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How physical therapy can help patients who need palliative care.

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As physical therapists, we are educated to be practitioners who evaluate, treat and manage movement dysfunction due to injury or disease with the overriding goal of improving function and quality of life. 1,2 However, as we continue to see our population age, our profession is now routinely managing those who suffer from chronic disease process(es). In many cases, physical therapists treat these patients under the umbrella of palliative care. 

Palliative Background

Palliative care is a relatively new medical model; there were hardly any formalized palliative programs 10 years ago. Now, however, 63 percent of hospitals with greater than 60 beds, offer palliative care.  Similarly, home health and SNF's are also now able to provide this service.3 Palliative care is a term used to describe the skilled care that a patient would receive if they were seeking care to manage symptoms associated with the advanced stages of their illness, while simultaneously seeking disease modifying medical treatment. There is no near term prognosis of death, and the main purpose is to provide treatment for disease related symptoms such as pain, nausea, constipation, shortness of breath, insomnia, etc. in order to promote a better quality of life for that patient.4 The care is multidisciplinary and may include the primary physician, pharmacist, RN, aide, clergy, specialty physician, family, therapist (s), and/or psychologist. The palliative care approach makes the patient/family the centerpiece of the treatment plan.3

In an effort to raise awareness about palliative care and also the role of physical therapy, both the Joint Commission and the House of Delegates of the American Physical Therapy Association (House) have recently made developments within their organizations.  In 2011, the House added to the position of the PT role in hospice and palliative care. The revised concepts stated are 1:

  • Continuity of care and the active, compassionate role of physical therapists and physical therapist assistants in hospice and palliative care;
  • Respect for the rights of all individuals to have appropriate and adequate access to physical therapy services, regardless of medical prognosis or setting;
  • An interdisciplinary approach, including timely and appropriate physical therapist and physical therapist assistant involvement, especially during transitions of care or during a physical or medical change in status;
  • Education of physical therapists, physical therapist assistants, and respective student in the concepts related to treating an individual while in hospice and palliative care;
  • Appropriate and comparable coverage and payment for physical therapy services for individuals who have transitioned to hospice or palliative care in all clinical settings.1

The Joint Commission has developed a palliative certification program for those hospitals that have achieved excellence in managing patients with chronic illnesses. Here, the focus is a patient centered model of care which includes a multifactorial approach to treatment using evidenced based medicine.  Certification is granted upon on site evaluation of standards and if granted, must be renewed every 2 years. 3

Assessment and Intervention

The heightened awareness of the "palliative patient" has given many physical therapists the opportunity to develop a specific plan of care for the complex patient. Well documented and evidence-based assessments for the palliative patient  can include the Tinetti, Berg Balance Scale, Timed Up and Go (TUG), Dynamic Gait Index (DGI), 2 minute walk test, and/or the 5 times sit/stand test. 4,6

Pain, however, can be more challenging to assess due to fluctuations in symptoms, patient response, and patient perception. The Visual Analog (VAS) is a more common pain assessment where the patient must rate his/her pain on an ordinal 0-10 scale where 0 is no amount of pain and 10 is the most.7 However, in many instances the patient who is receiving palliative care, may be unable to provide a response using this scale. Therefore, there are many other measures that can be used to quantify pain.  Included are the Pain Assessment in Advanced Dementia Scale, FACES pain scale, and the Checklist for Nonverbal Pain Indicators (CNPI) to name a few.8

Some well documented therapy clinical interventions include home safety, pain management, DME training, caregiver education, patient positioning, energy conservation, breathing techniques, strengthening, balance reeducation, gait training, transfer training  and transition discharge planning.6,9 These treatments are not unlike treatments that we do with other patient populations but what the physical therapist must now take into consideration is that the palliative patient may have routine disease specific fluctuations that impact performance. Knowing this can sometimes create questions revolving around lack of patient progression and discharge timing. 

While these concerns are valid, often the fluctuating clinical presentation of the palliative patient should encourage the therapist to redirect their care to treatments that allow the patient to live better with the disease versus curing an aspect of the disease process; goals may change throughout the episode of care.10 Ultimately, best practice would be to develop patient centered goals which are meaningful. One tool that supports this is the Palliative Performance Scale.4

The Palliative Performance Scale (PPS) is a valid and reliable tool that assists in the identification of changing patient care needs in response to disease fluctuations. It consists of 5 domains (ambulation, activity level, self-care, intake and level of consciousness) which are rated by the clinical observer. For a patient with cancer, the scoring correlates with an estimated survival time.11,12  This can be very useful to the therapist; our interventions can impact several of the PPS categories. 

Although the palliative patient may not be able to achieve independence in these various domains, therapists have the unique ability to enhance performance through education, compensatory techniques, and modification of the living environment. This is what will allow a patient to not only be successful in therapy, but more importantly have a positive impact on their preservation of function and dignity to enhance their quality of life for as long as possible. What must be at the forefront of our treatment plan is a intervention and long-term goal that is supportive to the patient having preservation of function and dignity as long as possible.

References

  1. American Physical Therapy Association.  Standards of practice for Physical Therapy http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/HOD/Health/RoleofPTinHospiceandPalliativeCare_HOD_P06-11-14-11.pdf#search=%22standards of practice palliative%22  Accessed January 24, 2013
  2. American Physical Therapy Association.  The Role of Physical Therapy in Hospice and Palliative Care http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/HOD/Health/RoleofPTinHospiceandPalliativeCare_HOD_P06-11-14-11.pdf#search=%22palliative care role of physical therapy%22 Accessed January 24, 2013
  3.   The Joint Commission. Facts About the Advanced Certification Program for Palliative Care. http://www.jointcommission.org/assets/1/18/Palliative_Care.pdf  Accessed February 10, 2013
  4. Panke, J. What is Palliative Care? www.getpalliativecare.org/2012/01/what-is-palliative-care-article/  Accessed January 2, 2013
  5. Mueller, K., Briggs, R.  Hospice and Palliative Care:  The collaborative Role of Physical Therapy (video). American Physical Therapy Association 2012.
  6. Javier, N., Montagnini, M.  Rehabilitation of the Hospice and Palliative Care Patient.  Journal of Palliative Medicine.2011;14(5); 638-648
  7. Mosby's Medical Dictionary. Visual analogue scale for pain.  www.medical-dictionary.thefreedictionary.com/visual+analog+scale+for+pain  Accessed February 4, 2013
  8. Iowa Geriatric Education Center.  Geriatric Assessment Tools:  Pain  www.healthcare.uiowa.edu/igec/tools/categoryMenu.asp?categoryID=7  Accessed February 4, 2013
  9. Wilson, C.  Palliative and Acute Care (podcast).  American Physical Therapy Association.  2013. 
  10. Gudest, S. Services Provided by Palliative PT (podcast).  American Physical Therapy Association.  2013
  11. Jo,F., Lau,F., Downing,M., Lesperance,M. A reliability and validity study of the Palliative Performance Scale. BMC Palliative Care. 2008;7(10). http://www.biomedcentral.com/content/pdf/1472-684X-7-10.pdf
  12. Wilner, S.; Arnold, R.  End of Life/Palliative Education Resource Center. Fast Facts and Concepts #125.  http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_125.htm Accessed February 5, 2013.

Marissa Cruz received her Masters of Science in Physical Therapy from Central Michigan University, and her doctorate in Physical Therapy from Simmons College. She obtained board certification in geriatrics from the American Physical Therapy Association. Currently she works in the homecare setting where she is actively involved in geriatric program development, patient care, and staff training. She also is an adjunct clinical lecturer at University of Michigan Department of Physical Therapy.






     

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