Cancer rehabilitation and palliative care: critical components in the delivery of high-quality oncology services

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Read Full Text: Cancer rehabilitation and palliative care: critical components in the delivery of high-quality oncology services (Free to access)
Journal: Supportive Care in Cancer
Year Published: 2015
Ranked 22nd on our 2015-2020 list of the 100 most influential OT-related articles

Isn’t it nice when really smart people sit down to explain the value of OT on our behalf? :slight_smile:

This special report outlines the role of occupational therapy in cancer care, and it explains how OTs work alongside other rehab professionals and palliative care teams.

The author’s arguments may push you to think more broadly about the services you could potentially provide to patients with cancer. This paper might also serve as a shared resource to get your whole team on the same page with how to provide high-quality oncology services.

Let’s dive in.

The current problem: rehab and palliative care are underutilized in the cancer population

The majority of cancer patients (and survivors) would benefit from rehab and palliative care—but the underutilization of these services is well documented.

In fact, in the Club, we’ve already looked at research that highlighted the underutilization of OT in a specific hospital system.

The reasons for this underutilization are complex.

But, in order to provide patients with the care they deserve, we need to start with the basics: we must encourage healthcare professionals to better understand the roles of both rehab and palliative care in managing the effects of cancer. (Ideally, this will lead to more professionals recommending rehab and palliative care early in the course of oncology care.)

Which is where this paper comes in…

What was the intent behind this report?

Due to the underutilization of these valuable cancer care services, the authors sought to:

  1. Define cancer rehab and palliative care
  2. Explain these services’ roles in care delivery
  3. Highlight how these services can be critical to providing high-quality oncology care

How are cancer rehab and palliative care similar?

Let’s start by emphasizing how cancer rehab and palliative care are similar. (I know we like to focus on the distinct value of OT in the Club—but when it comes to a team approach, understanding our shared mission and values is essential.)

Cancer rehab and palliative care share a common clinical philosophy and approach, including:

  • Using an interdisciplinary model of care
  • Seeking to improve patients’ function
  • Developing treatment plans that are patient- and family-centric
  • Taking into account medical, physical, social, and psychological components
  • Valuing shared decision-making
  • Improving healthcare efficiency (and decreasing costs!) by reducing the duration of hospital visits and preventing unanticipated readmissions

Considering the gravity of the list above, it’s not surprising that there are set policies and procedures for referring patients to rehab and palliative care. (You can find American College of Surgeons’ Standards for Optimal Cancer Care here.)

Ok. Next let’s look at the unique value of cancer rehab, and then we’ll move on to palliative care:

Fostering a better understanding of cancer rehab

Let me preface this section by acknowledging that too many people (including fellow healthcare professionals) are confused about the role of rehab in cancer care.

In fact, the authors specifically mentioned the tendency of people to confuse rehab with exercise programs. They also mentioned a concerning trend of oncologists adopting a “cardiac rehab” approach to cancer care, where doctors tend to focus on one bodily system or impairment. Any therapist would immediately recognize the flaw in not considering the multiple co-occurring impairments cancer patients often experience.

Patients with cancer can present with complex profiles, including many functional impairments, which can be overwhelming for oncologists to navigate alone. That’s why it’s so critical they turn to the expertise of rehab professionals, who are accustomed to treating complex diagnoses.

The article goes on to specify two areas of cancer rehab:

Prehabilitation:

Prehabilitation is the cancer rehab that occurs between the time of diagnosis and the beginning of acute treatment. It includes physical and psychological assessments in order to:

  • Establish a baseline level of function
  • Identify impairments
  • Provide targeted interventions that promote physical and psychological health, in order to reduce the incidence and/or or severity of treatment-related impairments

Impairment-driven cancer rehab:

This is the phase of rehab with which we are probably most familiar. The article cited “Impairment-driven cancer rehab: an essential component of of quality care survivorship” as a resource related to this topic. OTs and other rehab professionals can help address some of the following impairments experienced by patients with cancer:

  • Fatigue
  • Pain
  • Weakness/asthenia/cachexia
  • Dyspnea
  • Delirium
  • Anxiety
  • Depression
  • Cognitive decline
  • Peripheral neuropathies
  • Plexopathies
  • Myopathies
  • Radiation fibrosis

Fostering an understanding of palliative care

As you probably know, palliative care is focused on providing relief from the symptoms, pain, and stress caused by serious illness.

Unfortunately, palliative care has become primarily associated with end-of-life care. And, it’s often viewed as something to try only when rehab and other interventions are no longer effective.

But, this is simply not the case.

Palliative care is appropriate at many stages of disease—and should be provided in conjunction with interventions (like rehab) that are intended to cure or halt progression.

So, how do we move into this new era of closer collaboration?

Step one of closer collaboration between rehab, palliative care, and the entire cancer care team seems to be education; we should simply seek to understand each profession’s shared values and distinct contributions to care.

