1. Cancer care trajectory
復健與安寧緩和照護
Palliative Care
林慧芬
臺大醫院物理治療師
臺灣大學物理治療博士候選人
Palliative Care
Goals
To relieve often
Focus on functional consequence of the
disease and its treatment, including
physical and psychological aspects
Functional reserve and maximize
F
ti
l
d
i i
function
To cure sometimes
Goal: achievement of the best quality of
life for patients and their families
To comfort always
1
2. How?
Structure: multidisciplinary team
Process: reiterative, active, educational,
problem-solving process
Assessment Goal setting intervention reassessment
Outcome
maximize the participation in patient’s social setting
Minimize
carers
the pain and distress of patients and
Where?
What?
Hospital
Hospice/specialist palliative setting
Disease related: brain tumor…
Day care center
Community
Treatment related: chemotherapy
induced, radiotherapy induced…
Symptoms, etiology of the symptoms
y p
,
gy
y p
2
4. Deconditioning
Fatigue
Complications of
treatment
Under nutrition
Neurological and
musculoskeletal
problems
Pain
Disability
y
Functional loss
Dependent ADL
Bowel and bladder
dysfunction
Thromboembolic
disease
Depression
Coexisting
comorbidities
Poor quality of life
Caregiver need
Healthcare resource utilization
Need for institutionalization
Physical disability
Cancer patients in the hospital setting
35% experienced functional loss due to physical weakness
32% required assistance with performance on ADLs
23% experienced difficulty with ambulation
7% had deficits in transfers
(Lehmann et al., 1978)
Significant functional impairments in patients
with advanced and terminal cancer (Yoshioka
Progressive debility and being a burden to
others as reasons for desiring death among
cancer patients (Breitbart et al., 1998; Morita et al., 2004)
,
)
et al., 1994)
Maintain highest level of functional ability
of
Hospice and palliative care patients
Patients’ desire
Reduce burden of care
Improve overall quality of life
Satisfaction of care function pain
care, function,
and anxiety
4
5. Patient & Family Centered
Patient & family’s expectation
family s
Environmental
Patient
What brings you the most pleasure?
What are the most important things prevented?
Physical ability
Expected activity
Questions
What do you most like to do tomorrow if you can?
Caregiver
Red Flags or Yellow Flags
Anemia
Neutropenic
What are you allowing the patient to do independently?
Physical Functioning
Complete blood count
What’s the most concerned in caring for the physical
What s
needs of the patient?
Strength, ROM, muscular and cardiopulmonary
endurance, pain
Thrombocytopenic
Eastern Cooperative Oncology Group (ECOG) scale
Neural impairments
Skeletal impairments
Karnofsky Performance Status scale (KPS scale)
y
(
)
Cardiovascular or pulmonary system
5
6. ECOG performance status
KPS scale
0
Fully active, able to carry on all pre-disease performance
without restriction
1
Restricted in physically strenuous activity but ambulatory and
able to carry out work of a light or sedentary nature, e.g., light
house work, office work
2
Ambulatory and capable of all selfcare but unable to carry out
any work activities. Up and about more than 50% of waking
hours
3
Capable of only limited self care, confined to bed or chair more
than 50% of waking hours
4
Completely disabled. Cannot carry on any selfcare. Totally
confined to bed or chair
5
100
Normal no complaints; no evidence of disease.
90
Able to carry on normal activity; minor signs or
symptoms of disease.
80
Normal activity with effort; some signs or symptoms of
disease.
Unable to work; able to
live at home and care for
most personal needs;
varying amount of
assistance needed.
70
Cares for self; unable to carry on normal activity or to do
active work.
60
Requires occasional assistance, but is able to care for most
of his personal needs.
50
Requires considerable assistance and frequent medical
care.
Unable to care for self;
requires equivalent of
institutional or hospital
care; disease may be
progressing rapidly.
40
Disabled; requires special care and assistance.
assistance
30
Severely disabled; hospital admission is indicated
although death not imminent.
20
Very sick; hospital admission necessary; active supportive
treatment necessary.
10
Grade ECOG
Able to carry on normal
activity and to work; no
special care needed.
Moribund; fatal processes progressing rapidly.
0
Dead
Dead
Oken, et al. Am J Clin Oncol 1982;5:649-655
Patient assessment
Category
Physical
function
Karnofsky Performance Scale (KPS)
Eastern Cooperative Oncology Group
(ECOG) Functional Index
Katz Activities of Daily Living (ADLs)
Lawton Instrumental Activities of Daily
Living (IADLs)
Barthel Index (BI)
Functional Independence Measure (FIM)
Goal setting
Assessment tools
Balance/Fall
Risk
Patient and family need
Achievable within one week
Compensatory approach is concerned
Berg Balance Scale
Tinetti Assessment of Balance and Gait
Timed Up and Go (TUG)
Endurance
6 Minute Walk Test (6MWT)
6
8. Palliation
symptoms
mobility
Slowing functional decline
Maintaining QOL
6-week structured PA: significant decrease in
fatigue & increase in physical performance &
emotional functioning
(Oldervoll et al, 2005, 2006 )
50 patients, home-based PA, walking
Intervention—function
Managing
Improving
(Lowe, et al. Support Care Cancer 2010;18:1469-75)
Role of PT
Strength training, ROM exercise, muscular and
St
th t i i
i
l
d
cardiopulmonary endurance training, pain
management
Activity modification
Assistive devices
Environmental adaptation
Physical modalities for pain
control
Functional tasks
Massage
Physical modalities
heat/cold
Provision of adaptive and assistive
equipment
USD
Environment modification
TENS
Education on energy conservation
MLD
Exercise
Soft tissue mobilization
8
9. Adaptive equipment and
assistive devices
Caregiver education and
support
Adaptive equipment is used to improve performance in
ADLs.
