PHYSIOTHERAPYPHYSIOTHERAPYININ

PALLIATIVE CAREPALLIATIVE CARE

Pauline Cerdor - PhysiotherapistPauline Cerdor - PhysiotherapistPalliative Care UnitPalliative Care UnitPeninsula HealthPeninsula Health

FrankstonFrankston

DEFINITIONDEFINITION

"care which provides coordinated medical, "care which provides coordinated medical, nursing and allied services for people who nursing and allied services for people who are terminally ill, delivered where possible in are terminally ill, delivered where possible in the environment of the person's choice, and the environment of the person's choice, and which provides physical, psychological, which provides physical, psychological, emotional and spiritual support for patients, emotional and spiritual support for patients, and support for patients' families and friends.and support for patients' families and friends.---- includes grief and bereavement support ---- includes grief and bereavement support for the family and other carers during the life for the family and other carers during the life of the patient and continuing after death.“of the patient and continuing after death.“(http://www.palliativecare.org.au)(http://www.palliativecare.org.au)

Palliative CarePalliative Care

“… “… the active, total care of patients the active, total care of patients whose disease no longer responds to whose disease no longer responds to curative treatment and for whom the goal curative treatment and for whom the goal must be the best quality of life for them must be the best quality of life for them and their families”. and their families”.

What do you let the patient tell you? by Barbara Martlew quoting from Lamerton, 1980 and Doyle, What do you let the patient tell you? by Barbara Martlew quoting from Lamerton, 1980 and Doyle, 1987.1987.

WHEREWHEREPalliative physiotherapy is found in:-Palliative physiotherapy is found in:- Specific palliative care wardsSpecific palliative care wards Nursing homesNursing homes General wardsGeneral wards Oncology wardsOncology wards Community rehabilitation (homes)Community rehabilitation (homes)

OBJECTIVES of TREATMENTOBJECTIVES of TREATMENT to be as free as possible from unnecessary to be as free as possible from unnecessary

suffering (physical, emotional or spiritual); suffering (physical, emotional or spiritual); to maintain patient’s dignity and to maintain patient’s dignity and

independence throughout the experience; independence throughout the experience; to be cared for in the environment of to be cared for in the environment of

choice; choice; to have patient’s grief needs recognised to have patient’s grief needs recognised

and responded to; and responded to; to be assured that families needs are also to be assured that families needs are also

being met. being met. (http://www.palliativecare.org.au)(http://www.palliativecare.org.au)

PHYSIOTHERAPYPHYSIOTHERAPY Physiotherapy in palliative care is orientated Physiotherapy in palliative care is orientated

to achieve the optimum quality of life as to achieve the optimum quality of life as perceived by the patient. perceived by the patient.

Wholistic & problem solving approach to Wholistic & problem solving approach to therapytherapy

Achieve maximum physical, psychological, Achieve maximum physical, psychological, social, vocational functionsocial, vocational function

Adapt traditional therapy to the patient’s Adapt traditional therapy to the patient’s changing functionchanging function

More beneficial if begins with diagnosis of More beneficial if begins with diagnosis of cancer and continues as required through the cancer and continues as required through the various stages --various stages --

preventative, restorative, supportive, palliativepreventative, restorative, supportive, palliative(Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical Therapists)(Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical Therapists)

PreventativePreventative

Aims at restricting or inhibiting the Aims at restricting or inhibiting the development of disability in the course of development of disability in the course of the disease or treatment before disability the disease or treatment before disability occursoccurs

Education for patient and families Education for patient and families commencing immediately after diagnosiscommencing immediately after diagnosis

Mobility and exercise programs.Mobility and exercise programs. Availability of therapist as a resource for Availability of therapist as a resource for

patients and familiespatients and families

(Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical Therapists)(Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical Therapists)

Restorative Restorative

Rehabilitation is the objective when no or Rehabilitation is the objective when no or little residual disability is anticipated for little residual disability is anticipated for some time and patients are expected to some time and patients are expected to return to normal living stylesreturn to normal living styles

