1. PHYSIOTHERAPY IN PALLIATIVE CARE Pauline Cerdor - Physiotherapist Palliative Care Unit Peninsula Health Frankston

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.“ "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”. “… 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. 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 Specific palliative care wards Nursing homes Nursing homes General wards General wards Oncology wards Oncology wards Community rehabilitation (homes) Community rehabilitation (homes)

5. OBJECTIVES of TREATMENT to be as free as possible from unnecessary suffering (physical, emotional or spiritual); to be as free as possible from unnecessary suffering (physical, emotional or spiritual); to maintain patient’s dignity and independence throughout the experience; to maintain patient’s dignity and independence throughout the experience; to be cared for in the environment of choice; to be cared for in the environment of choice; to have patient’s grief needs recognised and responded to; to have patient’s grief needs recognised and responded to; to be assured that families needs are also being met. 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. Physiotherapy in palliative care is orientated to achieve the optimum quality of life as perceived by the patient. Wholistic & problem solving approach to therapy Wholistic & problem solving approach to therapy Achieve maximum physical, psychological, social, vocational function Achieve maximum physical, psychological, social, vocational function Adapt traditional therapy to the patient’s changing 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 -- More beneficial if begins with diagnosis of cancer and continues as required through the various stages -- preventative, restorative, supportive, palliative 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 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 Education for patient and families commencing immediately after diagnosis Mobility and exercise programs. Mobility and exercise programs. Availability of therapist as a resource for patients and families 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) (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 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 Encouragement, education and treatment in achieving physical, work and lifestyle goals Specific treatments as required Specific 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)

9. Supportive Enhance independent functioning when residual cancer is present and progressive disability is probable Enhance independent functioning when residual cancer is present and progressive disability is probable Encouragement, education and treatment in achieving physical, work and lifestyle goals Encouragement, education and treatment in achieving physical, work and lifestyle goals Availability of therapist as a resource Availability 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)

10. Palliative Primarily directed at promoting maximum comfort Primarily directed at promoting maximum comfort Maintaining the highest level of function possible in the face of disease progression and impending death 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) (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 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 function Optimise independence and function Education and participation of the carer (Fulton and Else, 1997). Education and participation of the carer (Fulton and Else, 1997).

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

13. AIM of Physiotherapy 1 Assess and optimise the patient’s level of physical function 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 Take into consideration the interplay between the physical, psychological, social and vocational aspects of function Understand the patients underlying emotional, pathological and psychological condition, 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. 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 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. Facilitate and optimise the patient's ability to function with safety and independence in the face of diminishing resources. Maintain optimum respiratory & circulatory function Maintain optimum respiratory & circulatory function Listen to patient Listen to patient Set realistic goals with the patient Set realistic goals with the patient

15. AIM OF PHYSIOTHERAPY 3 Prevent muscle shortening & joint contractures Prevent muscle shortening & joint contractures Influence pain control Influence pain control Educate in all aspects of physical function Educate in all aspects of physical function Education and participation of the carer Education and participation of the carer Treat the patient with dignity – allowing them to “live until they die” Treat the patient with dignity – allowing them to “live until they die” Build a relationship of confidence and trust 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 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 Treatments are brief often less than 10 minutes and are repeated several times per day if possible Frequent rests are required Frequent rests are required Patient’s status can change suddenly and rapidly Patient’s status can change suddenly and rapidly Requirement to balance ‘effort’ and ‘fatigue’ Requirement to balance ‘effort’ and ‘fatigue’

17. Requirement to:- 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 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 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 Coordinate & participate with nursing staff in transfers of patient

18. Major issues the patient and therapist face Major issues the patient and therapist faceFatigue,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 Assessment of patient’s physical, & transfer abilities Respiratory management/education Respiratory management/education Mobility towards maximum level independence – treatment & education Mobility towards maximum level independence – treatment & education Active &/or passive mobilization Active &/or passive mobilization Pain & symptom management Pain & symptom management Exercise prescription Exercise prescription

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

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

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

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

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

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

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

27. OUTCOME Discharge home after 6.5 weeks Discharge home after 6.5 weeks Walking with supervision & 4ww, 10-15m Walking with supervision & 4ww, 10-15m Supervision with ADL Supervision with ADL Light supervision with transfers 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. 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 83 years old, married with independent children Wood and hand craft worker Wood and hand craft worker Prostate Cancer, colostomy, bowel obstructions Prostate Cancer, colostomy, bowel obstructions Neuropathic pain – pelvis, right side abdominal area Neuropathic pain – pelvis, right side abdominal area Non-mobile when first referred Non-mobile when first referred

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

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

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

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

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

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

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

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

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