ADLs
Assistive devices are prescribed to help
Mobility
Balance
Pain
F ti
Fatigue
Joint instability
Excessive skeletal loading
Utilizations of strategies to prevent
falls and maintain balance
Weakness
Use of good body mechanics
Ambulation
Instructions on the use of equipment
Elimination of weight bearing on an affected extremity
Exercise
Maintenance of muscle strength, joint
flexibility, range of motion, and balance
Improvements in functional capacity, body
composition, mood, self-esteem, quality of
life
Fatigue
Pain
Muscle spasm
Edema
癌症末期療護最常見症狀
36
疼痛 70%
口乾 68%
缺乏食慾 61%
無力 47%
便秘 45%
呼吸困難 42%
噁心 嘔吐
噁心、嘔吐 36%
失眠 34%
盜汗 25%
吞嚥問題 23%
泌尿問題 21%
神經精神症狀 20%
皮膚問題 16%
消化不良 11%
腹瀉 70%
9
10. Case 1
Case 1
BC, bone meta with spine compression fracture
BC, bone meta with spine compression fracture
Intervention—pain
S
Somatic
ti
pain
i
Neuropathic
Visceral
Total
Sit, dinner with family
Pain, weakness, contracture of knee, poor
endurance
Intervention—pain (I)
Medication:
mouth, clock, the ladder
pain
pain
suffering
10
11. Intervention—pain (2)
PT
Pain and Function
measures
Exercise and movement
Graded and purposeful activity
Postural re-education
Massage
assage
Manual techniques
Pain control modalities: TENS, heat & cold
(Rehabilitation in cancer care, 2008)
Pathophysiology of pain
11
12. Dyspnea
Dyspnea
(Rehabilitation in
cancer care, 2008)
Intervention—dyspnea
Medical intervention
Alter the physiological mechanisms
Alter the central perception of dyspnea
(Rehabilitation
in cancer care,
2008)
12
13. Helpful Positions
High side lying
Sitting
Sitti upright in a chair with f t b k and
i ht i
h i ith feet, back d
arms supported
Forward lean sitting with arms resting on
pillows on a table
Standing relaxed, leaning forward with
arms resting on a support such as a
windowsill
Central Perception
Fear, anxiety
Fear anxiety, distress
Safe, relaxation (including physical
intervention)
Overbreathing
Communication and Understanding
(empathy)
Standing relaxed, leaning backwards
against a wall with the legs slightly apart,
chest forward and relaxed, arms hanging
Fatigue: Screening & Assessment
Cancer related fatigue
NCCN guideline
Screen and assessment
patient/family education and counseling
Primary evaluation
Intervention
non-pharmacologic
pharmacologic
Age 5-6 y/o: not tired, tired
g
y
,
Age 7-12 y/o: 1-5 scale
3: moderate
1-2: mild
4-5: severe
Age >12 y/o: 0 10 scale
0-10
0-3: none to mild
4-6: moderate
7-10: severe
13
14. Patient/family education
and counseling
Non to Mild
Not tired in age 5-6, scores 1-2 in age
7-12,
7 12 or scores 0 3 in age>12
0-3
Education
Post treatment
Active treatment
End of life
Active
Post
Post treatment
treatment
Active treatment
treatment
E d f lif
End-of-life
General strategies to manage fatigue
Information about known pattern of
p
fatigue during and following
treatment
End of life
General strategies for
management of fatigue
during active and post treatment
post-treatment
Energy conservation
active treatment and post
treatment
Self-monitoring of fatigue level
Energy conservation
Use distraction
Set priorities
Pace
Delegate
Schedule activities at times of peak energy
labor-saving devices
Postpone nonessential activities
P t
ti l ti iti
Limit naps to < 1 hour to not interfere with night-time
sleep quality
Structured daily routine
Attend to one activity at a time
14
15. Non to Mild: Active Treatment
Non to Mild: Post Treatment
Non to Mild: End of Life
Energy conservation
End-of-Life
Set priorities
Pace
Delegate
Schedule activities at times of peak energy
labor-saving and assistive devices
Eliminate nonessential activities
Structured daily routine
Attend to one activity at a time
Conserve energy for valued activities
15
16. Moderate to Severe
Tired in age 5-6, scores 3-5 in age 7-12,
or scores 4-10 in age>12
g
Primary Evaluation
Education
Fatigue
is not an indicator of disease progression
Self-monitoring
of the fatigue level
Expected
the end-of life symptom and the fatigue
intensity may vary
Primary evaluation
Interventions
Interventions: Active Treatment
Interventions: Post Treatment
