Patient Autonomy and Refusal of Physical Therapy in a CMO Patient
A patient who is CMO (comfort measures only) has the absolute right to refuse physical therapy, and this decision must be respected by healthcare providers. 1, 2 This is a fundamental principle of patient autonomy in medical decision-making, which is legally and ethically protected.
Understanding Patient Autonomy in Medical Decision-Making
When a patient has been designated as CMO, their care priorities shift toward comfort and quality of life rather than curative or rehabilitative interventions. In this context:
- An adult patient with decision-making capacity has the legal and ethical right to refuse any medical treatment, including physical therapy 1
- This right extends to withdrawing consent at any time, even during an ongoing intervention 1
- Healthcare providers are obligated to respect these decisions, except in very limited circumstances (such as when treatment relates to a mental disorder as defined by mental health legislation) 1
Assessing Decision-Making Capacity
Before accepting a patient's refusal of physical therapy, it's important to ensure they have capacity to make this decision:
- The patient should be able to understand information about physical therapy
- They should appreciate the consequences of refusing therapy
- They should be able to communicate their decision
- Their decision should be consistent with their values and goals of care 2
If capacity is in question, a formal assessment may be needed, potentially involving psychiatric or neurological consultation 1.
When a Patient Lacks Capacity
If a patient lacks capacity to make decisions:
- The decision must be made in their best interests 1
- Consider any previously expressed wishes, including advance directives 1
- Consult with legally appointed representatives (e.g., those with Lasting Power of Attorney) 1
- Take into account the views of family members and others involved in the patient's care 1
- Any intervention should be the least restrictive of the person's freedom 1
Documentation Requirements
When a patient refuses physical therapy, thorough documentation is essential:
- Record the patient's refusal
- Document the explanation of potential consequences provided to the patient
- Note the patient's stated reasons for refusal
- Include your assessment of their decision-making capacity
- Document any compromise or alternative plan discussed 2
Addressing Common Concerns
Patients may refuse physical therapy for various reasons:
- Pain or discomfort concerns: Discuss pain management options
- Privacy issues: Explain confidentiality protections
- Religious or cultural objections: Explore modified approaches
- Misunderstanding of purpose: Provide clear information about goals of therapy 2, 3
Continuing Care Despite Refusal
It's important to maintain the therapeutic relationship even when a patient refuses a specific intervention:
- Do not dismiss patients from care because they refuse physical therapy
- Continue to provide other aspects of care
- Avoid making patients feel judged for their decision
- Don't assume refusal of physical therapy means the patient doesn't want any care 2
Special Considerations for CMO Patients
For patients designated as CMO:
- Focus on comfort and quality of life rather than rehabilitation goals 2
- Consider whether physical therapy aligns with the patient's goals of care
- Recognize that reduced interventions may be appropriate to prioritize comfort 2
- Physical therapy may still have a role in symptom management (e.g., positioning for comfort, breathing techniques) if the patient consents
Conclusion
While physical therapy can provide benefits for many patients, including those with critical illness 4, the principle of patient autonomy is paramount. Healthcare providers must respect a CMO patient's right to refuse physical therapy, focusing instead on providing care that aligns with the patient's expressed wishes and comfort goals.