Re: [OTlist] Client without goals

Fri, 31 Oct 2008 05:59:07 -0700

I recently had this discussion with a good friend here who does home health. She had a patient that was very similar as far as not being able to identify goals. Her pt had a very flat affect and didn't do anything other than move from her bed to her couch during the day and occasionally get up to go to the kitchen for some snack food or similar that she just had to grab and eat.
The referral actually got to home health because the lady had a shoulder arthroplasty done. However, when my friend did the evaluation, this lady was able to do all of her basic ADLs and even some IADLS in her home. PT was also on the case and was addressing the specifics of range and exercise for the shoulder. The first thought was that there were not really OT goals. My friend wasn't totally comfortable with this, and I'm sure that was, at least in part, because my friend does have some background working in mental health. 


She talked with the pt who agreed to have her come back to "check" on  
her. On the next visit, they talked about depression and how having a  
schedule of doing things during the day can help alleviate symptoms.  
They made a very simple plan/schedule for the pt to begin following  
each day with just 3-5 activities scheduled throughout the day. Simple  
things like getting dressed instead of staying in pajamas, brushing  
her hair and teeth, making a sandwich or microwave meal for lunch,  
stepping out into the front or backyard once or twice a day, etc.



On just 1-2 follow-up visits, the pt was actually doing the things  
they scheduled and said she was feeling better and even smiled. The  
smile was huge because during the evaluation, the pt had an absolutely  
flat affect and showed no emotion the whole time. She was able to  
verbalize that she could understand why getting up for activities  
during the day made a difference in how she feels.



Now, of course, we don't know if she will continue to do those things  
when no one is "checking", but I think the OT intervention was valid  
and meaningful even though the pt could not initially verbalize goals.  
Certainly, a recommendation was given to the HH agency and physician  
that a pscyh referral would be a good idea. My friend did a lot of  
education regarding depression and basic things that the pt can do  
around her home to combat the depression.



What do y'all think? Was this appropriate US medical model home health  
OT intervention?

Sorry for being long-winded,
Mary Alice

Mary Alice Cafiero, MSOT/L, ATP
[EMAIL PROTECTED]
972-757-3733
Fax 888-708-8683


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On Oct 31, 2008, at 12:59 AM, FAY, Felicity wrote:



Hi there, I'm a Mental Health OT from Australia and work with clients
who find it difficult to engage and identify their goals daily.
Sometimes just engaging with the person and building rapport for a
couple of sessions is enough for them to feel safe to work with you on
re-engaging and devising personal goals that require some level of

functional ability: thereby making physical therapy more meaningful  
(?).



Occupational dysfunction often occurs previous ability, stability)
across many domains due to depression, poor motivation, grief (loss of
pet) and other mental health issues, in addition to aging and loss of
general function.  A good general screen is the DASS (Depression,
Anxiety and Stress Scale) to inform treatment, or maybe a cognitive
screen to ascertain whether she is able to formulate appropriate goals
due to low mood and requires more support to identify them?  Perhaps
there are some personality vulnerabilities present that compound her

current presentation of "rejecting" (or testing) you, then wanting  
more

input.


If her goal of being "normal" is strongly held then assistance to  
manage
depression symptoms and education re same may assist her to return  
to a

state that is more comfortable for her?  I'm not sure how your system
works or whether there is provision for OT's to work in this way?

Felicity Fay
Mental Health Occupational Therapist

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Today's Topics:

  1. Re: D/C'd Patient For Lack of Goals (McLaughlin, Jennifer)
  2. Re: Best Practice (Ron Carson)
  3. Re: D/C'd Patient For Lack of Goals (Ron Carson)
  4. Re: D/C'd Patient For Lack of Goals (Joan Riches)
  5. Re: D/C'd Patient For Lack of Goals (Ron Carson)


----------------------------------------------------------------------

Message: 1
Date: Thu, 30 Oct 2008 11:39:15 -0400
From: "McLaughlin, Jennifer" <[EMAIL PROTECTED]>
Subject: Re: [OTlist] D/C'd Patient For Lack of Goals
To: <[email protected]>
Message-ID:
        <[EMAIL PROTECTED]>
Content-Type: text/plain;       charset="us-ascii"

Possibly a referral for depression screening or treatment.  Sounds
fairly typical with lack of engagement and participation in daily
occupations.  If she is unable to identify goals she may need medical
assistance to get to a place to be able to identify goals.
Just my humble thoughts.
Jennifer McLaughlin, OT/L
Geriatric Rehab specialist
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------------------------------

Message: 2
Date: Thu, 30 Oct 2008 20:05:12 -0400
From: Ron Carson <[EMAIL PROTECTED]>
Subject: Re: [OTlist] Best Practice
To: "[EMAIL PROTECTED]" <[email protected]>
Message-ID: <[EMAIL PROTECTED]>
Content-Type: text/plain; charset=utf-8

Chris, I'm going to reply, but I need to take a break ...

