Right from the beginning of my professional career, it was very clear for me that the patient had to occupy centre stage. As I practised medicine, I understood that this preference had to be translated into practical choices, which were sometimes small but nonetheless fundamental.
The first consultation is very important for me in rehabilitation. I try to listen to the patient properly, to understand how he or she understands the illness or incapacity, how the patient lives with it, his expectations and how much motivation he has. Only after this am I able to plan with him a programme that is not standardised but made to measure to help him and motivate him to achieve possible objectives. I take into consideration his habits and comfort zone without wishing to impose my own criteria for well-being.
During the lengthy rehabilitation process, it is essential to keep his motivation going, to take on the patient’s burden and help him gradually take steps proportionate to his ability. It is essential to make him discover that each person is valuable and he too has a contribution to make to society.
I had a profound experience with a rather young patient. He was a professional driver and had an accident where he lost both legs. I found him crushed by the situation, he no longer wanted to do anything, and he was not interested in any other job. He only wanted to be discharged as soon as possible and have his invalidity recognised. We tried to motivate him without obtaining any result. As a team (composed of a psychologist, social worker, physiotherapist and myself), we decided to entrust him to the care of a physiotherapist who was not a member of our team. He had lost a leg and also used an artificial limb. They gradually built a relationship and together they managed to establish a rehabilitation programme that was acceptable to the patient.
I understood how important it is to listen to the person before speaking and to do this without making judgements as in the case of a patient who lost a foot in an accident. He had been driving while he was drunk. I tried to understand him deep down, listening while he was pouring out his sorrow, without immediately trying to cheer him up. Because of listening to him so intently, the patient trusted me and this allowed us to set up a treatment plan together.
When establishing a relationship with the patient, it is important to make him aware of his leading role. A drug dependent patient, still going through a detoxification programme, had a road accident where he sustained serious injuries with multiple widespread fractures. Rehabilitation seemed to be lengthy and difficult and even if he had begun the process with a lot of enthusiasm, it did not seem to be very realistic to me. He wanted to continue with detoxification therapy. As a team we set up a programme, giving attention to his need for analgesics (his pain threshold was very low), dosing the physiotherapy and trying to help him to constantly apply it, despite his opposition. Each time we tried to offer our guidance in his choices but never to force him. Some nurses created a personal relationship with him to such an extent that he was able to open up and to be prevented from relapsing into addiction. The psychologist regularly had sessions with him. Despite difficult moments, he managed to complete the detoxification programme and to accept his situation even if it was worse than expected as he ended up in a wheelchair. During his time with us, he managed to do sport and to take up hobbies. He basically found a way of life that satisfied him.
We try to improve the quality of life of patients as much as possible by keeping them in their own surroundings with community nurses, ongoing physiotherapy or even by adapting the home. This is the case of disabled servicemen and servicewomen, where we aim at deferring any move to a rest home. We seek to make them feel appreciated for what they have done for all of us.
Caring for patients requires due care to the environment and the family situation in which he lives. A young patient had a cerebral infarct. We noted progress on the physical side but there was persisting cognitive deficit of which he was unaware. He had a personality change and became impulsive, harsh and had problems with eating and communication. His wife was opposed to his discharge because she was afraid of her husband’s altered personality. She could hardly recognise him. Unresolved problems emerged. We had many interviews with the wife, explaining the illness to her and its consequences. We tried to find the best way for her to relate to him. We then planned a lengthy period of assistance, which included weekend home visits and weekly interviews with the couple. Even after discharge, the patient kept in constant contact with the centre and there was ongoing regular contact with the social worker to help stabilise his relationship.
Another aspect of my work is re-introducing patients into the working process and into a new position that is suitable for their new condition. I also assess people who have not worked for years or who have stated grounds of invalidity in order to re-evaluate their situations. It is important in this work not to be conditioned by external factors such as the patient’s appearance. Once we had a patient who had not worked for twenty years. He looked very neglected and dirty. Everyone advised me to send him away immediately and not to examine him. However, in order to treat him with dignity I went to look for some clean clothes for him that people sometimes donate and I asked the nurses to help him shower and to dress him with the clean clothes so that I could examine him afterwards. When he was ready, I saw him in my consulting room just like all the other patients. It was clear from the examination that he was not fit for work but at least we spoke to each other well and with respect.
Sometimes communication is the only means whereby we manage to help patients accept difficult situations that they consider unjust. The waiting lists for elective operations or the impossibility of having surgery because of co-existing morbidity are such examples.
by AINO MIRJAM INKERI KELO