Encouragement, education and treatment in Encouragement, education and treatment in achieving physical, work and lifestyle goalsachieving physical, work and lifestyle goals

Specific treatments as requiredSpecific treatments as required

(Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical Therapists)(Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical Therapists)

SupportiveSupportive

Enhance independent functioning when Enhance independent functioning when residual cancer is present and progressive residual cancer is present and progressive disability is probabledisability is probable

Encouragement, education and treatment Encouragement, education and treatment in achieving physical, work and lifestyle in achieving physical, work and lifestyle goalsgoals

Availability of therapist as a resourceAvailability of therapist as a resource

(Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical Therapists)(Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical Therapists)

PalliativePalliative

Primarily directed at promoting maximum Primarily directed at promoting maximum comfort comfort

Maintaining the highest level of function Maintaining the highest level of function possible in the face of disease progression possible in the face of disease progression and impending deathand impending death

(Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical (Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical Therapists)Therapists)

In BriefIn Brief

The Chartered Society of Physiotherapy www.csp.org.uk Page 8/43 Ref: EB 04 The Chartered Society of Physiotherapy www.csp.org.uk Page 8/43 Ref: EB 04

• • Prevent muscle shortening Prevent muscle shortening • • Prevent joint contractures Prevent joint contractures • • Influence pain control Influence pain control • • Optimise independence and Optimise independence and

function function • • Education and participation of the Education and participation of the

carer (Fulton and Else, 1997). carer (Fulton and Else, 1997).

Goal of PhysiotherapyGoal of Physiotherapy Determine the patient’s functional lossDetermine the patient’s functional loss Estimate functional potentialEstimate functional potential Implement a plan to progress from Implement a plan to progress from

measured loss to full potentialmeasured loss to full potential To improve quality of lifeTo improve quality of life To listen ‘actively and positively’ with an To listen ‘actively and positively’ with an

awareness of priorities as determined by awareness of priorities as determined by the patientthe patient

Achieve the best possible quality of life for Achieve the best possible quality of life for patients and their familiespatients and their families

Availability as a resource for patient and Availability as a resource for patient and familiesfamilies

Frost, M The Role of Physical, Occupational and Speech therapt in Hospice: Patient Empowerment. Frost, M The Role of Physical, Occupational and Speech therapt in Hospice: Patient Empowerment. 20012001

(Martlew, B. What do you let the patient tell you. 1996)(Martlew, B. What do you let the patient tell you. 1996) (wHO 1990)(wHO 1990)

AIM of Physiotherapy 1AIM of Physiotherapy 1 Assess and optimise the patient’s level of Assess and optimise the patient’s level of

physical function physical function Take into consideration the interplay Take into consideration the interplay

between the physical, psychological, social between the physical, psychological, social and vocational aspects of function and vocational aspects of function

Understand the patients underlying Understand the patients underlying emotional, pathological and psychological emotional, pathological and psychological condition, condition,

Focus is the physical and functional Focus is the physical and functional consequences of the disease and/or its consequences of the disease and/or its treatment, on the patient.treatment, on the patient.

Fulton and Else, 1997; p817 Fulton and Else, 1997; p817 Chartered Society of PhysiotherapyChartered Society of Physiotherapy

AIM of Physiotherapy 2AIM of Physiotherapy 2

Restore the patient’s sense of selfRestore the patient’s sense of self Facilitate and optimise the patient's ability Facilitate and optimise the patient's ability

to function with safety and independence to function with safety and independence in the face of diminishing resources. in the face of diminishing resources.

