In palliative care, physiotherapists look at ways to make patients living easier, by using pain relieving mechanisms. For example, I observed a physiotherapist in a palliative care setting and they did not use exercise as much as the physiotherapist used in PP, but they talked about ways of making their life more comfortable such as sleeping better, i.e. positioning of pillows, ways of sitting better to decrease any pain to correct their posture. Whereas in PP, the physiotherapist I observed was looking at ways to improve any musculoskeletal disorders that the patient was experiencing by using modalities such as ultrasound, using massage, mobilisation and TENS for pain relief. TENS was also used in palliative care for pain relieving purposes.
Physiotherapists may have to see patients with multiple health conditions (NHS 2006). Palliative care physiotherapy aims to maintain optimum respiratory and circulatory function that may present in patients (Laakso 2006). In pp I did not observe any respiratory, circulatory condition that the physiotherapist was treating. Their aim was to treat the condition they presented with.
I observed that physiotherapists in palliative care give chest treatments and advice on the management of breathlessness to patients. In pp chest treatments are seldom used. This is due to the types of patients that present in pp (musculoskeletal). I did not observe any chest treatment being used in this setting. Physiotherapists in pallative care treat swollen limbs (lymphoedema) by providing hosiery, bandaging and massage as necessary. In pp the physiotherapists are occasionally presented with patients with swollen limbs which they treat.
Education is an important aspect of physiotherapy. Physiotherapists in palliative care will educate the patient and the carer, in terms of showing them the types of exercises for example to be given to the patients, as the patient may not remember or they may not understand, depending on the stage of their illness. In pp the majority of the patients I observed did not come with the carer and they were able to participate in their treatment without any help and with full understanding. However, in pp they are still educating the patient about the benefits of exercise and the correct techniques. In an NHS setting of palliative care occasionally the physiotherapist has to educate the student physiotherapist. In pp where I was observing student physiotherapist were rare (longer than a few weeks), so the physiotherapist did not have to play much of an educative role.
Psychological aspect can play an important part in the role of a physiotherapist. However, there is debate to whether it is the physiotherapist’s role or not (Watson 1999). Stress and anxiety management are a part of the physiotherapist role in palliative care setting which they may deal with it through relaxation and/or massage therapy (Zimmerman 1986). The physiotherapist must be able to deal with a patient who is suffering from stress and anxiety as the majority of patients I observed had some form of anxiety. In pp, I did not observe the physiotherapist deal with any patients with anxiety or stress as the patient is paying for treatment, and time is money. Although psychological issues can also arise in pp.
Going through a thorough assessment is a part of any physiotherapists practice. In PP I observed that the physiotherapist will go through a thorough assessment with the patient and work with them to design a treatment plan. In palliative care I observed that they did not go through a long thorough assessment but they did very basic movements with them and observed more functional things such as walking, sitting and getting out of bed. The reason for the difference between PP and palliative care assessments is due to the abilities of the patients (mobility) and their lack of understanding (end stages) due to the nature of the illnesses in palliative care. In addition to, the aims of their treatments are different so their assessments would be different. In pp they are trying the find the underlying pathological condition of the patient so a thorough assessment is vital. In palliative care they are assessing the capacity of the patients understanding of movement of their limbs to see whether they are safe to do general things such as climbing stairs and going to the toilet (Doyle 1997).
Physiotherapists use preventative interventions to help the patient function optimally. In palliative care, I observed the physiotherapist helping to prevent muscle atrophy and muscle shortening, as well as preventing joint contractures. I observed a patient in palliative care who was beginning to get shortening of muscles and muscle atrophy as they were bed ridden and not mobile. The physiotherapist gave them gentle stretching and exercises to help to minimise the effects of immobilisation. In pp I did observe some patients that presented with shortening of muscles due to incorrect posture. The physiotherapist gave stretching exercises for this. The patient in pp who presented with muscle shortening would eventually resume their normal muscle length if they follow the appropriate advice given. However, the physiotherapist in palliative care has to bear in mind that the muscle shortening will remain as the patients condition deteriorates further. They could be getting better then if their condition deteriorates than they could take a step backwards. This is unlikely to happen in pp that I visited.
