Introduction
From the time that we take our first breath, there is one thing that is inevitable and that is death. The journey from birth to death defines life, and how well it is spent defines its quality. To ensure good quality of life for our patients, we must understand palliative care and rehabilitative measures and that early integration of these measures could promote a better and complete recovery from an ailment or even a better quality of death.
Palliative Care
The World Health Organization (WHO) defines palliative care as “… an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.”
Palliative Care in Acute Care Settings
The demand for palliative care is greater than ever before, largely driven by the increase in the aging global population and the accompanying increased burden of chronic disease, including stroke, ischemic heart disease, lung cancer, and other chronic progressive diseases—the leading causes of death globally. ,
According to the WHO Global Health Estimates, more than 20 million people worldwide require palliative care at the end of their life every year, with the majority from the older population over 60 years of age. The major noncommunicable diseases that account for palliative care requirement are cardiovascular diseases, cancer, chronic obstructive pulmonary diseases, HIV/AIDS, and diabetes. The increased burden of chronic disease that accompanies the aging population shows an alarming trend for increased palliative care requirements. This raises the question of where will all the people requiring palliative care be accommodated? Would it be at home, hospice, hospital, or communal establishment for the care of the sick? Are we future-ready to deliver these services?
Acute care hospital settings include more than one-third of inpatients who need palliative care services. The requirement of such care in cancer patients is well recognized, but despite this, many cancer patients are missed by physicians and die in hospitals without being identified as needing palliative care. Failure to recognize palliative needs could result in unnecessary interventions for the patient, and prolonged and inappropriate hospitalization, thereby increasing the financial stress on the patient and associated family members, thus impacting their quality of life. There is a need to train health care professionals to identify patients who are facing their last stage of life and require palliative care. Patients with chronic diseases often present to the hospital with acute exacerbations. At times, it becomes challenging for health care professionals to distinguish whether these deteriorations are treatable or require a palliative approach. Therefore it is very important to introduce the concepts of palliative care to all health care professionals to sensitize them to effectively deliver quality of care that embraces timely onset of palliative care when indicated.
Delivery of Palliative Care
Several models exist for the delivery of palliative care, including hospice care, care homes, community care, hospice programs in partnership with hospitals, or within acute care hospitals. Palliative care can be provided at three different levels: (a) primary palliative care, which refers to basic skills and knowledge acquired by all the physicians; (b) secondary palliative care, which refers to specialist clinicians providing consultation and specialty care; and (c) tertiary palliative care, which refers to an academic medical center where specialist care is provided along with academic research and the training of students and professionals. The provision of secondary or tertiary levels of palliative care embraces a more comprehensive management for patients and their family members that incorporates control for physical symptoms, psychologic distress, and spiritual and financial issues during patient management.
Palliative care is conducted within the framework of interdisciplinary teamwork, which comprises physician, specialist clinician, nursing staff, social worker, physical and occupational therapist, dietitian, pharmacist, and spiritual counsellor. They can provide their services on a consultative basis or be integrated within the hospital services. ,
Goals of Palliative Care in the Acute Care Setting
As in other fields of medicine, palliative care clinicians aim to provide comfort to their patients, and patients and caregivers are at the center of their management plans. It is important to discuss the goals of care with patients, their family members, and caregivers. A clear communication of goals will improve patient satisfaction, avoid aggressive interventions, reduce hospitalization, and help patients deal with pending family issues or events, if any. These factors contribute to better care through the end of life.
Transition or shift to palliative care also needs be addressed and studied carefully. Usually the patients are identified as palliative only a few months before death or at the final admission before death. The timing and frequency of providing palliative care needs to be reviewed so that it is not seen as the last option of management. There is an urgent need to understand that if introduced early in the disease trajectory, palliative care will be more beneficial to patients. ,
What Is Delivered Within a Palliative Care Pathway?
In an acute hospital environment, the intent of treatment is curative, and the majority of health care professionals are attuned to this approach of management. It is critical to integrate the knowledge of recognizing the palliative needs early in the trajectory of life-threatening diseases. Palliative care aims to manage physical symptoms, and the psychologic and spiritual needs of patients to provide maximum comfort to patients, their caregivers, and family members. Some of the most commonly experienced symptoms include pain, dyspnea, cough, nausea, vomiting, constipation, fever, anxiety, insomnia, and delirium, and studies have shown better control of pain and other symptoms if the palliative approach begins along with the curative intent in the early course of disease. The timing of providing palliative care is important; at the end stage of life, the focus of care should be linked with the physical symptoms and not with a specific diagnosis. While managing patients with life-threatening conditions in an acute hospital setting, an early recognition of the palliative care needs of the patient is very critical. An early palliative care can help in maximizing the comfort of the patient and their caregivers.
