Rehabilitative Palliative Care Research Articles

Holding On… and Letting Go

Holding On… and Letting Go

SP-0470: Rehabilitation in palliative care

SP-0470: Rehabilitation in palliative care

Evaluation of the Edmonton Functional Assessment Tool (EFAT2) within palliative care: a pilot study

There is increasing need for rehabilitation in both cancer and palliative care. However, there are few validated outcome measures that are suitable for measuring functional performance in this population. The present study evaluated the validity, sensitivity and reliability of the Edmonton Functional Assessment Tool (EFAT2) within a UK palliative care setting. Eleven participants aged 65 years and over (mean age 76.5 ± 6.7 years) receiving rehabilitation in a palliative care inpatient setting were studied. Concurrent validity was assessed by comparing EFAT2 with the Barthel Index. Inter-rater reliability of EFAT2 was examined using a sample of four participants recruited from a cancer care ward. A significant negative correlation was observed between the Barthel Index and EFAT2 (r = -0.765, p = 0.01) and both measures were found to be sensitive as determined by Cohen's effect size (EFAT2 = 0.60, Barthel Index = 0.72). High inter-rater reliability was noted for EFAT2 (ICC3, 1 = 0.85) and the agreement between scores was confirmed by Bland-Altman analysis. EFAT2 showed concurrent validity with the Barthel Index when used to assess the effects of rehabilitation on participants with advanced cancer. The tool was sensitive to change and was found to be reliable when used by different raters. The findings indicate that EFAT2 might be an appropriate outcome measure to use within the palliative care setting. However, the feasibility of using EFAT2 needs to be explored and larger studies are required to confirm its reliability.

Results from a structured interprofessional palliative care rehabilitation program in oncology.

e20598 Background: Post-treatment patients with active cancer face considerable burden from the effects of both disease and treatment. The Palliative Rehabilitation Program was designed to ease those challenges and to improve the patient’s functioning. The current study evaluated the changes in function scores of patients with advanced cancer upon completion of the structured program and examined the medical predictors of program completion. Methods: Referrals for 173 patients who were finished anticancer therapy were received. One hundred and thirty six patients were eligible and enrolled in the eight-week interprofessional palliative rehabilitation program. Of those, 84 completed the program. Measures of physical, nutritional, social and psychological functioning were evaluated at entry and completion of the program. Results: Significant improvements were experienced in physical performance (P =0.000), nutrition (P =0.000), symptom severity (P=0.005 to P= 0.000), symptom interference in functioning (P =0.001 to P=0.000), and fatigue (P=0.001 to P=0.000). Reasons for not completing the program were: disease progression, geographical inaccessibility, being too well, dying, and personal/unknown reasons. A normal CRP level (<10mg/L; P=0.013) was a predictor of program completion. Conclusions: Patients living with advanced heterogeneous cancers who underwent an interprofessional palliative rehabilitation program experienced significant improvement in their functioning in many domains. Program completion can be predicted by normal CRP level.

More than Physical Function? Exploring Physiotherapists’ Experiences in Delivering Rehabilitation to Patients Requiring Palliative Care in the Community Setting

Physiotherapists, as essential members of the multidisciplinary palliative care team, are key to the successful rehabilitation of palliative patients. There is, however, a scarcity of literature on the experiences of primary care physiotherapists delivering this service. This study explored the experiences of physiotherapists delivering rehabilitation in palliative care and identified perceived barriers and enablers. A qualitative approach was adopted involving semistructured interviews with a purposive sample of primary care physiotherapists (n = 11). Participants viewed rehabilitation as helping to maximize independence and improve quality of life for palliative patients. Their role was primarily focused on physical functioning but within an overall philosophy of providing comfort and supportive care. Several barriers and enablers to delivering rehabilitation were identified; these were related to communication, resources, teamwork, and training. Physiotherapists believed that rehabilitation adds value to palliative care, but existing barriers limit the service. Improved collaboration and timely access to resources could assist in the provision of rehabilitation to palliative patients.

Should community-based services be publicly funded or contracted out?

The introduction of Canada's Medicare in 1966 established precedence for a universally accessible and equitable healthcare system. Although Canada has been a leader in building the foundations of socialized medicine, it has stalled short of fulfilling a vision promulgated by its architects of a system that operates on a continuum of care. The aim of this review was to examine whether the expansion of publicly funded services under the Canada Health Act would be an economically and socially viable policy option. A literature review of the direct and indirect social and economic costs associated with contracting out community-based services in the form of outpatient rehabilitative care, palliative care, and home care was conducted. This article concludes that the private financing of community-based services increases healthcare costs in the long term through increased density and frequency of acute care utilization. It is associated with increased indirect costs in the form of caregiver burden and reduced labor market participation of informal caregivers. The expansion of publicly funded community-based services minimizes these direct health and indirect societal costs. The integration of publicly funded community-based services under the Canada Health Act would ensure that the principles of Medicare in the form of equity and accessibility would be enforced while maintaining an economically sustainable healthcare system.

