so even if you don’t get your time in, always notify nursing.
In the majority of these cases, I do like to check back later in the day to see if they’re feeling better do something easy. About 75% of the time, coming back later in the day when the patient has had time to rest provides the patient more willingness to work with me.
And then… there are the other types of refusals.
The even more challenging ones.
There are times when the patient is being stubborn and refusing over and over and it is due to a wide variety of reasons. This could be due to behavioral, psychological, or cognitive reasons.
The fact that they bounce around with many different excuses makes it hard to talk them through one particular thing. They may not necessarily be responding to logical reason at the moment.
We’ve all had these patients that want absolutely nothing to do with rehab or you. Working with these patients makes it difficult for clinicians since we have to get our minutes and achieve productivity.
So what to do in this predicament?
First off, remember what you learned in Ethics class. It would, of course, be unethical to force anyone to participate when they keep saying “No.”
Everyone has a right to refuse therapy.
However, if the refusals are due to behavioral or cognitive issues, there may be ways to work with these patients and provide them the therapy they need.
In order to assist in this, you learn to get creative and obtain positive outcomes. Next, you’ll see some of the ways I turn those challenging refusals into ongoing beneficial sessions.
How to Turn a Refusal Around
Method #1: Building Therapeutic Rapport
The majority of my more difficult patient refusals almost always come in the beginning of treatment, when the patient does not know me or know the reasoning behind why they will benefit from therapy.
I make it a point every session to always:
- Introduce myself and
- Discuss treatment ideas based on their deficits.
I like to give them a choice of what they would like to work on to give them a more empowering feeling. With each activity, I explain how it will benefit them.
- “These chair push-ups will make standing up easier for you.”
- “Working on your lower body dressing yourself will help you become more independent.”
Method #2: Focus on Why Occupational Therapy is Helpful
I also like to bring up the purpose of occupational therapy in an easy-to-understand manner. Many patients are surprisingly unaware of what it is, even after getting doctor’s orders. At the same time, I will go over their individual goals with them so they have a target to work toward.
I provide a lot of verbal encouragement and praise to ensure the patient feels safe throughout the session. When working with dementia, I will sometimes approach the person as more of an easy-going, calm “helper” versus a hard-core, authoritative drill-sergeant-esque therapist.
I find that I can get a lot more accomplished in this manner without making the patient feel uncomfortable or fearful.
I always make sure to listen to each patient. I let them vent about whatever is frustrating them while showing my support.
As your patient’s OT, you may be the only person they have to talk to, so providing them with empathy and understanding can go a long way.
Method #3: Bringing Function Into the Session
If you’re an 85 year old woman with dementia who is frail and may not have done therapy or exercise in years, how would you feel if you were suddenly told it was time to lift weights or get on a NuStep?
You would most likely refuse that in an instant.
I’m not saying exercise isn’t important, but starting off with functional activities that the patient wants to do goes a long way.
Activities like organizing the closet (UE ROM, functional reaching!), reminiscing about pictures while standing (building up standing tolerance!), and going for a walk outside for some fresh air (community mobility, dynamic balance and activity tolerance retraining!) can be excellent ways to encourage engagement in therapy.
Even just asking the patient if they need to use the bathroom is a great way to address goals. In fact, toileting is almost always my first go-to activity in these situations since everyone has to do this.
Method #4: Reduce Therapy Time
Many of your patients that are refusing may benefit from shortened, 20-30 minute sessions. You can see them for their additional time later in the day, and/or discuss with your supervisor that they will benefit from a lower minutes category and just see them once a day with the shortened time.
Of course it may take some back and forth with this (ugh), but hopefully your supervisor will get the picture when you continually discuss the challenges you may be having with the patient.
Additional “Quick Tips”
Don’t be afraid to ask family or caregivers what your patient enjoys most or what they will benefit from most and add that activity into your sessions.
Asking about past routines, careers and hobbies can really help to incorporate meaningful activity and reduce refusals.
I have also learned that asking questions like, “Would you like to get up and stretch your legs?” can be met with a resounding “No,” versus phrasing it like, “Okay Mrs. Smith, we’re going to get up now” (nicely) has better results and makes it easier to encourage your patient to get up and get ready to go.
For more tips on working with patient refusals, also be sure to check out this quick reference guide, Tips of the Trade to Overcoming Patient Refusals from SeniorsFlourish.com.
When Everything Else Fails
After you, nursing, doctors, and other therapists have tried everything from checking symptoms, incorporating caregivers, educating the patient on the benefits of therapy until you’re blue in the face and nothing helps, it might be time to call it quits.
Each facility has different policies on this, but in my experience I’ve seen that continuous (more than three) refusals in a row can lead to terminating therapy services.
This is a much safer of an option for you and your license than wracking up unskilled minutes trying to encourage participation day in and day out.
This is really tough as therapists since we will wonder if we did all we could and got nothing accomplished with the patient.
Unfortunately, it happens.
When this does occur, I educate the primary caregivers as much as I can to prepare the patient and caregivers for their discharge, in the case that may be necessary.
I would love to hear from you all in the comments below any other tips you may have from working with these types of patients.
Have any of these suggestions worked for you? Not worked? Tell me all about it!
This is a very helpful topic! I find it interesting how it varies across settings. I found in acute care that rescheduling was a major part of the job because patients were unable to participate in therapy or refused so much, which made it even more important to check in with the patient to get OT in because OT might be the only thing that gets them moving and out of bed. Yet in acute rehab, the lack of flexibility makes refusals difficult to deal with. However, I just had a patient that was constantly vomiting for 2 days. No therapists could get minutes in, but with OT I was able to use the opportunity to brush teeth and wash up with a cold wash cloth which the patient appreciated! I’m interested in what other settings do like OP, SNFs, or Homehealth?
How do you document your plan when a patient refuses? Do you just state that they refused treatment and you will meet with the care team to discuss?
-Kendell Blunden, OTA-S
In my personal experience, most facilities have a type of wording they “like” to use when a patient refuses, so I would check with your management and/or CI on how they prefer you document this to play it safe 🙂