From Persuasion to Coercion: Responding to the Reluctant Patient in Rehabilitation

Abstract

AbstractEarly mobilization of patients while in hospital has been demonstrated to provide better outcomes for patients and use fewer resources. Physical therapy–based rehabilitation is central to achieving those goals. Successful rehabilitation requires that patient's and therapist's goals align, and this is commonly the case. However, occasionally, physical therapists will come across patients who are competent but reluctant to mobilize. This situation leaves the physical therapist in an ethical quandary: either accept the patient's right to refuse proposed treatment or utilize other strategies to encourage the patient to adhere to treatment. Practically, physical therapists will use a range of treatment pressures, including persuasion, offering incentives, inducements, possibly threatening or coercing, and even explicitly overriding the patient's wishes (compulsion). Deciding which treatment pressure is ethically acceptable involves the physical therapist balancing his or her therapeutic view of what is in a patient's best interests against the therapist's ethical responsibility to respect patient autonomy. This article evaluates some common strategies used by physical therapists to influence, persuade, or perhaps pressure patients to adhere to rehabilitation. The work of Szmukler and Appelbaum is utilized in analyzing treatment pressures. The authors conclude that there is a spectrum of treatment pressures, with some (persuasion and incentives) being more acceptable than others (threats and compulsion). As physical therapists balance health system pressures for rapid turnover of beds with obligations to benefit patients within limited reimbursement models, while respecting the patients' autonomy, they must be mindful of the effects of treatment pressure on patient care.