DEFINITION

1. PHYSIOTHERAPYINPALLIATIVE CAREPauline Cerdor - PhysiotherapistPalliative Care UnitPeninsula HealthFrankston

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

3. Palliative Care • “… the active, total care of patients whose disease no longer responds to curative treatment and for whom the goal must be the best quality of life for them and their families”. • What do you let the patient tell you? by Barbara Martlew quoting from Lamerton, 1980 and Doyle, 1987.

4. WHERE Palliative physiotherapy is found in:- • Specific palliative care wards • Nursing homes • General wards • Oncology wards • Community rehabilitation (homes)

5. OBJECTIVES of TREATMENT • to be as free as possible from unnecessary suffering (physical, emotional or spiritual); • to maintain patient’s dignity and independence throughout the experience; • to be cared for in the environment of choice; • to have patient’s grief needs recognised and responded to; • to be assured that families needs are also being met. (http://www.palliativecare.org.au)

6. PHYSIOTHERAPY • Physiotherapy in palliative care is orientated to achieve the optimum quality of life as perceived by the patient. • Wholistic & problem solving approach to therapy • Achieve maximum physical, psychological, social, vocational function • Adapt traditional therapy to the patient’s changing function • More beneficial if begins with diagnosis of cancer and continues as required through the various stages -- preventative, restorative, supportive, palliative (Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical Therapists)

7. Preventative • Aims at restricting or inhibiting the development of disability in the course of the disease or treatment before disability occurs • Education for patient and families commencing immediately after diagnosis • Mobility and exercise programs. • Availability of therapist as a resource for patients and families • (Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical Therapists)

8. Restorative • Rehabilitation is the objective when no or little residual disability is anticipated for some time and patients are expected to return to normal living styles • Encouragement, education and treatment in achieving physical, work and lifestyle goals • Specific treatments as required • (Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical Therapists)

9. Supportive • Enhance independent functioning when residual cancer is present and progressive disability is probable • Encouragement, education and treatment in achieving physical, work and lifestyle goals • Availability of therapist as a resource • (Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical Therapists)

10. Palliative • Primarily directed at promoting maximum comfort • Maintaining the highest level of function possible in the face of disease progression and impending death • (Kuchler T., Wood-Dauphinee, S. Working with people who have cancer: Guidelines for Physical Therapists)

11. In Brief • The Chartered Society of Physiotherapy www.csp.org.uk Page 8/43 Ref: EB 04 • • Prevent muscle shortening • • Prevent joint contractures • • Influence pain control • • Optimise independence and function • • Education and participation of the carer (Fulton and Else, 1997).

12. Goal of Physiotherapy • Determine the patient’s functional loss • Estimate functional potential • Implement a plan to progress from measured loss to full potential • To improve quality of life • To listen ‘actively and positively’ with an awareness of priorities as determined by the patient • Achieve the best possible quality of life for patients and their families • Availability as a resource for patient and families • Frost, M The Role of Physical, Occupational and Speech therapt in Hospice: Patient Empowerment. 2001 • (Martlew, B. What do you let the patient tell you. 1996) • (wHO 1990)

13. AIM of Physiotherapy 1 • Assess and optimise the patient’s level of physical function • Take into consideration the interplay between the physical, psychological, social and vocational aspects of function • Understand the patients underlying emotional, pathological and psychological condition, • Focus is the physical and functional consequences of the disease and/or its treatment, on the patient. Fulton and Else, 1997; p817 Chartered Society of Physiotherapy

14. AIM of Physiotherapy 2 • Restore the patient’s sense of self • Facilitate and optimise the patient's ability to function with safety and independence in the face of diminishing resources. • Maintain optimum respiratory & circulatory function • Listen to patient • Set realistic goals with the patient

15. AIM OF PHYSIOTHERAPY 3 • Prevent muscle shortening & joint contractures • Influence pain control • Educate in all aspects of physical function • Education and participation of the carer • Treat the patient with dignity – allowing them to “live until they die” • Build a relationship of confidence and trust (Fulton and Else, 1997 Chartered Society of Physiotherapy). (Purtilo, R. Don’t mention it: the physical therapist in a death defying society. 1972)

16. DIFFERENCES IN PALLIATIVE PHYSIOTHERAPY TREATMENT • Traditional physiotherapy treatments need to be modified to accommodate the irregular changing needs of the patient • Treatments are brief often less than 10 minutes and are repeated several times per day if possible • Frequent rests are required • Patient’s status can change suddenly and rapidly • Requirement to balance ‘effort’ and ‘fatigue’

17. Requirement to:- - Monitor and respond appropriately to patient’s verbal & non-verbal expressions of pain - Monitor patient very closely during and between treatments • Timely communication to/with other team members is particularly important • Changes in patients status • Information given or obtained from patient • Contribute to staff confidence with patient transfers by accurate assessment and reporting of patient’s changing transfer abilities • Coordinate & participate with nursing staff in transfers of patient

18. Major issues the patient and therapist face Fatigue, nausea, pain, weakness, lack of confidence, disparity between perceived & actual physical ability, drug reactions, Cachexia (major weight loss), progressive , irregular decline in ability, muscle wasting, disease progression, ascities, varying grief reactions.

