1.Cancer care trajectory Palliative Care Palliative CareGoals To relieve oftenFocus on functional consequence of the disease and its treatment, including physical and psychological aspectsFunctional reserve and maximize F ti l d i i functionTo cure sometimesGoal: achievement of the best quality of life for patients and their familiesTo comfort always1

2. How? Structure: multidisciplinary teamProcess: reiterative, active, educational, problem-solving process Assessment Goal setting intervention reassessmentOutcome maximize the participation in patients social setting Minimizecarersthe pain and distress of patients andWhere?What?HospitalHospice/specialist palliative settingDisease related: brain tumorDay care centerCommunityTreatment related: chemotherapy induced, radiotherapy inducedSymptoms, etiology of the symptoms y p , gy y p2 3. SymptomsPalliative careFunctional limitationPainBreathless/DyspneaCancer related fatigue (CRF)M t l Health: communication i ti Mental H lth () Assessment3 4. Deconditioning Fatigue Complications of treatment Under nutrition Neurological and musculoskeletal problems PainDisability y Functional loss Dependent ADLBowel and bladder dysfunction Thromboembolic disease Depression Coexisting comorbiditiesPoor quality of life Caregiver need Healthcare resource utilization Need for institutionalizationPhysical disability Cancer patients in the hospital setting 35% experienced functional loss due to physical weakness32% required assistance with performance on ADLs23% experienced difculty with ambulation7% had decits in transfers(Lehmann et al., 1978)Signicant functional impairments in patients with advanced and terminal cancer (YoshiokaProgressive 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 desireReduce burden of careImprove overall quality of lifeSatisfaction of care function pain care, function, and anxiety4 5. Patient & Family Centered Patient & familys expectation family s EnvironmentalPatient What brings you the most pleasure?What are the most important things prevented?Physical abilityExpected activityQuestionsWhat do you most like to do tomorrow if you can?Caregiver Red Flags or Yellow Flags AnemiaNeutropenicWhat are you allowing the patient to do independently?Physical FunctioningComplete blood count Whats the most concerned in caring for the physical What s needs of the patient?Strength, ROM, muscular and cardiopulmonary endurance, painThrombocytopenicEastern Cooperative Oncology Group (ECOG) scaleNeural impairmentsSkeletal impairmentsKarnofsky Performance Status scale (KPS scale) y ( ) Cardiovascular or pulmonary system5 6. ECOG performance statusKPS scale0Fully active, able to carry on all pre-disease performance without restriction1Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work2Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours3Capable of only limited self care, confined to bed or chair more than 50% of waking hours4Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair5100Normal no complaints; no evidence of disease.90Able to carry on normal activity; minor signs or symptoms of disease.80Normal 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.70Cares for self; unable to carry on normal activity or to do active work.60Requires occasional assistance, but is able to care for most of his personal needs.50Requires considerable assistance and frequent medical care.Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly.40Disabled; requires special care and assistance. assistance30Severely disabled; hospital admission is indicated although death not imminent.20Very sick; hospital admission necessary; active supportive treatment necessary.10Grade ECOGAble to carry on normal activity and to work; no special care needed.Moribund; fatal processes progressing rapidly.0DeadDead Oken, et al. Am J Clin Oncol 1982;5:649-655Patient assessment Category Physical functionKarnofsky 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 settingAssessment toolsBalance/Fall RiskPatient and family needAchievable within one weekCompensatory approach is concernedBerg Balance Scale Tinetti Assessment of Balance and Gait Timed Up and Go (TUG)Endurance6 Minute Walk Test (6MWT)6 7. -2-1 1. 2.3. 4. () 5 5. 6. 7. 8.-3-4 1. 2.( ) 3. 3 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, walkingInterventionfunction Managing Improving(Lowe, et al. Support Care Cancer 2010;18:1469-75)Role of PTStrength training, ROM exercise, muscular and St th t i i i l d cardiopulmonary endurance training, pain managementActivity modificationAssistive devicesEnvironmental adaptationPhysical modalities for pain controlFunctional tasksMassagePhysical modalitiesheat/coldProvision of adaptive and assistive equipmentUSDEnvironment modificationTENSEducation on energy conservationMLDExerciseSoft tissue mobilization8 9. Adaptive equipment and assistive devicesCaregiver education and supportAdaptive equipment is used to improve performance in ADLs. ADLs Assistive devices are prescribed to help MobilityBalancePainF ti FatigueJoint instabilityExcessive skeletal loadingUtilizations of