Ron
--
Ron Carson MHS, OT

----- Original Message -----
From: [EMAIL PROTECTED] <[EMAIL PROTECTED]>
Sent: Wednesday, October 29, 2008
To:   [email protected] <[email protected]>
Subj: [OTlist] Best Practice


Ron>> And,  I  do not think? a? therapist? can? mentally? switch?  
from?
Ron>> component?  level?  to  occupation?  level?  treatment. Maybe  
I'm

Ron>> wrong, but I think it's one or the other.


cac> But  in  your  case  study  you  are switching back and forth  
from

the
cac> component  level  to  eventually  the  occupational  level.?
Standing
cac> tolerance=component   level   (cardiovasular,  quad  strength,
static
cac> standing  balance).?  Ambulation=componet  level (cardiovascular,
quad
cac> strength   both   concentric   and   eccentric  contractions,
dynamic
cac> balance).?  All  of  this  was  leading  to  the individual's
personal
cac> occupational goal.

cac> In  my  case  study  I was switching back and forth from the
component
cac> level  to  eventually  the  occupational  level.?  Estim  to the
digit

cac> extensors=component  level  (facilitation  of  the  neural   
pathway

to
cac> enhance neuroplasticity which in turn leads to digit extensor
strength
cac> and  control).?  All  of  this  leading?  to the individual's
personal
cac> occupational goal.

cac> Chris Nahrwold MS, OTR






cac> --
cac> Options?
cac> www.otnow.com/mailman/options/otlist_otnow.com

cac> Archive?
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------------------------------

Message: 3
Date: Thu, 30 Oct 2008 20:10:08 -0400
From: Ron Carson <[EMAIL PROTECTED]>
Subject: Re: [OTlist] D/C'd Patient For Lack of Goals
To: Joan Riches <[email protected]>
Message-ID: <[EMAIL PROTECTED]>
Content-Type: text/plain; charset=windows-1252

Thanks  Joan and Jennifer:

Because the patient is on HH, she is already
receiving  a  plethora of services; everything from social worker, RN,
aide to PT.

You  know  the  question  of  "why"  was never answered, either by the
patient,  her family or myself. When I earlier mentioned mind mapping,
it was because of this patient.

I  think  something  psychiatrically happened to her but she refuse my
suggestion for a psych eval.

One of the things that was even odder and leads me to think that maybe
"I"  was  the problem is that the patient was doing well in PT and she
took  a  bathe  with  the  assistance  of the aide. But, I swear, this
patient  would  NOT  verbalize  wanting to do anything on her own. The
only thing she said, especially in the beginning is that she wanted to
be "normal".

Ron
--
Ron Carson MHS, OT

----- Original Message -----
From: Joan Riches <[EMAIL PROTECTED]>
Sent: Thursday, October 30, 2008
To:   [email protected] <[email protected]>
Subj: [OTlist] D/C'd Patient For Lack of Goals

JR> Ron
JR> In a case like this I think that an OT eval may be the most
effective
JR> part of our offering. I am left with the question, "What referrals
have

JR> you offered to this family?" You have gathered valuable  
information.
JR> This is certainly an extreme case of occupational dysfunction  
due to

JR> ......what??
JR> If you have read English novels you may have run across similar
JR> descriptions of 'invalid' (emphasis on the first syllable) upper
class
JR> women. It is an interesting brain twig to then put the emphasis on
the
JR> second syllable. Thanks for all the brain twigs now and in the
future.

JR> Joan Riches B.Sc.O.T., OT(C)
JR> Specialist in Cognitive Disability
JR> Riches Consulting
JR> High River, Alberta, Canada
JR> 403 652 7928


JR> -----Original Message-----

JR> From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]  
On

JR> Behalf Of Ron Carson
JR> Sent: October 30, 2008 7:08 AM
JR> To: [email protected]
JR> Subject: [OTlist] D/C'd Patient For Lack of Goals


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

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

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

JR> At  the  end  of  my  second visit, I indicated that I was d/c'ing
the
JR> patient  for lack of goals. The patient was OK with it but the
husband
JR> talked  and  asked  me  to stay on. After a long conversation with
the
JR> patient, one in which I was apparently "mean", the patient agreed
that

JR> she wanted me to come back. So, I signed her up for 5x/week  
therapy.