Maintain optimum respiratory & circulatory Maintain optimum respiratory & circulatory functionfunction

Listen to patientListen to patient Set realistic goals with the patientSet realistic goals with the patient

AIM OF PHYSIOTHERAPY 3AIM OF PHYSIOTHERAPY 3 Prevent muscle shortening & joint Prevent muscle shortening & joint

contractures contractures Influence pain control Influence pain control Educate in all aspects of physical functionEducate in all aspects of physical function Education and participation of the carer Education and participation of the carer Treat the patient with dignity – allowing Treat the patient with dignity – allowing

them to “live until they die”them to “live until they die” Build a relationship of confidence and Build a relationship of confidence and

trusttrust

(Fulton and Else, 1997 Chartered Society of Physiotherapy). (Fulton and Else, 1997 Chartered Society of Physiotherapy). (Purtilo, R. Don’t mention it: the physical therapist in a death defying society. 1972)(Purtilo, R. Don’t mention it: the physical therapist in a death defying society. 1972)

DIFFERENCES IN PALLIATIVE DIFFERENCES IN PALLIATIVE PHYSIOTHERAPY TREATMENTPHYSIOTHERAPY TREATMENT

Traditional physiotherapy treatments need Traditional physiotherapy treatments need to be modified to accommodate the irregular to be modified to accommodate the irregular changing needs of the patient changing needs of the patient

Treatments are brief often less than 10 Treatments are brief often less than 10 minutes and are repeated several times per minutes and are repeated several times per day if possibleday if possible

Frequent rests are requiredFrequent rests are required Patient’s status can change suddenly and Patient’s status can change suddenly and

rapidlyrapidly Requirement to balance ‘effort’ and ‘fatigue’Requirement to balance ‘effort’ and ‘fatigue’

Requirement to:-Requirement to:-- Monitor and respond appropriately to - Monitor and respond appropriately to

patient’s patient’s verbal & non-verbal expressions verbal & non-verbal expressions of painof pain

- Monitor patient very closely during and - Monitor patient very closely during and between treatmentsbetween treatments

Timely communication to/with other team Timely communication to/with other team members is particularly importantmembers is particularly important

Changes in patients statusChanges in patients status Information given or obtained from patientInformation given or obtained from patient

Contribute to staff confidence with patient Contribute to staff confidence with patient transfers by accurate assessment and reporting transfers by accurate assessment and reporting of patient’s changing transfer abilitiesof patient’s changing transfer abilities

Coordinate & participate with nursing staff in Coordinate & participate with nursing staff in transfers of patienttransfers of patient

Major issues the patient and therapist face Major issues the patient and therapist face Fatigue, Fatigue, nausea, nausea, pain, pain, weakness, weakness, lack of confidence, lack of confidence, disparity between perceived & actual disparity between perceived & actual

physical ability, physical ability, drug reactions,drug reactions,Cachexia (major weight loss),Cachexia (major weight loss),progressive , irregular decline in ability,progressive , irregular decline in ability,muscle wasting,muscle wasting,disease progression,disease progression,ascities,ascities,varying grief reactions.varying grief reactions.

TREATMENT TREATMENT Assessment of patient’s physical, & Assessment of patient’s physical, &

transfer abilitiestransfer abilities Respiratory management/educationRespiratory management/education Mobility towards maximum level Mobility towards maximum level

independence – treatment & educationindependence – treatment & education Active &/or passive mobilizationActive &/or passive mobilization Pain & symptom managementPain & symptom management Exercise prescriptionExercise prescription

TREATMENTTREATMENT Assessment & education in functional ADLAssessment & education in functional ADL Provision of walking aidesProvision of walking aides Pain management Pain management - education- education

- TENS- TENS Lymph managementLymph management MassageMassage RelaxationRelaxation HydrotherapyHydrotherapy

TREATMENTTREATMENT

Home discharge planning with Home discharge planning with Occupational TherapistOccupational Therapist

- home visit- home visit- education, patient & family- education, patient & family- provision of aides- provision of aides- liaison with other palliative staff- liaison with other palliative staff

Multidisciplinary meetingsMultidisciplinary meetings Family meetingsFamily meetings Listening and supportingListening and supporting

