occupational therapy: supporting choice, independence and quality of life
DESCRIPTION
Rebekah Boffa Occupational Therapist Caritas Christi Hospice, St Vincent’s Melbourne 3 rd October 2013. Occupational Therapy: Supporting Choice, Independence and Quality of Life . Occupational Therapy. - PowerPoint PPT PresentationTRANSCRIPT
Occupational Therapy: Supporting
Choice, Independence and
Quality of Life
Rebekah Boffa Occupational Therapist
Caritas Christi Hospice, St Vincent’s Melbourne3rd October 2013
Occupational Therapy: Supporting independence, choice and quality of life3rd October 21013
Occupational Therapy
Occupational therapists use their skills to help to optimise the individual’s
function, promote dignity and support participation in essential and valued
activities. Consistent with palliative philosophy, interventions are developed in
consultation with patients, family and carers and support people to live and die
in the place of their choosing (AOT draft position paper, 2013).
“Doing” supports physical and mental functioning. Being engaged in meaningful
occupations supports social relationships and enables development of self
knowledge and supports self improvement (Lyons, Orozovic, Davis, & Newman,
2002).
Occupational Therapy: Supporting independence, choice and quality of life3rd October 21013
Through Occupation We…
• Conceptualise the world
• Define ourselves
• Learn about ourselves
• Care for ourselves
• Connect with others
• Demonstrate our love and
concern for others
• Contribute to society
• Connect with the spiritual
• Exercise choice
• Demonstrate our individuality
• Experience mastery
Occupational Therapy: Supporting independence, choice and quality of life3rd October 21013
Occupational Therapy
Occupational therapists working in palliative care:
• Support people to live in the face of dying
• Acknowledge that death is inevitable
• Acknowledge loss of function and the ongoing drive to be as active as
possible for as long as possible
• Help people redesign their lives and life goals (Pizzi and Briggs, 2004)
• Provide support for physical, emotional and spiritual issues at end of life
• Recognise the carer as part of “the unit of care”
• Support people in being cared for in the place of their choice
Occupational Therapy: Supporting independence, choice and quality of life3rd October 21013
Occupational Therapy Interventions
O.T supports patients to achieve THEIR goals through;
Assessment - Of Occupational Performance
Care Planning - Psychosocial care- Home assessment- Equipment provision- Discharge planning
Symptom Management - Equipment provision- Pressure care- Fatigue management- Pain and breathlessness- Maintaining occupational performance- Rehabilitation
Occupational Therapy: Supporting independence, choice and quality of life3rd October 21013
Care Planning; Psychosocial
Acknowledgement and validation of the patient’s difficulties and threatened
existence can be powerful.
This requires active listening and a preparedness to be uncomfortable, to sit
with someone while they cry, to discuss intimacy, spiritual and existential
issues.
Acceptance, empathy and encouragement are important.
Care for the carers and family is important. They too need validation and
encouragement.
Occupational Therapy: Supporting independence, choice and quality of life3rd October 21013
Home Assessment
• Usually completed with the patient
• A useful tool in promoting insight (patient/family), into care needs and clarifying future goals and expectations
• Emotionally and psychologically challenging
• Family feel empowered to ask questions they may not ask on the ward • Minimise home modifications
• Understand risks of catastrophic events prior to undertaking home assessment
• May need to take PRN meds on visit
Occupational Therapy: Supporting independence, choice and quality of life3rd October 21013
Home Assessment for End of Life Care
• Challenging but highly rewarding
• Often tight timelines
• Need to understand prognosis/disease progression
• Carers take the opportunity to ask all manner of questions
• Interventions include; counselling, education, exploration of issues relating to carer fatigue and degree of risk the individual/family are prepared to accept, prescription of equipment (hosp. bed, transporter commode, hoist wheelchair, pressure care equipment, call systems)
• Choose the room for delivery of care
Occupational Therapy: Supporting independence, choice and quality of life3rd October 21013
Equipment – What does it mean?