Giving advice about ways of making the patients life easier to live is apart of the physiotherapists role. In a palliative care setting, the physiotherapist gives advice to patients and their families about helping with stair lift and toilet seats for easier living. I observed the physiotherapist in pallative care giving advice on stairs and that it would be easier for the patient to sleep downstairs so they would not be using the stairs as it was dangerous to do so in the occasion. In pp such advice was rarely given unless the patients came in with stroke, which was a limited no of patients and the physiotherapist did not give advice, but just focused on mobility at the clinic.
The type of treatment given in palliative care given will depend upon the patient and the type and stage of their disease. The physiotherapist must have a sound knowledge of such diseases. The physiotherapist is there to help the terminally ill patient to adapt to any physical limitations that they may have. Physiotherapist must also possess the knowledge of issues regarding death, dying and grief. In private practice this is not necessary. For example, when I observed the pallative care physiotherapist they were helping a terminally ill patient who was in the very end stages. The physiotherapy had to support the patient and had to know the right things to say, as well as providing support to their families. In PP, I did not observe any terminally ill patients that the physiotherapist had to manage. In palliative care, the physiotherapist must be prepared for a level of emotional involvement, however in pp this rarely occurs.
Duty of care must be followed by all physiotherapist professionals (CSP 2002). Physiotherapist in palliative care must be ready to discontinue their treatment, if their treatment is no longer beneficial or in the patients best interest (Zimmermann 1986). In pp the physiotherapist must continue treatment as long as the paying patient wants treatment unless the physiotherapist advises otherwise. If they wish to discontinue treatment the patient’s decision would be final regardless of the physiotherapist’s advice, however if the treatment is no longer beneficial then the physiotherapist can refuse to provide treatment.
Community physiotherapy is not part of all physiotherapists role. Physiotherapists in pallative care setting work in the community going into the patient’s home and seeing how they are coping. They must be able to work within the situation and environment they are presented with. In pp physiotherapist occasionally make home visits which they would also have to work around the situation given, however I was told that the physiotherapist on average only made 1 home visit every 2/3 months and they are not obliged to make home visits.
Informed consent in physiotherapy is very important and a legal obligation under the Human Rights Act (1999) (CSP 2002). However, in the pp I observed, physiotherapist occasionally did not gain consent when carrying out assessment. This may be due to the fact that they are turning up and paying for the treatment the physiotherapist takes this as they are okay to proceed with physiotherapy. However, turning up for physiotherapy does not mean they consent to physiotherapy (CSP 2002). In palliative care I observed that consent is more regularly obtained as the physiotherapists are aware that the patients may not always feel like having physiotherapy.
In terms of confidentiality in private practice, from my experiences I believe that it is not as confidential as the palliative care setting. This is due to the high number of phone calls being made and messages being left with somebody other than the patient. This breaches the confidentiality rule if consent to leave information with others is not obtained. However, in a palliative care setting, I observed that confidentiality is maintained well.
The duty of the physiotherapist, as part of the scope of practice is to make sure they keep records regarding the care of their patients (CSP 2002). They types of records that are kept can vary from different physiotherapy settings. In palliative care, there are MDT folders where records are kept. The reason for this is that everyone treating the individual patient can see what is happening with the patient in terms of treatment. The physiotherapists also keep separate records for the patients they have seen. In pp, the physiotherapist keeps their own records as there is no MDT.
To conclude physiotherapists in pp and palliative care have diverse scopes of practice, but both settings working within their scopes of practice. Physiotherapists in palliative care have to accept that the course of their patients is one of deterioration, rather than that of rehabilitation and improvement that is seen in pp.
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