Case Study- Mr SCase Study- Mr S Male 65 years old, with SCLC, cord compressionMale 65 years old, with SCLC, cord compression

and neuropathic painSand neuropathic painS SOB on minimal exertionSOB on minimal exertion Chest – moist, productive coughChest – moist, productive cough Strength – R – 4/6; L – 3/6Strength – R – 4/6; L – 3/6 Joint mobility – full functionalJoint mobility – full functional Bed mobility – range from assist x 1 to assist x 2Bed mobility – range from assist x 1 to assist x 2 Mobility –used 4ww due to pain, not walked 4+ Mobility –used 4ww due to pain, not walked 4+

daysdays Pain – back and legs/hipsPain – back and legs/hips AscitiesAscities Fatigues easilyFatigues easily

GOALSGOALS

Improve chest status and managementImprove chest status and management Increase leg strengthIncrease leg strength Encourage bed mobility Encourage bed mobility Achieve best possible walking mobilityAchieve best possible walking mobility Liaise with wifeLiaise with wife Educate as appropriateEducate as appropriate

TREATMENTTREATMENT Education Education - breathing techniques- breathing techniques

- SOB management- SOB management- fatigue management- fatigue management

Exercise programExercise program Assist with bed/chair transfersAssist with bed/chair transfers

Progress to sit/stand exercisesProgress to sit/stand exercises Walking in Physiotherapy gymWalking in Physiotherapy gym Progress to walking with 4wwProgress to walking with 4ww

Education of patient in techniques to Education of patient in techniques to manage at homemanage at home

Education and support of wife, prior Education and support of wife, prior to dischargeto discharge

Liaison with Occupational Therapist Liaison with Occupational Therapist

OUTCOMEOUTCOME

Discharge home after 6.5 weeksDischarge home after 6.5 weeks Walking with supervision & 4ww, 10-15mWalking with supervision & 4ww, 10-15m Supervision with ADLSupervision with ADL Light supervision with transfersLight supervision with transfers

Patient was re-admitted 6 weeks later, Patient was re-admitted 6 weeks later, having been active at home for that time, having been active at home for that time, with increased severity of symptoms and with increased severity of symptoms and died 7days after re-admission.died 7days after re-admission.

Case 2 - BillCase 2 - Bill 83 years old, married with independent 83 years old, married with independent

childrenchildren Wood and hand craft workerWood and hand craft worker Prostate Cancer, colostomy, bowel Prostate Cancer, colostomy, bowel

obstructionsobstructions Neuropathic pain – pelvis, right side Neuropathic pain – pelvis, right side

abdominal areaabdominal area Non-mobile when first referredNon-mobile when first referred

TREATMENTTREATMENT

Exercise routineExercise routine Use overhead tracking in departmentUse overhead tracking in department mobilisation on 4ww mobilisation on 4ww Education in pacing activities, Education in pacing activities,

energy conservationenergy conservation Referred to rehabilitation GLRReferred to rehabilitation GLR

OUTCOMEOUTCOME

Discharged home after 4 weeks via Discharged home after 4 weeks via TCPTCP

(Transition Care Program)(Transition Care Program) At home 3-4 monthsAt home 3-4 months Re-admitted to Palliative Care with Re-admitted to Palliative Care with

increased painincreased pain Died 1 week laterDied 1 week later

Case 3 - GraemeCase 3 - Graeme

Colorectal cancer and caecum cancerColorectal cancer and caecum cancer Age 65, married with teenage sonAge 65, married with teenage son Fit and independent prior to diagnosisFit and independent prior to diagnosis Presented Presented - 3 drain tubes- 3 drain tubes

- large abdominal wounds- large abdominal wounds- unstable gait- unstable gait

Treatment - mobilisation with 4ww/wheel Treatment - mobilisation with 4ww/wheel chair chair