Occupational Therapy: Supporting independence, choice and quality of life3rd October 21013
Discharge Planning – What to consider?
• Avoid Friday discharges!!!!!
• Refer to Community Palliative Care
• Shared care - RDNS and Pall Care Provider
• Council services and PCA
• Alarms
• Trial discharge/overnight leave
• Planned Respite
• Buying in private supports and services
• Equipment and funding
• Access to allied health follow-up
Occupational Therapy: Supporting independence, choice and quality of life3rd October 21013
Symptom Management; Pressure Care
As individuals with pressure care problems frequently experience limitations
in function and restrictions to their participation in meaningful occupation,
pressure care is a core occupational therapy concern. (Macens, Rose, &
Mackenzie, 2011)
• Best managed by a multidisciplinary team
• High personal and social cost
• Education of patient and family
• Provision of equipment for seating surfaces
• Maintenance of occupational performance
• Education of nursing staff
Occupational Therapy: Supporting independence, choice and quality of life3rd October 21013
Fatigue
Fatigue is one of the most commonly reported symptom in palliative care
and can have a profound impact on quality of life. It is multidimensional and
impacts the function, cognition and affect of the individual.
Management of fatigue should be multidisciplinary:
• Education on Sleep Hygiene and the nature of fatigue
• Encourage exercise
• Modify activity patterns and task simplification
• Working out priorities
• Encourage nutrition and hydration
• Validate experience and acknowledge effort
Occupational Therapy: Supporting independence, choice and quality of life3rd October 21013
Pain and Breathlessness
Pain
• Education
• Activity modification
• Equipment
• Comfort
Breathlessness
• Education
• Relaxed breathing
• Activity modification
• Equipment
Occupational Therapy: Supporting independence, choice and quality of life3rd October 21013
Maintaining Occupational Performance - why is it important?
• People in the palliative phase have diminished reserve and capacity
to regain function
• Care needs increase with occupational decline
• Progressive debility and dependency is a cause of distress for many
people with advanced cancer (Cheville, 2001)
• Dependence impacts quality of life, it impacts relationships and
sense of self
• Palliative patients identify rehabilitation goals (Schleinich, et al,
2008)
• Functional decline can lead to longer inpatient admission
Occupational Therapy: Supporting independence, choice and quality of life3rd October 21013
Why does decline in Occupational performance occur?
Cancer disease and co-morbidities
Cancer treatments and side effects
Occupational disruption
The hospital environment
Our focus on comfort
In 2011 a quality project explored inpatients sitting out of bed (SOOB) for lunch;
Confirmed clinically observed low rate of SOOB – 53%
29% of patient’s with an AKPS of 40 SOOB for lunch
50% of patients for discharge planning SOOB
Occupational Therapy: Supporting independence, choice and quality of life3rd October 21013
What does a program which aims to support occupational performance look like?
• Requires a ward culture where there is “buy-in” from all members of the team
• Strategies are in place to support orientation
• Patients are encouraged to participate in self care
• Encouraged to dress
• Encouraged to sit out of bed for meals and other periods during the day
• Encouraged to be mobile and engaged in meaningful activity
Occupational Therapy: Supporting independence, choice and quality of life3rd October 21013
Occupational performance in action….
Occupational Therapy: Supporting independence, choice and quality of life
Rehabilitation
3rd October 21013
• People have rehabilitation goals
• People feel less sense of abandonment and a greater sense of control
(Bellchamber & Grousy, 2004)
• Participation has its own reward
• Rehabilitation possibilities can be overlooked
Occupational Therapy: Supporting independence, choice and quality of life3rd October 21013
Rehabilitation:OT and PTOT Home
assessment
Acute Admission:MSCC
SurgeryRadiotherapy
Pain Management
Palliative Care:Assessment
Symptom managementSeating
Pressure careEducation
Discharge planning
Community:Pressure care
EquipmentCommunity
access
Case Study – “Peter”
Occupational Therapy: Supporting independence, choice and quality of life3rd October 21013
Insights
OT plays a significant role across the care continuum
Diversity of OT role
Patients require access to allied health as they deteriorate
Despite advanced disease, patients have rehabilitation goals
Without access to allied health, patients are at risk of premature admission to residential
care
OT is instrumental in supporting people to exercise choice, achieve independence and
best possible quality of life until death
Occupational Therapy: Supporting independence, choice and quality of life
Rewards and Challenges
Rewards
Discharge against the odds!
