When to discharge?

On my last placement I was treating an elderly man who was 5 years post stroke – (R) MCA. He had been receiving physio at the centre for the past few months (after being referred from elsewhere) and was seeing a mixture of different physiotherapists or students each time. His impairments included:

- Increase (L) sided UL and LL tone
- No activation of (L) UL or LL (below knee) muscles
- (L) sided neglect
- Abnormal gait pattern

This man had had very little recovery of movement in the past few years even with weekly physio since his stroke. During one of my treatment sessions with him, he told me that he knew that he wasn’t getting any further recovery and that he hadn’t completed his HEP in years (even though he told the senior physio he did it daily). He said he knew he would never improve further or if he did the gains would be insignificant. The only reason he continued with physiotherapy was to get out of the house and talk with some younger people.

I told the senior physiotherapist this and that in my opinion this patient should be discharged and referred to a community program so that he could still get the social benefits. The physiotherapist however said that any improvement is worthwhile and that if he still enjoys physio he should still be treated there.

This raised issues with me of how to know when to discharge a patient who has had a stroke several years ago. I know that some people experience recovery many years post-stroke so when do you say that that particular patient has achieved as much as they can and therefore discharge them? I still fail to see how providing physio to this man is an efficient use of public health services as he has not seen improvements in years and is not actively trying to work on his recovery at home. I suppose it just takes experience to see when it is best to discharge each patient and to assess if they can receive help from a community program.