The Role of Acceptance in Rehabilitation in Life-Threatening Illness

ContextPalliative care rehabilitation aims to maximize physical and psychological functioning, but negative thoughts can hinder patients from attempting this approach. Acceptance and commitment therapy (ACT), a modified form of cognitive behavioral therapy, encourages individuals to experience and manage negative emotions by focusing on changing individual behavior and so improve functioning. ACT has been used in many health-related behavioral interventions but not in palliative care rehabilitation. ObjectivesTo investigate the relationship between acceptance (often called experiential acceptance in ACT) and psychological and physical status. MethodsCross-sectional study in which a consecutive sample of patients attending a specialist palliative care day therapy unit for rehabilitation completed the Acceptance and Action Questionnaire-II to measure acceptance and the Kessler-10 questionnaire to measure psychological morbidity. Physical function was assessed by a timed two-minute walking test and one-minute sit-to-stand test. Correlation statistics and multivariable regression analyses were used to explore the strength of relationships between acceptance and psychological morbidity and physical function. ResultsOne hundred one patients were recruited, mainly white women with a mean age of 64 years. Correlation analysis showed a negative association between acceptance and psychological morbidity (r=−0.59) and a positive association between acceptance and sit to stand (r=0.27) and distance walked (r=0.21). All three of these relationships were statistically significant after adjustment. ConclusionThese associations suggest that it may be possible to reduce psychological morbidity and improve physical mobility by increasing patients' acceptance using an ACT-based intervention. Future work is now needed to develop an ACT-based intervention in palliative care rehabilitation and test its acceptability and feasibility.

Allied health professional's views on palliative care for people with advanced Parkinson's disease

Mary Waldron, W George Kernohan, Felicity Hasson, Susan Foster, Barbara Cochrane, Cathy Payne Aims: Allied health professionals (AHPs) have a key role in the delivery of palliative care through rehabilitation. However, evidence suggests that rehabilitation remains an area of neglect in palliative care. This study explores the views of allied health professionals in delivering rehabilitation in palliative care to people with Parkinson's disease. Methods: Twelve allied health professionals, from both generalist and specialist settings, who had experience of working with people with advanced Parkinson's disease and/or palliative care took part in interviews and/or focus groups. Findings: Participants viewed palliative care as holistic care, however, the rehabilitation care they provided was impeded by a number of personal and organisational barriers, and negative perceptions. Misconceptions as to the value of rehabilitation in the palliative stage and a lack of training resulted in uncertainty as to when and how it could be introduced. While the importance of early referral to AHP rehabilitation services was highlighted, organisational and administrative barriers prevented many people from accessing such care. Conclusions: Many health professionals have a role in palliative rehabilitation, but barriers prevent early referral and ongoing access to such services. There is a need to educate professionals in the principles of palliative rehabilitation, combined with providing targeted resources to promote shared care and responsibility.

Improving quality of life through rehabilitation in palliative care: Case report

Occupational and physical therapists can have a significant impact on the quality of life of terminally ill cancer patients. In the critical care setting, rehabilitation is often overlooked. However, occupational and physical therapists work with critically-ill patients to create realistic and meaningful goals for improving comfort, mobility, socialization skills, and ability to care for oneself regardless of disease state and medical status. The following case report describes rehabilitation intervention with a young woman diagnosed with osteosarcoma and leukemia during the final stage of her life. This case report highlights the use of patient-centered goals and the importance of close collaboration between the patient, occupational therapist, and physical therapists to achieve a higher quality of life. A collaborative effort by the occupational and physical therapists yielded positive outcomes as defined by the patient, patient family, and the medical staff in the critical care setting. Palliative care patients may benefit from occupational therapy (OT) and physical therapy (PT) intervention. Rehabilitation specialists are skilled at working with patients to set realistic and meaningful functional goals. Further study on rehabilitation treatment to improve quality of life among patients in palliative care is needed.

