A Project to Investigate the Role of Allied Health Professionals AHP within the Palliative Care Team

1. A Project to Investigate the Role of Allied Health Professionals (AHP) within the Palliative Care Team By Sylvia Lowes (Occupational Therapist) Jill Taylor (Physiotherapist)

2. Current Service Provision (Locally & Nationally) A mapping exercise had recently been completed by an AHP from the North of England Cancer Network (NECN) Currently, there are no OTs working nationally within the acute hospital setting that deliver a full-time rehabilitation based service for palliative patients, or service for patients with long term conditions. Physiotherapy is similar, on investigation no PT’s working within the acute setting specialising in palliative care only, but there are a number of physiotherapists working in specialist units and the PCT’s who reach out into the acute setting. Palliative patients in acute hospitals are treated by the team who cover the ward they are admitted onto.

3. Rationale for the Project The specialist rehabilitation needs of acute palliative care patients have not previously been assessed nationally or locally. Using temporary funding a senior Physiotherapist (PT) and Occupational Therapist (OT) were recruited from 1 July 2008 to 30 June 2009 to undertake this project.

4. Expectations of health Care professionals Provide specialist knowledge and education Give an holistic approach. Provide interventions to compliment existing service See the AHP specialist posts developing into a closer MDT working Improved links with community. Conduct follow up Visits (FUV). fatigue management/ breathlessness management. May be missing key areas due to lack of knowledge about AHP services and core skills.

5. Outcome Measures Clinical practice in palliative care encompasses physical, emotional, social and spiritual aspects of illness, therefore a wide range of measures is needed to capture all the aspects of illness and measure the outcomes of care (WHICH TOOL GUIDE, 2001). Due to the acute nature of the environment we required tools that would be quick and simple to use with minimal disruption to the patient. The tool must be able to be filled in by multi-professionals not just therapy staff. The nature of this deteriorating client group made it difficult to identify a specific tool sensitive enough to capture changes in function following therapy input with this client group. We decided to pilot 3 tools We also planned to collect patient’s and relatives comments as well as gaining feedback from colleagues at the end of the project

6. Results Almost 2 projects: 1 quantitative: using outcome measures ( We are still awaiting decisions around the statistical analysis of the results and will add these to the completed project) 1 qualitative: looking at the project as a whole and utilising peer and patient feedback We have utilised vignettes of patient, relatives and colleagues feedback and comments within the body of the project and the case studies to illustrate benefits to patients and colleagues We are still waiting for valuable data to be analysed and collected which has taken longer to collate than expected. This will only further demonstrate the positivity of the project

7. Case Study (Level 4) HPC 88 year old male GP admission to EAU at RVI, with deteriorating mobility and a suspected chest infection, SOBOE, lower limb oedema and irregular bowels movements. PMH Chronic Cardiac Failure; Chronic Renal Failure; Peripheral Vascular Disease; Hypertension. Social History Lives in residential care. Widower. Has two daughters, one lives in Leeds, and one in Holland. Previous occupation was a banker, owned a café with his late wife. Until few years ago worked as a voluntary worker for St Oswald’s Hospice. Recent loss of his close friend. They had social contact everyday. Mobilised with a walking stick before admission. Lately reduced mobility/confidence. Sleeping in armchair, as having difficulty conducting all transfers.

8. Case Study (cont) RR was referred to OT for psychological support for low mood, particularly related to the recent loss of his good friend whom he had contact with everyday Goals To improve RR self esteem whilst in the hospital environment. To explore + address RR spiritual needs. Work closely with the palliative care physiotherapist to improve RR occupational performance with activities of daily living (ADL). Intervention Reminiscence Baking i.e. “doing” Grading activities to build confidence/self esteem/personal achievement Standing tolerance/balance supporting physiotherapist interventions Addressing spiritual pain Outcome Pt achieved a state of “well-being.” Mood/motivation improved. “I feel a great sense of achievement.” “This has been good therapy.”

9. Case Study (cont) Ward based PT were seeing RR for mobility practice once a day. We were asked to assess RR to see if we could address some of the wider issues such as motivation, mood and fatigue: Goal Setting (Patient centred): Goals to be achieved within 2 weeks Become independent with transfers sit to stand Become independent with mobility with wheeled Zimmer frame Goal to be achieved ASAP Spend some time off the ward out doors Intervention plan: acquire an appropriate chair which allows height alteration give a chair exercise programme for UL and LL to improve motivation and give patient some ownership of improvement Give extra session of transfer practice Take patient off ward to help with mood and motivation Outcome: D/C Home with community input

10. Discussion Worthwhile project benefiting health care professionals and patient, families and carers due to the time constraints benefits realisation to the ward based therapy staff has been limited Definite patient benefits but difficult to demonstrate Holistic treatment is a luxury to therapy staff Not a generic post Outcome measures? The most appropriate form of demonstrating benefits can anything else be used? Personal development Challenging working in a nurse lead team Delivering choices

11. Recommendations The OT post holder would benefit from experience of working with patients within a mental health setting, or who have required psychological support/counseling. The PT post holder would benefit from have a broad range of rotational experience to understand the range of symptoms presented. Key areas being surgery and medicine. Education to staff must play a key role Peer support and supervision are essential This is not a generic role A working model for AHP needs to be developed to compliment the current model used within the palliative care team. An integrated AHP service should be developed Research into appropriate outcome measures with this client group

12. References The 'Which Tool' Guide: Preliminary review of tools to measure clinical effectiveness in palliative care. 2001Association of palliative medicine of great Britain and Ireland Cooper, J and Hewison, A., (2002). Implementing audit in palliative care: an action research approach. Journal of Advanced Nursing, 39(4), pp. 360-369. Ellershaw, J.E, Peat, S.J, Boyes, L.c., (1995). Assessing the effectiveness of a hospital palliative care team. Palliative Medicine, 9, 145-152. EuroQoL Group. EuroQoL-a new facility for the measurement of health-related quality of life. Available at: http://www.euroqol.org Hearn, J and Higginson, I.J., (1997). Outcome measures in palliative care for advanced cancer patients: a review. Journal of Public Health Medicine, 19(2), pp. 193-199. Hearn, J and Higginson, I.J., (1999). Development and Validation of a core outcome measure for palliative care: the palliative care outcome scale. Quality in Health Care, 8, pp. 219-227. Kaasa, T., (2001). The Edmonton Functional Assessment Tool: Further Development and Validation for Use in Palliative Care. Journal of Palliative Care, 17, (1), pp. 5 – 10.