In this case, I probably would have written goals related to social 
participation and attempts to participate in such. I possibly have a pet owner 
visit the patient to encourage more participation in life's activities.
 
Just my two cents.
 
Audra Ray, OTR/L

--- On Thu, 10/30/08, Ron Carson <[EMAIL PROTECTED]> wrote:

From: Ron Carson <[EMAIL PROTECTED]>
Subject: [OTlist] D/C'd Patient For Lack of Goals
To: [email protected]
Date: Thursday, October 30, 2008, 6:07 AM

Yesterday,  I  d/c'd  a patient because she is unable to verbalize ANY
OT-related goals. It was a very strange and difficult case and I'm not
100%  comfortable  with  the d/c, but it seemed to be the best choice.
I'm VERY interested to hear others' opinions.

I  evaluated  a patient last week. Without going into a lot of detail,
the patient has mild arthritis, recently fell and had kyphoplasty. She
had  been  very  active  until  about  5 years ago when she
"suddenly"
became  very  sedentary. There assorted history and eval findings, but
this   is  basically  a  women  who  has  disengaged  from  life.  She
essentially lives on her couch and that's about it.

When  I evaled her last week, she was unable to identify ANY OT goals.
Against, my better judgement, I "made up" a couple goals and
scheduled
her for only two visits.

At  the  end  of  my  second visit, I indicated that I was d/c'ing the
patient  for lack of goals. The patient was OK with it but the husband
talked  and  asked  me  to stay on. After a long conversation with the
patient, one in which I was apparently "mean", the patient agreed
that
she wanted me to come back. So, I signed her up for 5x/week therapy.

On  the  next  visit,  I  was  told that the patient "did not like
me"
because I was mean. I promptly apologized to her, expressed my concern
and  methods  and asked for forgiveness, which she readily gave. After
that,  I again started talking about the patient's life and goals. Her
son  had  mentioned  that  the family had a pet that died and that was
sort  of  "the  beginning  of  the  end"  for the patient. The son
had
mentioned  possible  pet  ownership  which  I  followed up on, but the
patient denied wanting it.

I  came  back  two  more times, with each visit focused on identifying
goals. We did a mini life review but no matter what avenue I took, the
patient  denied  any  goals.  So,  I  reluctantly told her that in the
absence  of  goals,  d/c was the only option. She agreed and said she
was sad because she was "starting to like me".

She  and  I agreed that my time had not been wasted but that continued
visits would be a waste.

Without  doubt,  this  is  one of the hardest and strangest cases I've
ever  had. I've never met a person who was so unmotivated and yet able
to articulate the same.

I  know all the bases are not covered in this message but it hopefully
provides enough information to peak everyone's interest.

Thanks,

Ron
-- 
Ron Carson MHS, OT


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