University of Washington School of Medicine

University of Washington School of Medicine

Are You Ready for a Palliative Workout?: Utilizing Physical Rehabilitation in Palliative Care (729)

Are You Ready for a Palliative Workout?: Utilizing Physical Rehabilitation in Palliative Care (729)

Participants’ perceptions of groupwork in the management of cancer symptoms in older people

This paper explores groupwork within rehabilitative palliative care on three distressing cancer symptoms: pain, dyspnoea and fatigue. This was achieved through qualitative methodology using a phenomenological orientated psychological approach in a cohort with a median age of 66 years. Groupwork, which included: social, exercise and divertional therapy groups were seen as important components within rehabilitative palliative care. Through semi-structured interviews the participants’ perceptions of their symptoms, beliefs and attitudes towards their groupwork within rehabilitative palliative care were explored. The relevance and benefits of the groupwork were then identified using quality of life markers established during data analysis. The main factors uncovered and shown to contribute to the groupwork were: environmental factors, mobilisation and normalisation. However more research is required to comprehend how different forms of groupwork can help reduce pain, dyspnoea and fatigue in older people with cancer.

Palliative care rehabilitation survey: a pilot study of patients’ priorities for rehabilitation goals

Rehabilitation in palliative care is often overlooked. Settings that do consider occupational or physical therapy for palliative care patients often consult to therapists with competing caseloads. Few therapists specialise in palliative care, but nearly all ask, ‘What needs doing’? and ‘How well am I doing that’? No existing instruments address their questions. The objective is to develop and test a questionnaire for identifying patient goals and priorities for rehabilitation in palliative care. A questionnaire representing 11 domains of the Canadian Model of Occupational Performance was designed and pilot tested at four palliative care sites. Each question reflected a typical rehabilitation intervention in palliative care. Patients were asked to rate how important each of these interventions was on a numerical rating scale (0, not important–10, extremely important). Open-ended questions captured verbatim comments regarding thoughts of rehabilitation. The questionnaire was tested for test-retest reliability with two interviews approximately 1 week apart. Forty patients participated in the first interview and 32 in the second. Eight of eleven domain sub-scores achieved an intra-class correlation coefficient of 0.6 or higher. The highest means were for the physical (8.2), institutional (7.8) and self-care (7.8) domains on the first interview and for the spiritual domain (7.9) on the second interview. Suggestions are provided to shorten the questionnaire and strengthen validity. This work furthers the understanding of the role of rehabilitation in palliative care. It also illustrates the feasibility of involving palliative care patients in research that contributes to setting standards and measuring quality of service.

Biology, not chronology, driven treatment of breast cancer in the elderly

Breast cancer is the most common cancer site in women, with 1.15 million new cases worldwide each year, of which 361,000 (27.3% of all cancers in females) are in Europe and 230,000 (31.3%) in Northern America. This means that half, if not more, of these patients are in other parts of the world, a fact recognised by the World Health Organization (WHO), which has put cancer among its health priorities on a global scale. In 2002, 411,000 women died of breast cancer worldwide, and most of these were aged 65 years or older. This is explained by the following figures. The crude incidence of breast cancer in Northern America in comparison with North and Western Europe is 141.9 and 130.0 per 100,000 females per year, respectively. Breastcancer-related mortality is 29.8 and 41.0 per 100,000 females, respectively. For those aged 65 years and older, crude incidence rates are 432.7 per 100,000 females in Northern America and 295.0 per 100,000 in Northern and Western Europe; corresponding breast cancer mortality figures are 121.2 and 135.0 per 100,000 females, respectively. Similar incidence rates and mortality figures are found in South America (Argentina and Uruguay), New Zealand and Australia, and in Central/Eastern Europe. With increasing age, patients will suffer from ailments related both to senescence and to cancer. Many will need the expertise of the geriatrician and of the oncologist, who will participate in specific case discussions to look at social and medical issues that will affect the treatment plan (with surgery, radiation and drug therapy, rehabilitation and supportive and palliative care questions often intertwined). The wishes of the patient are key in this discussion. 1 The variable reality of family or community support must also be taken into consideration, as this differs so widely among cultures; the ways in which these cultures are changing are also important, especially as the modern world moves very fast – faster than most elderly (and not so elderly) people can apprehend. 2

