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, WikiSysop, Adam Vallely Farrell, Vidya Acharya, Shaimaa Eldib, Amrita Patro, 127.0.0.1, Elaine Lonnemann and Evan Thomas  

Introduction

Product: 

Online self-study and/or CPD (continuing professional development) package.

Intended audience:  

Physiotherapists and other allied health professionals (AHPs).

Purpose: 

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

Learning outcomes

LO1 Develop knowledge and understanding of palliative care.
LO2 Recognise and evaluate the role of physiotherapy in palliative care.
LO3 Gain knowledge of the evidence surrounding the benefits of palliative care physiotherapy.
LO4 Identify the referral of suitable palliative care patients to physiotherapy and be able to apply in clinical practice.
LO5 Formulate an awareness of family involvement, regarding compliance to and education about physiotherapy treatment in palliative care.
LO6 Appraise the changing demographics and the role of palliative care physiotherapy.

Background

Palliative care is a practice discipline, which involves progressive and life-limiting illnesses such a cancer, chronic obstructive pulmonary disease, motor neuron disease and multiple sclerosis, each of which can benefit from the involvement in physiotherapy. Providing pain relief and management of distressing and debilitating symptoms, palliative care improves quality of life (QoL) for patients with a life-limiting illness, and their families (World Health Organization 2007; NHS Choices 2012). Helping integrate the psychological, social and spiritual aspects of holistic care, palliative care manages patients’ symptoms and pain levels, providing relief from distress and ultimately, facilitating improved function (NHS Choices 2012; Prevost and Grach 2012).

All patients regardless of their diagnosis, should be able to access palliative care appropriate to their current individual needs, to allow this to happen an integrated approach to palliative care is required (McIlfatrick 2006).  The rise in the number of elderly people, especially those who have little home support, makes palliative care even more vital. People dying from stroke, dementia or multi-system failure and cancers need to be guaranteed the same level of care as those that have a diagnosis of cancer (Higginson 1993).
Palliative care was initially seen as ‘terminal care’ (McIlfatrick 2006). Its scope has recently broadened and the concept of ‘rehabilitation’ in palliative care is becoming more widespread (Scialla 2000; Bancroft 2003). Pain relief and the control of symptoms are employed where rehabilitation is not appropriate, depending on the stage of the illness (McIlfatrick 2006).

Relevance of physiotherapy in palliative care and the need for development in this area    

Allied health and rehabilitation in palliative care is well established (Horne-Thompson and Bramley 2011). Meeting patients’ physical, psychological, social and spiritual needs, palliative care rehabilitation fits the adopted bio-psycho-social approach to health care, suggested by the World Health Organization (2002). Involving symptom management and treatment effect minimisation in patients with progressive and irreversible illness (Cobbe et al. 2013), this essential service within health care must be utilised where appropriate, improving and maintaining patients’ and their families’ QoL. Physiotherapy aims to maximise movement and function, where threatened by ageing, injury or disease, essential for optimal wellbeing (Kumar and Jim 2010). A detailed explanation of physiotherapy’s role in palliative care can be viewed here.

Existing evidence, though in its preliminary stages, advocates the role of physiotherapists and rehabilitation in palliative care (Horne-Thompson and Bramley 2011; Nelson et al. 2012; Cobbe et al. 2013). Early referral to palliative care rehabilitation has been linked to higher-functioning patients (Cobbe et al. 2013), therefore appropriate referral to palliative care physiotherapy is critical for optimal and patient-centred care. Referral information and pathways can be viewed her'e'.

Despite potential benefits of palliative care physiotherapy, evidence suggests a lack of palliative care patients receiving physiotherapy treatment (Parliament UK 2004). As a result, to the detriment of patients and the NHS (National Health Service UK), specialist palliative care teams may be failing to deliver patient-centred care, in failing to refer (Parliament UK 2004). Research suggests the reluctance of referral, by other allied health professions, due to the misconceived perception of inappropriateness of terminally ill patients to rehabilitation (Horne-Thompson and Bramley 2011).

