The goal of palliative care is to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of their disease.1 The seeds for this philosophy of care were planted in England more than 5 decades ago by the work of physician Dame Cicely Saunders, the pioneering founder of the modern hospice movement. Although initially conceived as treatment for those with cancer and near the end of life, collaborative work resulted in the establishment of palliative medicine as a recognized medical specialty in the United States in 1988 and now addresses a wide range of debilitating chronic as well as life-threatening illnesses.
One essential aspect of palliative care includes a patient- and family-centered approach, recognizing their unique desires and relationships in the setting of goals and decision-making process. Comprehensive care from the time of diagnosis until cure or death must address physical, psychological, social, and spiritual needs. An interdisciplinary team with a broad range of skills should include physical, occupational, and speech therapists to address physical and functional concerns. Communication within the care team and with the patient and family is vital to share information and to allow well-informed decisions through the course of care. This patient-centered care model, while developed in the end-of-life spectrum, has now moved upstream and is applicable to the medical care of any severely ill person.
Cancer care has come a long way since the conception of the palliative care model. Dramatic changes in prevention measures, detection, and treatment options have transformed a once fatal prognosis for many to one with increasing cure and survival rates. Despite these improvements, in 2010, it was predicted that in the United States, more than 1.5 million people will be diagnosed with cancer, and following data trends from 2007, more than 440 000 adults older than 60 years will die from cancer.2 Whether one is to live or die with cancer, the seriousness and life-threatening nature of the illness as well as the many significant complications of treatment dictate a palliative approach to care from diagnosis through treatment to provide for the most positive outcomes including longer survival.3
Rehabilitation has in many ways been a palliative medical intervention since its inception almost 100 years ago. Restoration of function has been recognized as essential to quality of life for those who have experienced the limitations of a changed and challenged physical body. The American Physical Therapy Association in the “Guide to Physical Therapist Practice”4 recognizes health-related quality of life as composed of physical, functional, psychological, and social components, all of which must be considered in addressing disability.
Rehabilitative therapies (physical, occupational, and speech) are now recognized as an essential part of the palliative care interdisciplinary team. In cancer care with the older adults, there is not a significant curative role for rehabilitation as there might be in other niches of physical therapy practice. Restoring, maintaining, or adapting to declining function is the long historical role of therapy with people in rehabilitation as they work to “live again.” In this issue of Topics in Geriatric Rehabilitation, a comprehensive review of the many disease effects and complications to be considered as therapeutic interventions and goals are discussed with older adults experiencing cancer in any clinical setting.
Beyond utilizing appropriate palliative physical interventions, information sharing about cancer care is an excellent starting point for a palliative physical therapy approach. By communicating our knowledge of the disease and treatment sequelae with the patient and family, and connecting this information to their perceived and actual physical and functional limitations, the therapist can aid in the process of healing. This healing is not just of the physical body, but the mind (psychological and social) and spirit as well, an essential element of palliative care. By coming to understand these physical and functional relationships, patients gain some sense of control, even if limited by their condition. Therapy will allow them to achieve their maximum potential at any point during and following an active treatment process, whether they are in a phase of recovery, maintenance, or decline. What more can be asked from their efforts, supported by their family, the therapist, and other interdisciplinary care team members? The physical and functional losses experienced by each person in our care are central to rehabilitation practice, and thus, conversation around the broader effects of these losses on the person's life is likely to be engaged. Understanding the physical body's losses can lead to discussion as to one's existence as an entire human being with, mind, emotion, and spirit or consciousness. Patients and family members have identified geriatric and oncologic medical care that includes physical and intentional presence, developing an understanding of their individualized experience, and maintaining the patient's humanity and dignity as essential to their spiritual well-being.5
A remarkable transition is possible in older adults experiencing cancer care, in that they can feel complete, even though their bodies are no longer intact. Our challenge as therapists providing palliative care is to be a part in supporting this transformation. Rachel Naomi Remen, MD, cofounder and medical director of the Commonweal Cancer Help Program writes, “We do not serve the weak or the broken. What we serve is the wholeness in each other, and the wholeness in life.”6 Within this broader perspective lies the heart of palliative care, where each person and their family are treated as a special and unique entity on their path of life. As therapists, we are challenged to be open to uncertain outcomes, unable to alter a disease course during the care and treatment of the older adults with cancer. Can we serve them and support their wholeness, not only by using our knowledge and skill, but also by being present with our listening, compassion, and loving kindness throughout their care?
—Richard W. Briggs, MA, PT
Hospice and HomeCare
Enloe Medical Center
Chico, CA 95973
2. Jemal A, Siegel R, Xu J, Ward E. Cancer statistics 2010. CA Cancer J Clin. 2010;60:1–24.
3. Temel JS, et al. Early palliative care for patients with metastatic non-small-cell lung cancer N Engl J Med. 2010;363:733–742.
4. American Physical Therapy Association. Guide to physical therapist practice. 2nd ed. Phys Ther. 2001;81:9–744.
5. Daaelman TP, Usher BM, Williams SW, et al. An exploratory study of spiritual care at the end of life. Ann Fam Med. 2008;6(5):406–411.
6. Remen RN. My Grandfather's Blessings: Stories of Strength, Refuge, and Belonging. New York, NY: Riverhead Books; 2000:7.