Physiotherapy in Palliative Care

Original Editor - Shauna O’Connor, Rachael McMillan, Emma Mullen, Allison Quigley, Sarah Verwoerd as part of the QMU Current and Emerging Roles in Physiotherapy Practice Project

Top Contributors - Rachael McMillan, Allison Quigley, Sarah Verwoerd, Emma Mullen, Kim Jackson, Lucinda hampton, Shauna O' Connor, Admin, Lauren Lopez, Blessed Denzel Vudzijena, Shaimaa Eldib, Amrita Patro, 127.0.0.1, Elaine Lonnemann, Evan Thomas, WikiSysop, Adam Vallely Farrell and Vidya Acharya  

Introduction 

Product: Online self-study package.

Intended audience:

Physiotherapists and other allied health professionals.

Purpose:

To promote the role of physiotherapy in palliative care, while educating allied health professionals on the benefits and appropriateness of referral.

Locating physiotherapy in palliative care 

Palliative Care Settings
Everyone facing a life-threatening illness will need some degree of supportive care in addition to treatment for their condition (The National Council for Palliative Care, 2012).  Palliative care can be received by patients at any time and any stage of illness whether it be terminal or not, it can be offered:
• In a hospice
• In the patients home, or residential home
• As a day patient in a hospice, or
• In a hospital

Hospice Care
Most palliative care is received in a hospice (a specialist residential unit), run by a MDT, which include doctors, nurses and therapists    They are smaller and quieter than hospitals and often feel more like a home. Hospices can provide individual care more suited to the patient.  Hospice care is palliative in nature, but the illness has progressed to a point where curative treatment is no longer beneficial, the goal is no longer to cure but to promote comfort. Hospice care focuses on relieving symptoms and offering comfort from pain, shortness of breath, fatigue, nausea, anxiety, insomnia, constipation.

The patient must be referred to a hospice through their GP, hospital doctor or district nurse.

A person can be referred to a hospice at any time from initial diagnosis of a life-limiting illness and the end of life.

A patient can be discharged from the hospice once they no linger require palliative care, but can return at anytime if their condition changes.

Hospices can also offer respite care.

Care at Home
It is possible for the patient to be cared for at home, by hospice staff. The patient’s GP can arrange for community palliative care nurses, such as Macmillan nurses, to provide this level of care.

Day Patient
Patients can remain at home but visit a hospice during the day, allowing them to receive the care and support that they require without the distress often associated with leaving their home.

In Hospital
Specialist palliative care teams are available in hospitals, such teams are called Macmillan Support Teams or Symptom Control Team. Providing education, training and specialist advice on pain and symptom management to hospital staff. Also providing emotional support to the patients and families (NHS Choices, 2012).

Palliative care can include:
• Medical and nursing care
• Pain and symptom control
• Rehabilitation
• Therapies, including physiotherapy and complementary therapies
• Spiritual support
• Practice and financial advice
• Bereavement care for patients’ carers, families and friends.
•
General Palliative Care
General palliative care is an integral part of the routine care delivered by all health and social care professional to patients living with life-threatening illnesses, whether at home, in a care home or in hospital.

Specialist Palliative care
Specialist palliative care is based on general palliative care but can help patient’s with more complex palliative care needs. Provided by specially trained MDT specialist palliative care teams and can be accessed in any care setting (Scottish Partnership for Palliative Care  2012).

Within Scotland, palliative care services are provided by the Scottish Partnership for Palliative Care (SPPC) (National Council for Palliative Care in England). This is the body representing the major organisations involved in palliative care in Scotland, includes all 14 Health Boards, all 15 of Scotland’s voluntary hospices, 18 national health charities, 7 professional associations and 1 local support organization. Supporting the development and strategic direction of palliative care in Scotland and the promotion of service improvement at local level (Scottish Partnership for Palliative Care 2012).

To gain further information regarding the palliative care services available across the UK, visit Help the Hospices website. www.helpthehospices.org.uk

Access to Palliative care and Physiotherapy

All patients regardless of their diagnosis, should be able to access palliative care appropriate to their current individual needs, to allow this to happen and integrated approach to palliative care is required (McIlfatrick,2006)

Quality Statement and Definition of Specialist Palliative Care provided by National Institute for Health and Care Excellence (NICE) states “Specialist Palliative Care encompasses hospice care as well as a range of other specialist advice, support and care such as that provided by hospital palliative care teams. Specialist palliative care should be available on the basis of need and not diagnosis, offered in a timely way appropriate to their needs and preferences, at any time of day or night” (National Institute for Health and Care Excellence 2011).