16
17. Interventions: End of Life
Activity Enhancement (I)
Fatigue: **
during cancer treatment
g
following cancer treatment
Aerobic capacity:
11/22: significant difference between intervention and
control group
3/22: significant pre-post difference
8/22: non significant difference
Quality of life: - Anxiety: - Depression: -
Cramp et al, 2008
Activity Enhancement (II)
↑functional capacity so↓effort in activities
15~45min/session (no more than I hour)
5 5
/sess o ( o o e t a
ou )
1-5 sessions/week
3~32 weeks, average: 12 weeks
25~80% age-predicted HRmax (220-age)
walk, bicycle, ergometer, treadmill, yoga, tai-chi,
walk bicycle ergometer treadmill yoga tai chi
multidimensional (aerobic+stretching+resistance
exercise)
group/individualized, supervised/home-based ,
mixture of supervised and home-based
Psychosocial Interventions
Education:
energy
gy
conservation and activity management to
y
g
balance rest and activity
planning,
delegating, prioritizing, pacing, resting
Support group
Individual counseling
Comprehensive coping strategy
Stress management training
Behavioral intervention
17
18. Sleep Therapy
Stimulus control
avoidance of long or late day naps
Limiting total time in bed
注意力越來越差、皮膚顏色變化(濕冷、斑駁)、四肢
發冷末端發紺、脈搏減弱、血壓逐漸降低。
caffeine and exercise avoidance near bedtime
comfortable sleep surroundings (dark, relaxing…)
soothing activities at bedtime (music, …)
臨終脫水
– 不再進食及喝水。是一預備死亡的自然過程,大部分
Sleep hygiene
進行性惡化徵候
– 肌力下降 體重下降 神智混亂昏睡 時空感消失
肌力下降、體重下降、神智混亂昏睡、時空感消失、
Sleep restriction
go to bed when sleepy, get out of bed after 20 min of
wakefulness
Have a routine bedtime and rising time
癌末頻死症狀
患者不會感到不適
患者不會感到不適。
死亡咯咯聲(death rattle)
– 喉頭及支氣管內分泌物無法排出,隨呼氣及吐氣上下
移動發出聲音。
癌末頻死症狀
臨床的躁動不安
Care of palliative patient with
cancer related lymphedema
– 症狀包含:躁動、翻身/打滾、呻吟、意識不清、肌肉
痙攣
– 亦與下列症狀重疊:瞻妄、臨終痛苦(常因未完成遺願
而造成)
臨終大量出血
– 腫瘤在大血管周圍進而浸潤到血管壁,血管壁破裂後,
造成大量血液流出,好發於頭頸部腫瘤、骨盆腔內的
腫瘤合併陰道直腸廔管患者。
18
19. Possible causes of edema in
palliative patients
Malignant involvement or infiltration of lymphatic
structure,
structure lymphatic insufficiency
Venous obstruction (thrombosis, compression by
tumour)
Decreased albumin (anorexia/cachexia of advanced
cancer, ascites with repeated paracentesis)
Renal or hepatic failure
Cardiac failure
Dependent limb, immobility, neurological deficit
Effect of drug or cytotoxic chemotherapy intervention
Infection
19
20. Key points for care of palliative patients with
cancer related lymphedema
Lymphedema care in advanced
Thank you for you a e o
a
o your attention!
CDT elements may need to be
cancer can contribute to
increasing the quality of life of
the patient.
Edema in this context is often
multifactorial, and etiology needs
to be ascertained in order to
determine the appropriate
treatment.
The lymphedema therapist needs
to work closely with the palliative
team.
modified,
modified using lower
compression and avoiding MLD
directly over areas of
subcutaneous tumour.
Fitted compression garments are
often not suitable or welltolerated in the palliative context
because limb size may vary from
day to day.
Any Sharing?
Key concepts of palliative care-1
Understanding and respect for the uniqueness of the
p
patient
Inclusion of the family in providing care
Involvement of the community in providing resources
and care
Interdisciplinary (team) work with nurse, physician,
wound care or pain specialist, etc
p
p
,
Attention to detail and to what is important to the
patient
Good communication with the patient family and other
palliative care providers
20
21. Key concepts of palliative care-2
Ingenuity and creativity in dealing with therapeutic
problems
Good control of pain and other symptoms
Maintenance of independent and function
Focus on meaning of symptoms, patient fears and
expectations
Non-abandonment of the patient
Attention to the therapist’s own emotions in the caring
for patient with limited progress
病人的疼痛應先試物理治療,一個月
沒效再開始用強效止痛劑 (X)
病人無法經由訓練提升功能時,則應
停止物理治療 (X)
病人可以選擇不接受治療 (O)
Goals of care must be flexible
and realistic and adapted to
the patient’s ever-changing
physical condition
21