Barriers to Palliative Care in the Acute Setting
Providing palliative care in an acute care setting, where needs of the patients are complex and varied, is challenging and many barriers may be encountered. These barriers may include the following.
The Hospital Environment
The acute hospital setting is typically an environment of curative intent, where nursing and medical staff are attuned to diagnostic tests, prescribing drugs, and therapeutic procedures, and is quite unlike hospice care. The propensity to administer numerous procedures and medications, which are not actually required, places a barrier to effective palliative care. An acute setting often recognizes recovery as success and death as failure, thereby posing a hindrance to delivery of effective palliative care.
Reduced Awareness and Insufficient Knowledge
Although palliative care is gaining in much-deserved value, which is a need of the hour, there remains a dearth of awareness and knowledge amongst health care professionals. Specialist palliative care referrals are made in the hospital but are often limited to oncology patients, leaving a vast majority of noncancerous patients, especially in the older age group, requiring these specialized services. , It is important to educate nursing, allied health science, and medical students at the initial levels to sensitize them to the palliative requirements of the patient. , Working health care professionals also need to be updated regarding recent guidelines and practices for effective delivery of palliative services. ,
Disease Trajectory
With the diagnosis of terminal illness patients may experience varied symptom levels up until death, as disease trajectory does not follow a straight path. There may be times when the patient deteriorates and needs hospitalization but with prompt management they can recover from an acute episode. Recovery from such acute episodes creates hope among the patients, family members, and caregivers. Patients might experience such episodes repeatedly along the course of disease. Having seen patients recover from such acute episodes makes it difficult for the attending health care professionals, family members, and caregivers to recognize the terminal phase. It is important to identify transitions in the disease trajectory and to communicate this effectively to family members when the patient enters their terminal phase. Knowledge in palliative care serves as a guide to making the right decision.
Lack of Advance Care Planning
A lack of advance care planning often results in situations where patients are not able to fulfill their wishes, especially their last wishes. For example, a patient may wish to spend the terminal days of life at home, or the patient may have unfinished family matters, or may be waiting to see a close relative or friend. There are many such issues that could be dealt with by having an effective advance plan of care. Patients must be encouraged to discuss their wishes with their family members so that they can attempt to fulfill these wishes. Respecting the patient’s choice facilitates effective advanced planning, which is associated with more satisfied family members and caregivers. , The palliative care team must establish the goals of care and prepare in advance for the anticipated outcomes. The decision of withholding and withdrawal of treatments, consent for do not resuscitate (DNR) orders, role of parenteral feeding, diagnostic investigations, and intravenous antibiotic use are some of the points to be discussed.
Rehabilitation
Palliative care is best delivered within a multidisciplinary framework that involves health care professionals from various fields, such as medicine, psychiatry, oncology, anesthesiology, neurology, and nursing, and allied health practitioners, e.g., dietitians and rehabilitation medicine specialists. The role of rehabilitation is crucial to achieving and maintaining the maximum functional capacity of the patients to help improve their quality of life.
What is Rehabilitation?
Rehabilitation is defined as “A set of measures that assist individuals, who experience or are likely to experience disability, to achieve and maintain optimum functioning in interaction with their environments.” Rehabilitation is provided in a variety of settings, including acute care hospitals, nursing homes, institutions, hospices, residential educational institutions, military settings, and single multiprofessional practices. Longer-term rehabilitation is also provided inside community settings and facilities, such as primary health care centers, rehabilitation centers, schools, workplaces, or homes.
Why Do We Need Rehabilitation in an Acute Care Setting?
Patients may need hospitalization due to an injury or acute illness, or an acute episode of exacerbation from a chronic illness. During the hospital stay, patients encounter reduced activity levels, decreased mobility status, and often prolonged bed rest. All these factors lead to a decrease in the patient’s functional capacity, deconditioning of the body systems, and increased risk of disability. This is especially true for the patients with preexisting comorbidities or older age, and chronically ill or disabled patients. The reason for hospitalization is often treated, but patients are in a worse situation due to decreased functional capacity. Given that increased levels of physical activity are associated with improved quality of life, , it therefore serves that early rehabilitation is important for a speedy and complete recovery from an acute illness or injury.
Goals of Early Rehabilitation
Rehabilitation should begin early in case of an acute illness. We must establish the goals of rehabilitation after a thorough assessment of the patient’s musculoskeletal, neurologic, cardiovascular, psychologic, and functional status. , Their functional independence must be assessed, and they should be evaluated for the need of orthotic or prosthetic aids.