19. TREATMENT • Assessment of patient’s physical, & transfer abilities • Respiratory management/education • Mobility towards maximum level independence – treatment & education • Active &/or passive mobilization • Pain & symptom management • Exercise prescription

20. TREATMENT • Assessment & education in functional ADL • Provision of walking aides • Pain management - education - TENS • Lymph management • Massage • Relaxation • Hydrotherapy

21. TREATMENT • Home discharge planning with Occupational Therapist - home visit - education, patient & family - provision of aides - liaison with other palliative staff • Multidisciplinary meetings • Family meetings • Listening and supporting

22. Case Study- Mr S • Male 65 years old, with SCLC, cord compression and neuropathic painS • SOB on minimal exertion • Chest – moist, productive cough • Strength – R – 4/6; L – 3/6 • Joint mobility – full functional • Bed mobility – range from assist x 1 to assist x 2 • Mobility –used 4ww due to pain, not walked 4+ days • Pain – back and legs/hips • Ascities • Fatigues easily

23. GOALS • Improve chest status and management • Increase leg strength • Encourage bed mobility • Achieve best possible walking mobility • Liaise with wife • Educate as appropriate

24. TREATMENT • Education - breathing techniques - SOB management - fatigue management • Exercise program • Assist with bed/chair transfers

25. Progress to sit/stand exercises • Walking in Physiotherapy gym • Progress to walking with 4ww

26. Education of patient in techniques to manage at home • Education and support of wife, prior to discharge • Liaison with Occupational Therapist

27. OUTCOME • Discharge home after 6.5 weeks • Walking with supervision & 4ww, 10-15m • Supervision with ADL • Light supervision with transfers • Patient was re-admitted 6 weeks later, having been active at home for that time, with increased severity of symptoms and died 7days after re-admission.

28. Case 2 - Bill • 83 years old, married with independent children • Wood and hand craft worker • Prostate Cancer, colostomy, bowel obstructions • Neuropathic pain – pelvis, right side abdominal area • Non-mobile when first referred

29. TREATMENT • Exercise routine • Use overhead tracking in department • mobilisation on 4ww • Education in pacing activities, energy conservation • Referred to rehabilitation GLR

30. OUTCOME • Discharged home after 4 weeks via TCP (Transition Care Program) • At home 3-4 months • Re-admitted to Palliative Care with increased pain • Died 1 week later

31. Case 3 - Graeme • Colorectal cancer and caecum cancer • Age 65, married with teenage son • Fit and independent prior to diagnosis • Presented - 3 drain tubes - large abdominal wounds - unstable gait • Treatment - mobilisation with 4ww/wheel chair - exercises, - education • Currently patient for 3+ months

33. CRP REFERRALS RATIONALE • Often small window of opportunity for patient to return home • Monitor - return home - mobility - exercises • Act as education resource for patient and family • Treat new issues as they arise

34. What do palliative patients require from a physiotherapist • Flexibility • Understanding both emotionally and physically • Information – clarity - agreeing with other sources • Education • Encouragement • Respect for their choices

35. STATISTICS • 25% of Palliative Care patients are discharged, either home or to a care facility • Average length of stay --- 10 to 12 days • Physiotherapist currently works 16 hours/week • 15 bed ward • Average 21 referrals per week • Average over 22 treatments per week

36. BENEFIT OF INCREASE IN HOURS • 7.56% increase in daily referrals • 48% increase in number of daily treatments • 120% increase in the number of treatments per week • 60% increase in referrals per week • increase presence on the ward • increase staff assistance with transfers • increase in frequency of treatments • attendance at team meetings and some ward rounds • improved palliative approach to treatment • improved interactions and involvement on ward • availability for in-service • greater input into patient care • Availability for GLR staff and other meetings

37. Personal comments • Why I like working in palliative care * *****

38. BIBLIOGRAPHY • 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 Physical Therapists. 1991 • Purtilo, R. Don’t mention it: the physical therapist in a death defying society. 1972 • Martlew, B. What do you let the patient tell you. 1996 • WHO 1990 • Frost, M The Role of Physical, Occupational and Speech therapt in Hospice: Patient Empowerment. 2001 • Winningham, M.L. Walking Program fro People with Cancer. Getting Started. 1991 • Brown, D.J. The Problem of Weakness in Patients with Cancer. 1999 • Laakso, E. McAuliff, AJ. Cantlay, A. The Impact of Physiotherapy Interventions on Functional Independence and Quality of Life in Palliative Patients. 2003 • Shanks, R. Physiotherapy in Palliative Care. 1982