strategies to prevent falls and maintain balanceWeaknessUse of good body mechanicsAmbulationInstructions on the use of equipmentElimination of weight bearing on an affected extremityExercise 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 36 70% 68% 61% 47% 45% 42% 36% 34% 25% 23% 21% 20% 16% 11% 70%9 10. Case 1 Case 1BC, bone meta with spine compression fractureBC, bone meta with spine compression fracture Interventionpain S Somatic tipain i Neuropathic Visceral TotalSit, dinner with family Pain, weakness, contracture of knee, poor enduranceInterventionpain (I) Medication:mouth, clock, the ladderpainpainsuffering10 11. Interventionpain (2) PT Pain and FunctionmeasuresExercise and movement Graded and purposeful activityPostural re-educationMassage assageManual techniquesPain control modalities: TENS, heat & cold (Rehabilitation in cancer care, 2008)Pathophysiology of pain11 12. DyspneaDyspnea(Rehabilitation in cancer care, 2008)Interventiondyspnea Medical interventionAlter the physiological mechanismsAlter the central perception of dyspnea(Rehabilitation in cancer care, 2008)12 13. Helpful Positions High side lyingSitting Sitti upright in a chair with f t b k and i ht i h i ith feet, back d arms supportedForward lean sitting with arms resting on pillows on a tableStanding relaxed, leaning forward with arms resting on a support such as a windowsillCentral PerceptionFear, anxiety Fear anxiety, distressSafe, relaxation (including physical intervention)OverbreathingCommunication and Understanding (empathy)Standing relaxed, leaning backwards against a wall with the legs slightly apart, chest forward and relaxed, arms hangingFatigue: Screening & AssessmentCancer related fatigue NCCN guideline Screen and assessment patient/family education and counseling Primary evaluation Intervention non-pharmacologic pharmacologicAge 5-6 y/o: not tired, tired g y ,Age 7-12 y/o: 1-5 scale 3: moderate1-2: mild 4-5: severeAge >12 y/o: 0 10 scale 0-10 0-3: none to mild4-6: moderate7-10: severe13 14. Patient/family education and counselingNon to Mild Not tired in age 5-6, scores 1-2 in age 7-12, 7 12 or scores 0 3 in age>12 0-3Education Post treatmentActive treatmentEnd of life Active PostPost treatmenttreatmentActive treatmenttreatment E d f lif End-of-lifeGeneral strategies to manage fatigue Information about known pattern of p fatigue during and following treatmentEnd of lifeGeneral strategies for management of fatigue during active and post treatment post-treatmentEnergy conservation active treatment and post treatment Self-monitoring of fatigue levelEnergy conservationUse 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 time14 15. Non to Mild: Active TreatmentNon to Mild: Post TreatmentNon to Mild: End of LifeEnergy conservation End-of-Life Set prioritiesPaceDelegateSchedule activities at times of peak energylabor-saving and assistive devicesEliminate nonessential activitiesStructured daily routineAttend to one activity at a timeConserve energy for valued activities15 16. Moderate to Severe Tired in age 5-6, scores 3-5 in age 7-12, or scores 4-10 in age>12 gPrimary EvaluationEducation Fatigueis not an indicator of disease progression Self-monitoringof the fatigue level Expectedthe end-of life symptom and the fatigue intensity may varyPrimary evaluationInterventionsInterventions: Active TreatmentInterventions: Post Treatment16 17. Interventions: End of LifeActivity Enhancement (I) Fatigue: ** during cancer treatment g following cancer treatmentAerobic 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, 2008Activity Enhancement (II) functional capacity soeffort in activities15~45min/session (no more than I hour) 5 5 /sess o ( o o e t a ou )1-5 sessions/week3~32 weeks, average: 12 weeks25~80% 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-basedPsychosocial Interventions Education: energy gyconservation and activity management to y g balance rest and activity planning,delegating, prioritizing, pacing, restingSupport groupIndividual counselingComprehensive coping strategyStress management trainingBehavioral intervention17 18. Sleep Therapy Stimulus control avoidance of long or late day naps Limiting total time in bed() caffeine and exercise avoidance near bedtime comfortable sleep surroundings (dark, relaxing) soothing activities at bedtime (music, ) Sleep hygiene Sleep restriction go to bed when sleepy, get out of bed after 20 min of wakefulness Have a routine bedtime and rising time (death rattle) Care of palliative patient with cancer related lymphedema / () 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 Infection19 20. Key points for care of palliative patients with cancer related lymphedema Lymphedema care in advancedThank you for you a e o a o your attention! CDT elements may need to becancer 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 providers20 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 therapists own emotions in the caring for patient with limited progress X X OGoals of care must be flexible and realistic and adapted to the patients ever-changing physical condition21