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

3. Symptoms
Palliative care

Functional limitation


Pain


Breathless/Dyspnea


Cancer related fatigue (CRF)


M t l Health: communication
i ti
Mental H lth



有效的溝通
依照疾病的病程與病人狀態提供以病人
為中心的決策過程
處理癌症或非癌症的併發症
症狀控制
心理社會及靈性的照護
瀕死照護(生命末期照護)
照護的協調性與持續性
Assessment
3

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

7. 確認現有的資源及優勢-2
確認現有的資源及優勢-1
病患本身及家屬
1.
是否認清疾病進展對功能的影響？
是否認清疾病進展對功能的影響
2.
期望，是否好高騖遠？
3.
達成病患的目標需要花多少時間或
介入的次數？
4.
病患的家庭支持系統好嗎？家屬願
病患的家庭支持系統好嗎 家屬願
意配合嗎？照顧者是固定的嗎？
病患本身及家屬(續)：
5
5.
病患現有的身體功能，有哪些可以安全的參與
於活動當中？
6.
病患現有的輔具有哪些？合適嗎？可以維修
或修改嗎？有輔具資源可運用嗎？
7.
病患使否有身障手冊？可爭取到哪些社會福利
資源？
8.
後續的安置問題
尊重病人自主權
確認現有的資源及優勢-3
確認現有的資源及優勢-4
照顧團隊的考量：
和病患、家屬及團隊共同擬訂計畫後一
和病患 家屬及團隊共同擬訂計畫後一
起解決問題。
1.
對於病患的期望或需要，緩和病房
團隊成員覺得可行嗎？

2.
可以給予怎樣的配合及幫助？(護理
師、社工、志工、宗教師)
★ 病患的參與可以減少其對疾病的絕望
★ 增進和病患、家屬和醫療者間的關係
3.
3
如何以最有效率、節省人力、物力
如何以最有效率 節省人力 物力
成本的方式提供服務呢？
★ 提升病患的生活品質和減輕照顧者的
負擔
7

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