|Nuala O’Faolain’ brave and frank radio interview has brought issues around the end of life into sharp focus. Nuala, faced with devastating news, made her own decisions to see out her life according to her own wishes and then discussed them openly. Debating how we as a society face the last days of life is ….|
Much of medicine is to do with restoring good health or at least managing disease to reduce long term consequences. Research from all quarters demonstrates that health is all about Quality of Life. In terminal illness, quality of life and care of the individual and their family becomes the overwhelming concern of every member of the healthcare team. Most patients in end stage disease express the desire to live as independently as possible, right to their end.
This presents special challenges for all health care professionals. The focus changes from ‘cure’ to ‘enablement’. Palliative care does not have return to full health as clinical objective. Rather the emphasis is on empathy and ease from dis-ease.
The general principle of physiotherapy may at first glance appear to focus only on ‘wellness’, getting people back to work or sport. While physiotherapy apparently focuses in the main on the physical side, in fact, we all know that physical function contributes to overall wellbeing. Mind and body are of course inextricably linked and nowhere is that more true than in palliative care. Thus the principles of physiotherapy in palliative care are similar; to be part of a team whose clinical focus is on assisting the individual to live and die well, ensuring terminally ill people achieve maximal levels of independence in their last weeks and days, with little or no pain and able to function as well as possible. This has positive affects for the family, friends and even society as a whole.
On entering the palliative stage, active medical intervention often leaves the person weak and debilitated. Cancer patients may have undergone many sessions of surgery, chemotherapy or radiotherapy. The effects of this treatment may have significantly reduced physical function. End stage respiratory or cardiac disease presents a similar picture. This is often seen in a general slowing down of movement and activity, where each of the simple activities of daily living takes much longer than previously. Even getting up and dressing after a night’s sleep may be enough to exhaust a deconditioned person.
Deconditioning is the result of not being physically active. It can include general muscle weakness, loss of balance, shortness of breath on activity and a feeling of less confidence in moving around. It certainly reduces quality if life. But eve in final days and weeks much can be done to recondition an individual to improve independence and function.
Keeping pain under control at the end of life is a crucial component in assisting the individual to function at best possible level. Intractable pain is unbearable to watch. However huge advances have been made in the science of pain management in palliative care. Sophisticated cocktails of drugs are now available to the medical team to reduce end of life pain. Physiotherapy can play a role here also, as pain is acknowledged as the primary reason for people seeking physiotherapy at every stage of life.
Dealing with pain on a daily basis means that Chartered Physiotherapists have a detailed understanding of the complexities of pain, how it occurs and emerges. Through specific and thorough assessment, even at end stage, the multiple causes of pain can be broken down and then each addressed separately. Joint stiffness and achiness may be present from prolonged resting while undergoing medical intervention or from lying in particular positions. A couple of sessions of gentle manual therapy and mobilisation on a sore neck, back, shoulder or hip can make a difference.
Local use of a small electrical stimulator, known as TENS, can target pain producing tissues. It used be considered that TENS should just be applied in short 20 minute sessions, but new research suggests that TENS is much more effective when left on for prolonged periods. Best positioning and application of the TENS electrodes for maximum effect is within the scope of practice of doctors or Chartered Physiotherapists.
Sometimes surgery or disuse will have left a local strength deficit that contributes to impairment. One example is that after removal of a tumour in a limb, the whole arm or leg may feel useless. Appropriate gentle muscle strengthening and on occasion stretching can improve limb function and thereby contribute to greater independence in dressing, eating, self care, or walking and moving around.
Reduced exercise tolerance and shortness of breath may hamper daily activities. Again, these symptoms respond well to simple graduated exercise regimes. Tasks can be broken down into manageable chunks by a Chartered Physiotherapist. Each component can be worked on and the sum of the parts improves the individual’s ability to move around better.
It is not surprising that improving independence, even in small ways reduces psychological stress. Even in the last days of life, interaction of each member of the healthcare team with the person and their family has been shown to assist the overall goal of preparing to face death with dignity.