As our population ages, people aged 85 or older are predicted to account for 43.5% of all deaths by 20301. This longevity is often compromised as people live with and die from chronic diseases such as chronic obstructive pulmonary disease (COPD), heart failure and dementia, which can lead to increasing levels of disability and dependency on informal carers and healthcare services2. Palliative care providers need to think strategically about how to support these patients in the future, many of whom have conditions other than cancer.
‘Rehabilitation as an approach to palliative care’ challenges how we care for patients with advanced conditions to promote and empower greater patient independence3. While rehabilitation is not a new concept in palliative care, the difference lies in the whole interdisciplinary team adopting a ‘rehabilitative approach’ to care, which enables patients to do as much as they can for themselves and supports them to adapt to changes in function related to their condition. In all care settings, there is a danger that care that is intended to be supportive may disable patients by compromising opportunities for them to do things for themselves.
For example, Janet has a diagnosis of advanced COPD and is admitted to the hospice for control of her breathlessness. She normally lives at home alone, gets up on her own and uses her adapted shower independently. She dresses into clothes and spends the day indoors, walking with her frame, able to prepare light meals and cups of tea.
During her admission, supported by the hospice team Janet’s breathlessness improves; however, she spends most of the day in her pyjamas, has an assisted wash, uses the commode, has cups of tea brought to her bedside and only walks when the physios take her down to the gym. She feels more uncertain about walking to the toilet yet she easily managed the same distance at home two weeks earlier. Within two days of discharge home Janet is readmitted to the hospice as she is not coping.
A rehabilitative approach aims to prevent the deconditioning described above and to maintain a patient’s ability to function independently within the limitations of their illness. Central to this is the establishment of a patient’s functional level before admission, which allows care to be tailored to their individualised routines and abilities. By assessing Janet’s function, enabling her to actively participate in care, eg having a supported shower, dressing into clothes and walking to the toilet, we may help Janet to maintain independence and give her confidence to manage at home.
Several rehabilitative initiatives are listed in the box above; these draw on increasing evidence to support that patients have scope for functional improvement despite advanced disease and short prognosis4, 5, 6.
Rehabilitation as an approach to palliative care represents an increasingly key part of the future picture, bringing together health promotion and supportive palliative care to maximise the quality of life of patients and their carers.
References
- Gomes B, Higginson IJ. Where people die (1974-2030): past trends, future projections and implications for care. Palliative Medicine 2008; 22(1):33-41.
- Hall S et al, (eds). Palliative care for older people: better practices. World Health Organization Europe, 2011.
- Cane F, Jennings R, Taylor JA rehabilitation training programme at the end of life. End of Life Journal 2011; 1(1).
- Scialla S, Cole R, Scialla T, Bednarz L, Scheerer J. Rehabilitation for elderly patients with cancer asthenia: making a transition to palliative care. Palliative Medicine 2000; 14(2):121-7.
- Cheville A. Rehabilitation of patients with advanced cancer. Cancer 2001; 92(4s):1039-48.
- Oldervoll et al. Physical exercise for palliative care patients. 2011. (accessed 31 January 2013).
This article was originally published in volume 9, issue 1 of the Hospice Information Bulletin.
You can contact Rebecca at R.Jennings@STJH.org.uk
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