This column, written by 2014 Doctor of Physical Therapy graduate Dan Kelleher, originally was published in the November 19, 2015 issue of Massachusetts General Hospital’s Caring Headlines. Kelleher is a staff physical therapist at the hospital.
My name is Dan Kelleher, and I am a staff physical therapist. Mrs. R was an 82-year-old woman who was admitted to the Ellison 11 Cardiac Unit for a work-up on her mitral valve. The hope was that she’d be a candidate for mitral-valve-replacement surgery or the less invasive mitral-clip insertion to help manage her symptoms. Six months prior to being admitted, Mrs. R was doing well in the community. She prided herself on being independent. She was able to perform all her activities of daily living independently, she ambulated without assistive devices, and she lived with a loving and caring husband.
When I first met Mrs. R, she had a great deal of strength and motivation. She was excited that MGH might be able to help manage her heart condition. She was looking forward to having the procedure so she could get back to her normal life. Mrs. R and I became fast friends. Working with her taught me a lot about patient-centered care and the importance of listening to patients’ goals.
Mrs. R’s initial evaluation included monitoring her vital signs at rest and with activity, obtaining a social history, and observing her gait, balance, strength, and range of motion. At 82, she had been mobilizing well until just recently. She told me she lived with her husband, to whom she’d been married for almost 62 years. They had met when they both served in the Navy during the Korean War.
Their anniversary was coming up next month. Mrs. R said one of her favorite things was to go dancing. She and her husband still went dancing every Friday night. She had a picture of the two of them on their wedding day, a picture of them at a dance on their 61st anniversary, and a picture of Mrs. R in her 20s lined up with several other dancers. She had danced with a famous New York City dance troupe when she was younger.
When I asked what her goals for physical therapy were, she said she wanted to be able to dance again. Clearly, this woman loved to dance and was highly motivated to work with me to improve her strength and endurance. As I conducted my evaluation, I discovered that Mrs. R was weaker than her baseline strength assessment, and she easily became short of breath. I suggested using a walker to help with both balance and energy-conservation. We worked on progressing her gait and lower-extremity strength, and I suggested she’d benefit from further therapy after discharge. I worked with Mrs. R over the next several weeks as she prepared for potential cardiac surgery.
About a week into her stay, doctor’s notes indicated that mitral-valve-replacement surgery would not be an option for Mrs. R as she most likely wouldn’t be able to survive a sternotomy. The team favored the less invasive, mitral-clip insertion, which can be performed via catheter through the femoral artery. So Mrs. R began a work-up for mitral-clip insertion.
Over the next week or two, Mrs. R began to decline functionally. She couldn’t ambulate nearly as far as she’d previously been able to, and she required supplemental oxygen. She was weaker and more frail. Soon, she needed to be placed on dialysis when her kidneys began to fail. I knew she was dying. Mrs. R remained motivated throughout all our sessions. She loved to tell me stories about her and her husband, about how they met, and how much in love they were.
Mr. and Mrs. R’s 62nd wedding anniversary was approaching. She told me her husband often gave her jewelry, but she wasn’t interested in jewelry this year. All she wanted was to be able to dance with her husband one more time. On the day of their anniversary, Mr. R gave Mrs. R a beautiful diamond ring. She loved the ring, of course, but felt a diamond was for other people to look at and enjoy—Mrs. R valued her husband’s love more than any material gift.
One day Mrs. R asked me if I was in love with anyone. I told her I had a girlfriend whom I loved. She asked if we ever went dancing, and I said we didn’t; I wasn’t much of a dancer. She told me I should take lessons and get into ballroom dancing, it was one of her favorite things to do with her husband. Mrs. R’s medical condition continued to worsen. She was only able to ambulate a short distance with the use of a walker, stopping frequently to rest. She had fallen trying to get out of her chair unassisted. I kept thinking about how I could make Mrs. R happy, what I could do to give her hope. She was becoming more and more discouraged.
I went back to her goals; she wanted to be able to dance again. I had never danced before. But I knew it would be an activity I could try with Mrs. R that would challenge her balance, posture, endurance, and strength. And I knew it would motivate her. So I suggested we try dancing as part of our therapy sessions. She was beyond excited! She quickly began to teach me how to ballroom dance. As I danced with her, I noticed she required physical assistance to maintain an upright posture, she moved slowly and was off balance. I could see how dancing could help us work on some of her physical impairments.
Every time I danced with Mrs. R, she’d tell me I was too stiff, that I needed to ‘flow’ more. I saw how dancing allowed her to feel less like a patient and more like a person. She was doing something she wanted to do and at the same time seeing some improvement in her static and dynamic balance.
Unfortunately, from a medical perspective, Mrs. R remained on a gradual decline. The team was unable to perform the mitral-clip procedure due to her worsening clinical status. Palliative care was consulted, and ultimately she was set to be discharged home with hospice care. I had known this was coming, as I’d seen her decline rapidly over the past month. When I went to see her for our last treatment session, she told me she knew she was going to die and she’d made peace with that. She was more worried about her husband who, she said, wasn’t ready to see her go. She thanked me for helping her to do the things she wanted to do most, and for truly listening to her. She gave me a big hug and kiss and told me to, “Keep dancing.”
I learned that Mrs. R died at home two weeks later. I don’t think I’ve ever had such a strong emotional connection to a patient before. I cried when I heard the news. Working with Mrs. R reminded me why I love being a physical therapist. The impact she had on me as a clinician is truly what being a physical therapist is all about. Every patient has a goal. Paying attention to that goal can make all the difference in that patient’s quality of life, even when the outcome may not be the one we’re hoping for.