The goal is to move into a phase the authors call “collaborative interdisciplinary care”—where the teams work together within their own respective specialties to address cancer-related issues.

The authors also stressed the importance of patient-centered outcome measures. They highlighted the report “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life,” which emphasized that end-of-life care continues to be characterized by fragmented care and unmet needs.

(Honestly, I do not need to look beyond my own social circle to confirm this is still the case.)

What screens are appropriate for referral to rehab and palliative care?

The authors’ last step toward increased collaboration was access to rehab and palliative care. Performing regular screens throughout the continuum of care is one way to promote more timely referrals. While there is not one universally recognized screen, I’m going to list the currently available screens, because many of them can be used in your assessment, as well:

What did the authors conclude/discuss?

I love how the authors summed it up:

“With the challenging goals of simultaneously lowering healthcare costs while improving patient outcomes and satisfaction with care, there is an urgent need to address under-utilization of both cancer rehabilitation and palliative care services, as well as improve access."

Takeaways for OT practitioners

(These are my personal takeaways, and were not mentioned in the article.)

1. You play a unique and extremely important role on the cancer care team.

One of the barriers to rehab collaboration in care was simply lack of perceived experience with medically complex patients. I have personally felt this as a practitioner. But, one thing this article drove home for me was how important it is to have these patients on our caseloads—not because we have all of the answers, but because as a team member we bring a needed and valuable approach to care.

2. Maybe we need to be more intentional about forming relationships with our local cancer care centers?

For some reason, when I thought of health professionals in my community with whom to reach out to and build relationships, I never thought to reach out to our local cancer care center. I think I thought of their care as too specialized and stand-alone, and I guess I assumed that they didn’t need contact with a general OT. In retrospect, these are exactly the kinds of relationships we need to be building.

3. And, finally, “pre-habilitation” seems like a very important research trend for us to follow.

Even though the section on pre-habilitaiton was pretty short in this article, it seemed like a really important opportunity for us to consider. Cancer care has such a unique timeline, where there is usually a “window of opportunity” between diagnosis and beginning acute treatment. This timeframe seems optimal for beginning therapy to set the stage for patients to receive responsive and timely care. I’ll be curious to hear if anyone has any experience with this!

Here’s the full APA citation for this article:

Silver, J. K., Raj, V. S., Fu, J. B., Wisotzky, E. M., Smith, S. R., & Kirch, R. A. (2015). Cancer rehabilitation and palliative care: Critical components in the delivery of high-quality oncology services. Supportive Care in Cancer, 23 (12), 3633-3643. doi:10.1007/s00520-015-2916-1

What questions/thoughts does this article raise for you?

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As an occupational therapist in homecare, I see cancer patients quite often. We have a HOPE program that is a stepping stone to hospice. From the OT side there not that much difference then a typical patient as it is more for the RN’s and what they can do.

With that being said, I am a stage 3 cancer survivor…4 years out.

I get this article. Being an almost OT as well as a person in my 50’s at the time, I had an advantage through knowledge. I knew the questions to ask and how to help myself. And it still almost sucked the life out me.

What I find with the patients I see, is a general lack of knowledge surrounding both health in general AND the role their mental health plays into it all.

I often lead a session with the history of OT as a mental health guided practice. Then how the medical model through insurance, basically hijacked our methods.

Cancer is the perfect example of where we are often most needed. People are surviving cancer in record numbers, but are left with side effects that often last the rest of their lives.

I am one of those people! Radiation damage to my pelvis has left me with osteoporosis, insufficiency fractures, bowel urgency, and extreme pain if I sit too long (as in traveling from patient to patient on bumpy back roads).

I also had adhesive capsulitis in both shoulders from a year with limited movement and a PICC line.

OT’s are uniquely suited to be advocates for our cancer patients. Let’s step up and assist them in a return to normal. It’s not about exercise, although fresh air helps, it’s about purpose.

I remember going to see one patient and she was just about to go into hospice. She was basically bed bound. I brought a little frame and paints in. She sat up with the biggest smile and started planning the colors. She sad “this will be for my son”. We sat and she happily painted through the entire session and I documented ‘activity tolerance’. She passed away two weeks later! Now her son has that frame to put a picture of his mother into.

Thanks for listening!

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Lisa,
What a great example of your client! Thanks for sharing your example and perspective on this diagnosis.

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Sarah,
Thank you for including this topic in the club. I think that rehab and palliative care have come a long way. I recall years ago, in our acute care hospital, if a client was on palliative care or “comfort care” as they called it, it was an automatice discharge from rehab as everyone assumed that the patient was at the “end of life” and did not need any rehab. Things changed and even though a patient was on “comfort care” we went to see them and ask them what they wanted/wished to do in their remaining days. There were many patients and families who opted to continue rehab and do the best they could and not just “lie in bed and die”. Now we have a deisgnated OT and PT on the palliavtive floor who see many patients regularly before they are transferred to a hospice facility or home.
There is a great book by Dr. Atul Gawande titled “Being Mortal” which talks not only about dying but about living to the end with dignity, autonomy, and joy.

