10a Rehabilitation

The length of survival for most patients with cancer and other chronic progressive cardiac, respiratory and neurological illnesses has increased over the past 25 years. In some patients this is associated with prolonged disability due to the disease itself and/or the side-effects of treatment.

In general medicine, rehabilitative techniques are generally associated with chronic benign disease and disability with an aim of restoring functional independence. In palliative care, rehabilitation shares the same principles of maximizing a person’s potential regardless of life expectancy.

Most patients are fearful of being dependent on others, how-ever they can be helped to be as independent as possible and to live a fulfilled life within the constraints of their illness. This not only helps patients but also relieves the stress of caregivers. Patients within palliative care settings are deteriorating and techniques need to be individually tailored to the rate of clinical deterioration. Techniques include setting realistic and achievable goals which are determined in conjunction with the multidisciplinary team. These goals must be reassessed continually in parallel with the exacerbations and remissions of disease and symptoms. In the later stages of the disease trajectory the goals may have to be reassessed on a day-to-day or even hour-to-hour basis. At different stages of the illness the purpose of goals may vary. It may be appropriate for a patient with a prognosis of weeks/months to set goals for mobilizing with comfort in order to get away for a holiday or to attend an important family event. For patients with a prognosis of days/weeks, goals may include providing physical, emotional, social and spiritual support to both patient and carers to enable them to manage a home death with confidence.

A careful medical assessment of the underlying disease, and other disease pathologies which may be contributing to morbidity, needs to be undertaken in order to direct treatment to optimize the control of symptoms (e.g. correction of anaemia or congestive heart failure, treatment of spinal cord compression). In the absence of reversible pathology the empirical control of symptoms is paramount. Consideration should also be given to prognosis. In this way, patients will be in the best position to be able to achieve their own realistic goals.

Patients experience many losses as their illness progresses. These include loss of mobility, self-esteem, position or role in the family as well as expectations for the future. These factors, together with loss of control over their lives, may intensify their feelings of anger, apathy, depression and hopelessness, which will have a negative impact on rehabilitation.

A lack of motivation may need to be explored, to ensure that there are no reversible factors such as clinical depression which may impede their ability to think in any positive way about the future. A competent unwillingness to participate in rehabilitation, on the other hand, should be respected. Palliative rehabilitation offers positive psychological support to overcome lack of confidence, poor motivation and to adjust to losses.