The goals of rehabilitation are to improve functioning, maximize recovery, achieve early mobility, minimize complications, and prevent long-term disabilities. Providing physical therapy in an acute setting can be challenging, in that therapists do not just treat a particular system or body part but rather manage the patient as a whole. The patient must be monitored for any fluctuations in their heart rate, blood pressures, oxygenation levels, pain levels, and other vital observations. After setting the goals for a prehabilitation program this must then be communicated to the treating physician, nursing staff, patients, and their family members.
Rehabilitation Interventions
To achieve the aforementioned goals of rehabilitation, the rehabilitation team or the physical therapist can make use of the following techniques/methods that consider the desired goals, patients’ limitations, and abilities.
Therapeutic Exercises
Immobilization due to an acute illness can induce musculoskeletal deconditioning as a result of a decrease in the muscle mass and reduced recruitment levels. , Active exercises have been shown to improve muscle strength by increasing motor neuron recruitment and muscle mass. Patients must be encouraged to actively move their joints and strengthen the muscles. Therapeutic exercises are based on the needs of the patient and are outlined in Table 44.1 . For example, if the patient has complete loss of muscle strength, passive range of motion exercises along with neuromuscular stimulation is the intervention of choice. If the patient is unable to initiate muscular contraction due to pain, neuromuscular electrical stimulation (NMES) can be used along with active-assisted exercises to prevent disuse atrophy of muscles. NMES has been useful in many fields, including cardiovascular, orthopedic, neurologic, geriatric, and sports medicine and many more for improving muscle strength. , NMES is used extensively after total knee arthroplasty. Its early use in the postoperative phase has been shown to reduce the loss of quadriceps muscle strength and improve functional performance.
| S. No. | Type of Exercise | Description of Exercise | Therapeutic Effects of Exercise |
|---|---|---|---|
| A. | Active exercises | ||
| Free Exercise | During these exercises the active muscle groups are subjected only to the force of gravity. |
| |
| Assisted exercise | These exercises are assisted by an external force to compensate for inadequate muscle strength or coordination. |
| |
| Assisted-resisted exercise | During these exercises the active muscle groups are subjected to resistance only in a part of the range, as they are still not strong enough to endure resistance throughout the range. |
| |
| Resisted exercise | During these exercises the working groups of muscles are subjected to resistance systematically to develop power and endurance. |
| |
| B. | Passive Movements | ||
| Relaxed passive movements | These movements are produced by an external force (by the therapist or an external device) during muscle inactivity or when the muscle strength is too low to permit active movements. |
| |
| Mobilization of joints | Small repetitive oscillatory localized movements performed by the therapist. |
| |
| Manipulation of joints | These are small amplitude and high velocity movements performed by the therapist at the limit of the available range of motion of joint. |
| |
| Controlled sustained stretching of tightened muscles | This involves passive stretching of the muscle and other soft tissue to increase the range of movement. |
| |
Movement can also be promoted by using cycle ergometry either actively or passively. This enhances blood circulation and prevents bed rest complications. Studies promote their early use to improve the functional status of the patient. ,
Once the patient has mastered active exercises, they can be progressed by the addition of resistance. Resistance can be applied manually (by the therapist) or mechanically (using free weights, pulleys, springs, water, elastic tubing, etc.). Low-resistance strengthening exercises with high repetitions have been shown to improve muscle strength, force generation capacity, and overall physical function in patients with an acute illness or during an acute exacerbation of a chronic illness. ,
When prescribing an exercise program the feasibility and safety of the exercises must also be considered. Berney et al. conducted a cohort study in which 74 patients admitted to the intensive care unit (ICU) received a protocolized rehabilitation program that began in the ICU and continued in the acute care ward for a further 8 weeks following hospital discharge to the outpatient program. The protocol included strength training, functional retraining, and cardiovascular exercises. These exercises were found to be safe and feasible for survivors of critical illness.
Positioning
A comfortable position promotes the well being of the patient. Proper positioning should make the patient pain free, help to increase lung function, support the affected area or limb, and prevent bedsores. Prone positioning is found to facilitate oxygenation, improve ventilation-perfusion mismatch, and enhance lung compliance and mobilization of secretions. , Positioning on the patient’s side, with the affected lung on the upper side, helps to improve oxygenation of the affected lung. , Positioning can also be used in various neurologic conditions such as stroke, multiple sclerosis, and spinal cord injury to reduce abnormal tone, maintain skeletal alignment, and prevent contractures. ,
Pulmonary Rehabilitation
Regular chest physiotherapy in an acute care setting helps in early recovery, reducing the dependency on mechanical ventilation and decreasing the days of hospitalization. It also helps in reducing the incidence of respiratory infection. The goals of respiratory physiotherapy are to enhance lung function and lung capacities, promote secretion clearance, optimize oxygenation, and prevent ill effects of bed rest such as atelectasis and infection. , There are various techniques utilized for pulmonary rehabilitation, and some are described in Table 44.2 .
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