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

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

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

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

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

JR> Thanks,

JR> Ron





------------------------------

Message: 4
Date: Thu, 30 Oct 2008 19:04:50 -0600
From: "Joan Riches" <[EMAIL PROTECTED]>
Subject: Re: [OTlist] D/C'd Patient For Lack of Goals
To: <[email protected]>
Message-ID: <[EMAIL PROTECTED]>
Content-Type: text/plain;       charset="us-ascii"

So work at not feeling so badly, Ron. Have you never heard the saying

'when all else fails refer to OT'. Because with all our angst about  
not
being appreciated lots of folks know that OT expertise means we do  
make
a difference many times when 'the others' were stumped. Sounds like  
you

were a sacrificial lamb in this case. The fact that you are suffering

because you worry about not helping this woman shows what a good OT  
you

are.

Special blessings, Joan

-----Original Message-----
From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On
Behalf Of Ron Carson
Sent: October 30, 2008 6:10 PM
To: Joan Riches
Subject: Re: [OTlist] D/C'd Patient For Lack of Goals


Thanks  Joan and Jennifer:

Because the patient is on HH, she is already
receiving  a  plethora of services; everything from social worker, RN,
aide to PT.

You  know  the  question  of  "why"  was never answered, either by the
patient,  her family or myself. When I earlier mentioned mind mapping,
it was because of this patient.

I  think  something  psychiatrically happened to her but she refuse my
suggestion for a psych eval.

One of the things that was even odder and leads me to think that maybe
"I"  was  the problem is that the patient was doing well in PT and she
took  a  bathe  with  the  assistance  of the aide. But, I swear, this
patient  would  NOT  verbalize  wanting to do anything on her own. The
only thing she said, especially in the beginning is that she wanted to
be "normal".

Ron
--
Ron Carson MHS, OT

----- Original Message -----
From: Joan Riches <[EMAIL PROTECTED]>
Sent: Thursday, October 30, 2008
To:   [email protected] <[email protected]>
Subj: [OTlist] D/C'd Patient For Lack of Goals

JR> Ron
JR> In a case like this I think that an OT eval may be the most
effective
JR> part of our offering. I am left with the question, "What referrals
have

JR> you offered to this family?" You have gathered valuable  
information.
JR> This is certainly an extreme case of occupational dysfunction  
due to

JR> ......what??
JR> If you have read English novels you may have run across similar
JR> descriptions of 'invalid' (emphasis on the first syllable) upper
class
JR> women. It is an interesting brain twig to then put the emphasis on
the
JR> second syllable. Thanks for all the brain twigs now and in the
future.

JR> Joan Riches B.Sc.O.T., OT(C)
JR> Specialist in Cognitive Disability
JR> Riches Consulting
JR> High River, Alberta, Canada
JR> 403 652 7928


JR> -----Original Message-----

JR> From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]  
On

JR> Behalf Of Ron Carson
JR> Sent: October 30, 2008 7:08 AM
JR> To: [email protected]
JR> Subject: [OTlist] D/C'd Patient For Lack of Goals


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

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

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

JR> At  the  end  of  my  second visit, I indicated that I was d/c'ing
the
JR> patient  for lack of goals. The patient was OK with it but the
husband
JR> talked  and  asked  me  to stay on. After a long conversation with
the
JR> patient, one in which I was apparently "mean", the patient agreed
that

JR> she wanted me to come back. So, I signed her up for 5x/week  
therapy.


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

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

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

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

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

JR> Thanks,

JR> Ron



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------------------------------

Message: 5
Date: Thu, 30 Oct 2008 21:31:04 -0400
From: Ron Carson <[EMAIL PROTECTED]>
Subject: Re: [OTlist] D/C'd Patient For Lack of Goals
To: Joan Riches <[email protected]>
Message-ID: <[EMAIL PROTECTED]>
Content-Type: text/plain; charset=windows-1252


Joan  it  so funny you mention sacrificial lamb, because that's  
exactly

how  I felt. It seemed that no matter what, I could not "connect" with
the  patient.  But  in  the  end, we both agreed that OT had been very
helpful. The whole experience was just strange!

I like your saying! Here's one that I made up:

OT  -  the  Other  Therapy!  Sort  of  goes hand in the hand with your
statement!

Ron
--
Ron Carson MHS, OT

----- Original Message -----
From: Joan Riches <[EMAIL PROTECTED]>
Sent: Thursday, October 30, 2008
To:   [email protected] <[email protected]>
Subj: [OTlist] D/C'd Patient For Lack of Goals

JR> So work at not feeling so badly, Ron. Have you never heard the
saying

JR> 'when all else fails refer to OT'. Because with all our angst  
about

not
JR> being appreciated lots of folks know that OT expertise means we do
make

JR> a difference many times when 'the others' were stumped. Sounds  
like

you
JR> were a sacrificial lamb in this case. The fact that you are
suffering

JR> because you worry about not helping this woman shows what a good  
OT

you
JR> are.

JR> Special blessings, Joan






------------------------------

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