Assisting in the achievement of patient goals
Being part of the journey to acceptance
Promoting a “good death”
The honour of being part of the journey
Challenges
Working backwards
Conversations around death and dying
Regularly seeing and interacting with
distressed families
Connecting but being able to detach
Symptoms that are difficult to treat
Rapid deterioration
Predicting the course/prognosis
3rd October 21013
Occupational Therapy: Supporting independence, choice and quality of life3rd October 21013
What are the Challenges for Occupational Therapists?
• To generate understanding of our role as more than equipment prescribers
and discharge planners
• To lobby government and service planners for equity in access to
occupational therapy for all people receiving palliative care, across Australia
• To remind the broader health community of the fact that many people
receiving palliative care have rehabilitation goals
• Identify outcome measures and undertake research to demonstrate the
effectiveness of our interventions
Occupational Therapy: Supporting independence, choice and quality of life3rd October 21013
What are the Challenges for the Palliative Care Community?
• To remember that people with advanced disease, in the final stages of life value the
opportunity to experience independence, exercise choice, demonstrate care, experience
mastery and to have access to rehabilitation services which enable them to live until they die
• Reflect on practice to ensure that structures, systems and delivery of care do not adversely
impact occupational performance
• Speak with people about their rehabilitation goals
• When planning services, include adequate allied health resource allocation
Occupational Therapy: Supporting independence, choice and quality of life
References
3rd October 21013
Australian Occupational Therapy Association Oncology and Palliative Care Special Interest Group Submission to the Senate
Committee Inquiry into Palliative Care Services in Australia. (2012).
Australian Occupational Therapy Association Draft Position Paper (2013) Occupational Therapy in Palliative Care
Belchamber, CA., & Grousy, MH. (2004). Rehabilitative Care in a Specialist Palliative Care Day Centre: a Study of Patient’s
Perspectives. International Journal of Ther Rehabilitation 11: 425- 434
Cheville, A., (2001). Rehabilitation of Patients with Advanced Cancer, Cancer Supplement, Vol. 93, No. 4, 1039 – 1048.
Frost, M. (2001) The Role of Physical, Occupational and Speech Therapy in Hospice: Patient Empowerment. American Journal
of Hospice and Palliative Care , Vol. 18, No. 6, 397 - 402
Lyons, M., Orozovic, N., Davis, J ., & Newman, J. (2002)., Doing-Being-Becoming: Occupational Experiences of Persons with
Life-Threatening Illnesses. American Journal of Occupational Therapy Vol. 56, 285 – 295.
Occupational Therapy: Supporting independence, choice and quality of life
References
3rd October 21013
Macens, K., Rose, A., and Mackenzie, L. (2011). Pressure Care Practice and Occupational Therapy: Findings of an Exploratory
Study. Australian Occupational Therapy Journal, Vol. 58, 346-354.
Morgan,D. & White, K., (2012). Occupational Therapy Interventions for Breathlessness at the End of Life. Current Opinion
Supportive and Pallliative Care, Vol. 6, 138 – 143.
Pearson, E., Todd, J., and Futcher, J, (2007) How can Occupational Therapists Measure Outcomes in Palliative Care? Palliative
Medicine , Vol. 21, 477 – 485.
Pizzi, M. & Briggs, R. (2004). Occupational and Physical Therapy in Hospice; the Facilitation of Meaning, Quality of Life and
Well Being. Topics in Geriatric Rehabilitation, Vol. 20, No. 2 , 120 – 130.
Wilcock, A. (1998). An occupational perspective of health. Thorofare, NJ: Slack.
Occupational Therapy: Supporting independence, choice and quality of life3rd October 21013