Physiotherapy is an autonomous profession concerned with the care, management and rehabilitation of patients. These principles apply to the management of patients with cancer through all care and rehabilitation programmes from diagnosis to the end of life (Chartered Society of Physiotherapy, 2003). Palliative care physiotherapy has an important supportive role in the management of pain and other distressing symptoms, such as respiratory symptoms due to lymphoedema ( Clemens et al. 2010).

The purpose of rehabilitation in palliative care is to improve the quality of survival so that patient’s lives will be as comfortable and productive as possible and they can function at a minimum level of dependency regardless of life expectancy (Dietz 1981). Therefore, early referral to physiotherapy is advisable to ensure early implementation of rehabilitation goals, especially those which are preventative or restorative.

Quality Statement and Definition of Specialist Palliative Care provided by NICE states “Specialist Palliative Care encompasses hospice care as well as a range of other specialist advice, support and care such as that provided by hospital palliative care teams. Specialist palliative care should be available on the basis of need and not diagnosis, offered in a timely way appropriate to their needs and preferences, at any time of day or night” (National Institute for Health and Care Excellence, 2011).

Physiotherapy in the field of palliative care is a continually evolving and developing specialty both in malignant and non-malignant disease.

Rehabilitation for these patients in now recognized as an essential part of the clinical pathway, as earlier diagnosis and treatment is allowing the patients to live longer and with a better quality of life.

According to the Association of chartered Physiotherapists in Oncology and Palliative care (ACPOPC), by working within the MDT, the physiotherapist’s core skills- ability to set realistic goals along with their patient-centered, problem solving approach, they can help people adapt to their changing conditions (Association of Chartered Physiotherapists in Oncology and Palliative Care 1993).

Ongoing assessments are carried out by physiotherapists assessing the needs of palliative care patients, in order to apply the necessary skilled interventions, which are vital to the patient’s independence, functional capacity and quality of life (Chartered Society of Physiotherapy 2003). The MDT must set both medium and long-term goals with the patient. Due to the changing needs of the patient over time, it is vital that a flexible approach is undertaken. Goal setting for a palliative care patient is determined by a combination of factors including age, type and stage of disease, presence of other disease, inherent physical ability and socioeconomic factors (Chartered Society of Physiotherapy, 2003).

If patient’s did not receive physiotherapy this could be detrimental to the patient’s care and the ability of the patient/family to cope with the effects of the illness or its treatment on their functional capacity and quality of life (Clemens et al. 2010)

Services for cancer patients have been the focus of a range of policy developments in recent years. Saving Lives: Our Healthier Nation (DoH 1999) propose action on cancer at 4 levels: reducing risk: early recognition: more effective treatment: and integrated action. Rehabilitation is now high on the UK health and social care agenda, with a shift in focus from a preoccupation with the disease to one, which is needs’ led. (Chartered Society of Physiotherapy 2003).

This shift in focus offers significant opportunities for physiotherapy within palliative care and rehabilitation, palliative care patients may present with a wide range if needs that may benefit from physiotherapeutic interventions (Clemens et al. 2010)

The aim of physiotherapy for palliative care patients is:

“…to minimize some of the effects which the disease or its treatment, has on them It is often possible to improve their quality of life regardless of their prognosis by helping them to achieve their maximum potential of functional ability and independence or gain relief from distressing symptoms” (Association of Chartered Physiotherapists in Oncology and Palliative Care 1993).

Effective cancer rehabilitation is often faced with barriers; Fulton (1994) believes that the main barriers are attitudinal problems, poor disease knowledge and rehabilitation awareness and poor detection of rehabilitation problems.

Referral to Palliative care Physiotherapy

Physiotherapy objectives within each of the palliative care setting differ depending on what stage the patient is at. Some may be actively dying, the physiotherapy input here is based on positioning and respiratory care. Longer term patients physiotherapy looks at maximizing quality of life and maintaining mobility and independence (Chartered Society of Physiotherapy 2008).

Early referral is advisable to ensure early implementation of rehabilitation goals, especially those which are preventative or restorative. Referral is advised if a patients has:
• Dyspnoea or other respiratory symptoms such as cough or excessive secretions
• Oedema or lymphedema
• Central or peripheral neurological symptoms
• Spinal cord compression

Or if a patient requires:
• Portable nebulisers or instruction in the correct use of inhaler devices
• Treatment to improve, maintain or manage the deterioration of exercise tolerance and muscle strength
• Treatment to maintain or improve joint range of movement and soft tissue flexibility
• Gait re-education and/or provision of walking aids/equipment to maximize independence in mobility and/or transfers
• Adjuvant, non-pharmacological pain management, including the use of TENS, acupuncture/acupressure, hot/cold therapy
• Adjuvant therapies to support pharmacological intervention in the management of nausea and vomiting as well as breathlessness
• Stress and anxiety management, for example through relaxation and/or massage therapy.