In addressing this commonly altered perception of palliative care physiotherapy on a preliminary level, this self-study CPD (continuing professional development) package will demonstrate the vast capability and variability of rehabilitation in such a setting. With palliation, physiotherapy treatment aims to maintain QoL while alleviating stress from symptoms in particular, pain, and effects from treatment.

Palliative care physiotherapy has been found to positively influence QoL and perceived wellbeing in a range of palliative care populations, including cancer, HIV, neurological disorders, cardiopulmonary conditions and mental illness (Kumar and Jim 2010). Palliative care physiotherapy specialists demonstrate extensive knowledge and vast experience working with life-limiting illnesses, with competency responding to rapidly changing situations (Watson and Payne 2008, cited in Cobbe et al. 2013, p. 40).

In response to staggering research on palliative care rehabilitation perceptions and lacking numbers of referral, this self-study package has been designed as an educational resource for all allied health professionals in the United Kingdom (UK). The package aims to void a trough in knowledge, and degree of uncertainty or misconception, surrounding referral of appropriate palliative care patients, to physiotherapy. It is not exclusive to any one palliative care specialty area, but can be adopted for a range of palliative care areas. While providing up-to-date factual information for allied health professionals, this package will endeavour to extend beyond the tangible requirements for referral to physiotherapy in palliative care. It will provide a sound explanation of necessary personal values and the importance of suitable communication skills (Pitman 2013), for interaction with patients and families in or being referred to palliative care.

Accessing physiotherapy in palliative care

The ‘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 pp*).

General palliative care is an integral part of the routine care delivered by all health and social care professional to patients living with life-limiting illnesses, whether at home, in a care home or in hospital (Chartered Society of Physiotherapy 2012).

Specialist palliative care is based on general palliative care but can help patients with more complex palliative care needs. Specialist palliative care focuses on complex care needs. It is provided by a specially trained multi-disciplinary team (MDT) and can be accessed in any care setting (Scottish Partnership for Palliative Care 2012).

Settings

Within Scotland, palliative care services are provided by the Scottish Partnership for Palliative Care (SPPC) (The National Council for Palliative Care 2012). This is the body representing the major organisations involved in palliative care in Scotland, including all 14 Health Boards, all 15 of Scotland’s voluntary hospices, 18 national health charities, 7 professional associations and 1 local support organization. They aim to support 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).
Everyone facing a life-limiting illness will need some degree of supportive care in addition to treatment for their condition (The National Council for Palliative Care 2012). Patients can receive palliative care physiotherapy at any time and any stage of illness, whether it is 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

Most palliative care is received in a hospice (a specialist residential unit), run by an MDT comprising 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 must have 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 (NHS Choices 2012).

Marie Curie Hospices (link through to website)

St Columba's Hospice, Lothian, Scotland UK (link through to website)

Here you can view a patient's experience, from St Margaret of Scotland Hospice (link through to YouTube)

Care at home

It is possible for the patient to be cared for at home, by hospice staff. The patient’s general practitioner (GP) can arrange for community palliative care nurses, such as Macmillan nurses, to provide this level of care (NHS Choices 2012).

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 (NHS Choices 2012).

Hospital

Specialist palliative care teams are available in hospitals; such teams are called Macmillan Support Teams or Symptom Control Team. Their role lies in providing education, training and specialist advice on pain and symptom management to hospital staff with the ultimate aim of enhancing patient care. They also provide emotional support to the patients and families (NHS Choices2012).

An example of hospital palliative care in Scotland, is the Beatson West of Scotland Cancer Centre provides hospital palliative care (link through to website)

Community

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). It is an area in which large growth is proposed for in the future.

Rationale for physiotherapy in palliative care

Patients needs and our role as a physiotherapist

References

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