- exercises, - exercises, - education- education

Currently patient for 3+ monthsCurrently patient for 3+ months

CRP REFERRALS RATIONALECRP REFERRALS RATIONALE

Often small window of opportunity for Often small window of opportunity for patient to return homepatient to return home

Monitor Monitor -- return homereturn home

-- mobilitymobility

-- exercisesexercises Act as education resource for patient and Act as education resource for patient and

familyfamily Treat new issues as they ariseTreat new issues as they arise

What do palliative patients What do palliative patients require from a physiotherapistrequire from a physiotherapist

Flexibility Flexibility Understanding both emotionally and Understanding both emotionally and

physicallyphysically Information Information – clarity– clarity

- agreeing with other - agreeing with other sourcessources

EducationEducation EncouragementEncouragement Respect for their choicesRespect for their choices

STATISTICSSTATISTICS

25% of Palliative Care patients are 25% of Palliative Care patients are discharged, either home or to a care facilitydischarged, either home or to a care facility

Average length of stay --- 10 to 12 daysAverage length of stay --- 10 to 12 days Physiotherapist currently works 16 Physiotherapist currently works 16

hours/weekhours/week 15 bed ward15 bed ward Average 21 referrals per weekAverage 21 referrals per week Average over 22 treatments per weekAverage over 22 treatments per week

BENEFIT OF INCREASE IN BENEFIT OF INCREASE IN HOURSHOURS 7.56% increase in daily referrals7.56% increase in daily referrals

48% increase in number of daily treatments48% increase in number of daily treatments 120% increase in the number of treatments per 120% increase in the number of treatments per

weekweek 60% increase in referrals per week60% increase in referrals per week increase presence on the wardincrease presence on the ward increase staff assistance with transfers increase staff assistance with transfers increase in frequency of treatmentsincrease in frequency of treatments attendance at team meetings and some ward attendance at team meetings and some ward

roundsrounds improved palliative approach to treatmentimproved palliative approach to treatment improved interactions and involvement on wardimproved interactions and involvement on ward availability for in-serviceavailability for in-service greater input into patient caregreater input into patient care Availability for GLR staff and other meetingsAvailability for GLR staff and other meetings

Personal comments Personal comments

Why I like working in palliative careWhy I like working in palliative care

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BIBLIOGRAPHYBIBLIOGRAPHY http://www.medicineau.net.au/clinical/palliativecare/PhysioLymph.html http://www.pallcarevic.asn.au http://www.palliativecare.org.au http://www.csp.org.uk/uploads/documents/evidencebrief_palliative_EB04.pdf Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for

Physical Therapists. 1991Physical Therapists. 1991 Purtilo, R. Don’t mention it: the physical therapist in a death defying society. 1972Purtilo, R. Don’t mention it: the physical therapist in a death defying society. 1972 Martlew, B. What do you let the patient tell you. 1996Martlew, B. What do you let the patient tell you. 1996 WHO 1990WHO 1990 Frost, M The Role of Physical, Occupational and Speech therapt in Hospice: Patient Frost, M The Role of Physical, Occupational and Speech therapt in Hospice: Patient

Empowerment. 2001Empowerment. 2001 Winningham, M.L. Walking Program fro People with Cancer. Getting Started. 1991Winningham, M.L. Walking Program fro People with Cancer. Getting Started. 1991 Brown, D.J. The Problem of Weakness in Patients with Cancer. 1999Brown, D.J. The Problem of Weakness in Patients with Cancer. 1999 Laakso, E. McAuliff, AJ. Cantlay, A. The Impact of Physiotherapy Interventions on Laakso, E. McAuliff, AJ. Cantlay, A. The Impact of Physiotherapy Interventions on

Functional Independence and Quality of Life in Palliative Patients. 2003Functional Independence and Quality of Life in Palliative Patients. 2003 Shanks, R. Physiotherapy in Palliative Care. 1982Shanks, R. Physiotherapy in Palliative Care. 1982