Palliative care physiotherapists may devise an exercise regime based on a full assessment of the patients’ abilities and condition. The focus will always be to maintain the patient’s lifestyle as much as possible whilst receiving medical treatment, and on improving fitness levels and strength between the treatments. The programme will always be goal orientated, with objectives discussed and agreed upon with the patient.

Physical therapy has been shown to be of great benefit to cancer patients in terms of pain management. The first step is to establish the nature and position of the pain that the patient is experiencing, in order to tailor the treatment as best as possible. The physiotherapist will then proceed to use different interventions such as massage, postural adjustments, hold/cold treatments and therapeutic exercise.

Referral to Specialist Palliative care
It is not possible to predict individual prognosis accurately so evidence informed, clinical reasoning is used to identify people who may benefit from supportive and palliative care. Clinical indicators can help identify patients who are candidates for assessment to see if they have unmet needs (Supportive and Palliative Care Indicators Tool – SPICT) (NHS Scotland 2012). http://www.palliativecareguidelines.scot.nhs.uk/documents/SPICT_Sept2012.pdf
Palliative care specialists can offer additional advice and care for complex problems:
• Uncontrolled breathlessness or other symptoms
• Complex end of life care needs
• Complex physical, psychological, family or spiritual needs that cannot be met with existing care/support (NHS Scotland 2009).

Examples of Palliative Care Settings

Marie Curie Hospices – Provide specialist care and support for terminally ill patients. Each hospice can offer in-patient and outpatients care as well as day care, with the aim to promote quality of life for these patients, families and carers.

There are 9 hospitals throughout the UK; Belfast, Bradford, Edinburgh, Glasgow, Hampstead London), Liverpool, Newcastle, Penarth (Cardiff and the Vale) and Solihull (West Midlands).

Each hospice provides a service which includes medical and nursing care; physiotherapy; occupational therapy; social; practical and emotional support; and complementary therapies.

The community service provides specialist palliative care in the community, with the aim to avoid unplanned admission to hospital for patients who have complex needs but prefer to be care for at home. (Marie Curie Cancer Care 2013).

Specialist Palliative Care Services in Lothian – There are two specialist palliative care inpatient units, Community palliative care services, hospital palliative care teams and palliative care day services . Specialist advisory services are available for all Lothian hospital and throughout the Community Division. Telephone advice, a single assessment visit or a period of specialist care according to need is offered (NHS Lothian 2012).

Referral can be made for a patient who has advanced, progressive or incurable illness. Click on the link for a Lothian Specialist Palliative Care Services Referral form.

St Columba’s Hospice- Lothian
All patients who are within the care of St Columba’s Hospice as either an inpatient, a Day hospital patient or a Community Palliative Care patient, can be referred for physiotherapy to help maximize their independence.

Most people find physiotherapy a positive experience and feel the benefit of being actively involved in exercise which improves the ability and confidence to move about and can lead to a sense of well-being (St Columba’s Hospice 2008).

The Beatson West of Scotland Cancer Centre
The Beatson physiotherapy team are specialize din dealing with cancer patients and problems that may arise related to cancer treatment. The service is currently only available to in-patients, referral may be for an assessment of problems related to the patients change in daily function whether mild or severe, they may also be referred for respiratory conditions such as chest infections, asthma and/or breathlessness.

The physiotherapists work closely with other professions in order to facilitate patient discharge or transfer from hospital, with a view to referral to other physiotherapists possibly in the community (The Beatson West of Scotland  Cancer Centre 2013).

Referral criteria for Northamptonshire Specialist Palliative Care (Macmillan Physiotherapy Service
The Specialist Palliative Care (SPC) Physiotherapy Service for Northamptonshire is a hospice based service with appropriate community referrals being seen in an outpatient clinic setting throughout Northamptonshire.

Click on the link Referral Criteria to access the SPC referral information guide.

Referrals are accepted by the Macmillan Physiotherapy service from:
• Consultants/Registrars
• GPs
• Clinical Nurse Specialists
• District Nurses
• Band 7 Physiotherapists/Occupational Therapists
• Palliative Care Occupational Therapists.

References

References will automatically be added here, see adding references tutorial.