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Sanchala…you make some great points. As an acute care and rehab Occupational Therapist for many years, I think the challenge is time. Particularly in the acute setting! Some of these patients require additional time to even think about what they want. Or if and why they want to participate in rehab. Having dedicated therapists makes sense. As long as they are allowed the time these patients require. As pointed out in the article the Medical model vs. the whole person make this a challenge.

Additionally, facilitating these patients to express their needs/wants to their healthcare providers and family members is key. So many times patients struggle to “keep up” or “push harder” for their family members, literally stating “I don’t want to let them down.” While physically, mentally and emotionally exhausting themselves. I feel Occupational Therapists are excellent facilitators of these crucial conversations.

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Hi, I enjoyed reading this article and the takeaways. I work in home care in Canada, and I have many clients with cancer on my caseload. Both rehab clients and palliative. In this system, the MD doesn’t refer, but the case manager. I address all of the areas above, for the rehab client. If the client is palliative, my role on the team is to make them comfortable. I teach the caregivers safe transfers and positioning; I order–and set up–equipment–to decrease the risk of skin breakdown. We don’t have a hospice system like the States, it is a part of home care.

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@sanchala, I’m so glad you brought up Being Mortal! That book was such an incredibly helpful read. I always remember the 4 questions that he asks patients- I think that these question could be extremely helpful to OTs, especially the first two.

The questions are:

• What is your understanding of the situation and its potential outcomes?
• What are your fears and what are your hopes?
• What are the trade-offs you are willing to make and not willing to make?
• What is the course of action that best serves this understanding?

@lauren2, we just talked about health literacy related to stroke, and this current article reminded me that with any patient that has a complex course of care, we need to be part of helping them understand both what happened and what moving forward may look like.

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Lisa S thank you for sharing your story and Sanchala it is exciting that your acute care facility placed OT and PT on the Palliative care unit for individuals who desired continued services. Lisa B, I can see where productivity would negatively impact the ability to meet the needs of cancer patients using a traditional model.
Lisa S, I continue to find that these articles often bring us as practitioners back to our beginning history and re-connecting with the mental needs of the clients. Like last week’s note that rehabilitation after stroke did not affect emotions. I clearly see the need to focus occupational therapy practice addressing all the pieces of the person: including client factors (Values, beliefs, and spirituality, Body functions, Body structures) as well as considering the context/environment (Cultural, Personal, Physical, Social, Temporal, Virtual) ( American Occupational Therapy Association, 2017). This article challenges us to stay client-centered and support the client’s desired function as well as their mental health. The two-word check-in mentioned last week appears appropriate as well as the role of OT in self-management and helping the client advocate for their health care needs.

My mom died from ovarian cancer in 1999. Lisa S like your client who left a framed picture behind my mom left my kids each a hand quilted spread. She had neuropathy in her hands and had to wear leather thimbles on all her fingers so as not to sew her fingers to the quilt. (yes trial and error helped her realize this and she told me after the fact). Quilting and typing stories to her grandchildren kept her going longer than the doctors expected. Life hobbies are good supports for mental health. Many of us develop hobbies to offer us an outlet for stress.

Sarah, another timely article.

American Journal of Occupational Therapy, September 2017, Vol. 68, S1-S48. https://doi.org/10.5014/ajot.2014.682006
Sorry, I know the 4th edition is out but the PDF would not download.

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What great comments about this whole topic and helpful ideas. I agree that we as OTs are given special gifts to work with patients with cancer and many other diagnosis’s in their time of need. It is such a fine line knowing when to make suggestions and then push for the patient doing less to conserve their energy. It often becomes a pride thing especially if they are a caretaker of their spouse.
I do agree that we should get involved sooner than when the cancer becomes terminal to help the client establish their purpose or help them define what they want to accomplish before their time comes. We as OTs can look at alternatives for pain management and quality of life in terms of hobbies or connecting with others. Almost like a bucket list.
There’s is another great book called Final Gifts by Maggie Callahan and Patricia Kelley. They are two hospice nurses who take you through stories of families who experience cancer. It is a good read.
I think too its also looking at the home setup and how can we adapt the surroundings. They can maybe stay at home with family in the end.

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I am a post professional OTD student and interested in the role of OT in palliative care/end of life - so this article was relevant and helpful. Appreciate the link to the book as well. I came across an interesting resource The Conversation Project https://theconversationproject.org/ that some may find helpful. In my thinking, if patients who are nearing end of life (with cancer or other illnesses) and do indeed want to remain engaged in meaningful activities/maintain functional independence then OT should play a much larger role in hospice/palliative care across settings. I am interested in how many OTs in acute care actually are working with patients on comfort measures/comfort care? Appreciate any guidance as I begin to launch my innovation project in this area. What questions should I be asking as I begin my research? Thanks in advance!

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