Lung compliance

On a particular cardiopulmonary placement I treated a memorable patient who had some issues with treatment compliance. The patient was in hospital for a number of problems including one that affected their mobility necessitating the use of a gait aid and one that required general (abdominal) surgery. By the end of my placement they had been in hospital for more than 5 weeks and were likely to require several more weeks before being transferred to a rehabilitation hospital. My role in their recovery was to provide chest physiotherapy following their surgery and encourage mobilisation around the ward to increase lower limb strength and fitness. This was no easy task.

The patient was quite capable of mobilising to the shower with their gait aid and one assist for attachments but refused to do so instead requiring the nurses to do a sponge bath each day. They were very particular about how everything was done and would frequently refuse to have bloods taken, do deep breathing exercises, sit up in bed, or use oxygen therapy (at one point SpO2 was 80%) unless it suited him/her at the time. Curtains must be drawn at all times throughout the day and blankets should be folded perfectly following treatment. When treatment was refused the patient would even dictate how it must be written- ‘patient declined treatment’ rather that ‘patient refused treatment.’

I knew from the first 10 seconds of meeting the patient that they would not be easy to treat and made an effort from the start to develop a good rapport with them. At first I would make an effort to explain exactly why we were doing each exercise and mobilising. Unfortunately the patient would agree with me that the exercises were important but promptly refuse to do them anyway. Next I tried being firm with him/her and telling them that it was about time they got serious about getting better and started listening to advice. This was made easier because they had developed a lung infection (too much immobility and resting in bed???) but still resulted in treatment being refused on more occasions than it was complied with.

I finally came across a system that seemed to work. I would see the patient early in the morning and when they refused to mobilise I would make an agreement with them to come back in the afternoon and we could walk then. This seemed to work most of the time and my fondest memory of the placement was pulling back the curtains only to find the patient sitting on the edge of the bed doing their deep breathing exercises and some knee extension exercises.

Throughout all of the time I treated the patient I tried to act in a way they he/she couldn’t dislike me and I think this was key to maximising their compliance with treatment. I would also attempt to joke as much as possible with them and try to be interested in them as a person and I think this was appreciated. I guess the most important thing I learnt is that all patients are different and need to be treated in different ways to maximise their outcome. This particular patient was definitely a challenge but the greater the challenge the better the reward and I savoured the times when treatment compliance was successful.