Biology- not Chronology-driven Treatment of Breast Cancer in the Elderly

Breast cancer is the most common cancer site in women, with 1.15 million new cases worldwide each year, of which 361,000 (27.3% of all cancers in females) are in Europe and 230,000 (31.3%) in Northern America. This means that half, if not more, of these patients are in other parts of the world, a fact recognised by the World Health Organization (WHO), which has put cancer among its health priorities on a global scale. In 2002, 411,000 women died of breast cancer worldwide, and most of these were aged 65 years or older. This is explained by the following figures. The crude incidence of breast cancer in Northern America in comparison with North and Western Europe is 141.9 and 130.0 per 100,000 females per year, respectively. Breastcancer-related mortality is 29.8 and 41.0 per 100,000 females, respectively. For those aged 65 years and older, crude incidence rates are 432.7 per 100,000 females in Northern America and 295.0 per 100,000 in Northern and Western Europe; corresponding breast cancer mortality figures are 121.2 and 135.0 per 100,000 females, respectively. Similar incidence rates and mortality figures are found in South America (Argentina and Uruguay), New Zealand and Australia, and in Central/Eastern Europe. With increasing age, patients will suffer from ailments related both to senescence and to cancer. Many will need the expertise of the geriatrician and of the oncologist, who will participate in specific case discussions to look at social and medical issues that will affect the treatment plan (with surgery, radiation and drug therapy, rehabilitation and supportive and palliative care questions often intertwined). The wishes of the patient are key in this discussion. 1 The variable reality of family or community support must also be taken into consideration, as this differs so widely among cultures; the ways in which these cultures are changing are also important, especially as the modern world moves very fast – faster than most elderly (and not so elderly) people can apprehend. 2

The management of motor neurone disease

The management of motor neurone disease (MND) has evolved rapidly over the last two decades. Although still incurable, MND is not untreatable. From an attitude of nihilism, treatments and interventions...

The NCI-Ireland consortium: a unique international partnership in cancer care.

The Ireland-Northern Ireland-National Cancer Institute Cancer Consortium was launched in October of 1999, at a conference in Belfast, Northern Ireland, for the development of cancer programs in Ireland and Northern Ireland, where cancer is a significant cause of mortality and morbidity. Cancer services there have undergone major restructuring as a result of several government reports. Specifically, the National Strategy Document for Cancer proposed that cancer treatment services should be centered around primary care services, regional services, and a national coordinating structure where supra-regional centers would deliver specialist surgery, medical and radiation oncology, rehabilitation, and specialist palliative care. Therefore, this was an opportune time to bring the National Cancer Institute (NCI) on board in a determined effort to redevelop and significantly improve services and outcomes for cancer patients throughout the island. During the NCI All Ireland Cancer Consortium, initial major goals were established as follows: A) To share best available technology and enhance clinical research; B) conduct joint clinical research studies involving people from all jurisdictions; C) sponsor formal training exchanges for Irish and American scholars in cancer programs in partner institutions; D) implement the use of teleconferencing, telesynergy, and other information technology capabilities to facilitate education, and E) consolidate the Cancer Registries of Ireland and Northern Ireland and learn more about cancer incidence and trends on the entire island. In the past year, significant advances have been made in all these areas. Plans are already under way for the second NCI All Ireland Cancer Conference which will be held in late 2002 and feature speakers from Ireland, Northern Ireland, the U.S., and other areas. It will be open to all oncologists, researchers, nurses, students, and other health care professionals interested in learning and enhancing cancer care and research.

Rehabilitation and specialist palliative care

Enabling individuals to achieve their maximum potential and quality of life following a diagnosis of advanced cancer, has long been a stated aim of palliative care. Increased life expectancy and the introduction of specialist palliative care to patients at an earlier stage of their illness presents professionals in the specialty with new challenges in meeting the need for rehabilitative care. This article examines some of the recent developments affecting the provision of rehabilitative care and describes one specialist palliative care unit's response to the challenge, highlighting the role of a nurse-led clinic within the service framework.

The NCI All Ireland Cancer Conference

The NCI All Ireland Cancer Conference

District nurses' views on the role of rehabilitation in palliative care.

Recently, there has been a surge of interest in the notion that rehabilitation should become an integral part of palliative care. The World Health Organization (WHO; 1987) asserts that integrating a rehabilitative approach will assist in achieving the aims of palliative care by enhancing the patient's quality of life. However, WHO suggests that health-care workers have not yet appreciated the opportunities presented by this approach in order to be able to succeed in achieving the aims of palliative care. District nurses (DNs) are in a key position to integrate the philosophy of rehabilitation and their approach to palliative care. A small study was undertaken to investigate the beliefs of DNs in relation to rehabilitation in palliative care, specifically with regards to patients with cancer. The findings demonstrated that DNs generally support the view that rehabilitation has a role to play in palliative care. However, barriers which, according to the literature, prevent a rehabilitative approach being used were identified as problematic for this sample group. The findings have helped to identify areas that should be addressed; these have implications for clinical practice, management of resouces and education.