Worldwide, populations are experiencing an increase in life expectancy with associated serious chronic illnesses towards the end of life (World Health Organisation (WHO), 2011). In the UK, 457,000 people require palliative care services annually; however there are significant shortcomings in providing care to all those in need.
In a recent survey, by the Palliative Care Funding Review (2011), it was estimated that 92,000 people are not being reached by palliative care services. After decades of declining death rates, we now face the dual demographic challenges of increasing life expectancy and an increase in chronic illnesses towards the end stage of life. One outcome of this would be a corresponding increase in the number of patients with more complex healthcare requirements.
Palliative care advocates a holistic, problem-based approach for patients facing end of life in order to improve quality of life and symptom control (WHO, 2009). Studies have shown that, in addition to receiving the best possible treatment, patients want to be approached as individuals and have autonomy regarding decisions affecting their care (Gomes and Higginson, 2008).
This essay aims to discuss how an ageing population will influence the delivery of physiotherapy to the older person in palliative care. It will address the current necessary factors required to meet the needs of the older person whilst also evaluating the barriers preventing access to physiotherapy services in palliative care. The role of the physiotherapist will be evaluated with reference to appropriate and current health care policies.
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In order to discuss meeting the needs of the older person, it is essential to establish a definition of the ‘older person’. As defined by WHO (2012) (1) ‘most developed world countries have accepted the chronological age of 65 years as a definition of ‘elderly’ or ‘older person”. Whilst it has generally been agreed by the United Nations (UN) that 60+ years is thought of as the cut-off point when referring to an ‘older person’ (WHO, 2011).
Over the last 25 years, the number of people aged 65 and over in the UK has increased by 18%, from 8.4 million to 9.9 million, and it continues to steadily increase (Office for National Statistics, 2010). Changing demographics mean that on average, people worldwide are living 30 years longer than they did a hundred years ago with life expectancy continuing to increase by approximately 4 months every year (United Nations, 2008). WHO (2011) estimates indicate that by 2050, more than one quarter of the population will be aged 65 years and older.
Whilst changing demographics indicate an inevitable increase in the population of the older person, patterns of disease are also changing, with more people dying from multiple debilitating conditions such as cardiovascular disease, neurological conditions, and diabetes. It could be argued that advances in medical knowledge and technology have allowed many patients to live longer, however a paradox of this success is that many will struggle in managing such a wide range of diseases, symptoms, and disabilities towards the end of life (Wu and Quill, 2011). Inevitably the combined pressures of increasing life expectancy and greater numbers of people living with multiple conditions at the end of life means that pressure will be put on palliative health and social care capacity in order to adapt (NCPC, 2010).
Palliative care is defined by The World Health Organisation (WHO) as:
An approach that improves quality of life of patients and their families facing the problems associated with life-threatening illness, through prevention, assessment and treatment of pain and other physical, psychosocial and spiritual problems.’
(WHO, 2002)
Physiotherapists are vital members of specialist palliative care teams, with a critical role to play in the management of the older person in palliative care (CSP, 2004). Physiotherapists work to restore physical function, reduce pain and disability and increase mobility ultimately improving the life of patients, regardless of life expectancy (Medscape, 2011).
The Association of Chartered Physiotherapists in Oncology and Palliative Care (ACPOPC), guidelines for Good Practice (1993) described the role of the physiotherapist in palliative care as being:
“. . To improve the patients’ quality of life by helping to achieve maximum potential of functional ability and independence.”
A fundamental core value of palliative care is to allow the older person to feel empowered as they face the end of their life. Wikman and Faitholm (2006) describe an empowered patient as a patient who works with the multidisciplinary team to formulate goals and make treatment decisions. Physiotherapists within palliative care are fundamental team members to provide patients with autonomy and sense of empowerment. A fundamental component of physiotherapy is to establish achievable goals with patients and work in partnership with both the patient and relatives to achieve these goals. Within palliative care, realistic joint goal setting provides the patient with control over their treatment when they are experiencing a loss of independence (Robinson, 2000).
As recognised by Baldwin and Woodhouse (2011), rehabilitation and palliative care may appear to be at the opposite ends of the spectrum however the World Health Organisations’ definition of palliative care (WHO, 2002) advocates offering support to improve quality of life and maximize functional ability until death. The appropriate physiotherapeutic intervention can allow functional ability and mobility levels to be maximized, thus improving quality of life, this in return promotes independence for the older person.
There are various well documented studies which demonstrate that exercise can improve reduced mobility prevalent among the elderly. From the outcome of a study where a high intensity strength training program was initiated for 100 nursing home residents, William (1999) concluded that because of their low functional status and high incidence of chronic disease, there is no segment of the population that can benefit more from exercise than the elderly. Although a relatively small sample size, this is just one of many studies with a similar outcome.
However, regardless of the evidence demonstrating the benefits of physiotherapy intervention to the older person, the National Institute of Health and Clinical Excellence (NICE) guidelines (2004) found that some patients are still unable to receive access to rehabilitation services. It is suggested that this is due to the patients’ needs not being recognized by healthcare members and a lack of allied health professionals who are adequately trained in the care of patients under palliative care (NICE, 2004).
Despite the important role physiotherapists can contribute and provide to the older person in palliative care, there are current barriers preventing the ageing population from accessing such services. With the current ageing population estimated to increase it is essential these barriers are overcome with measures set in place so that the demands and needs of such changing demographics can be met.
To date, the needs of the older person in palliative care has not been a research priority. Current research predominantly focuses on recommendations on the needs of the older person facing end of life as opposed to formal evaluations of the effectiveness of palliative care (WHO, 2004; WHO, 2011).
Until recently palliative care has been largely focused towards patients with a cancer diagnosis, with a large majority of palliative care research focusing upon palliative care specifically for the cancer diagnosis (Baldwin and Woodhouse 2011). However it is estimated by the National Council for Palliative Care that 300,000 people die each year from progressive non-malignant disease (Royal College of Physicians, 2007). For example, the Coronary Heart Disease Collaborative (2004) concedes that ‘heart failure produces greater suffering and is associated with a worse prognosis than many cancers’ (Baldwin and Woodhouse 2011). Whilst a study by Byrne et al (2009) concludes that there is a scarcity of evidence identifying the palliative care needs of patients with neurological conditions.
Considering that the number of older people having prolonged long-term medical conditions towards the end of life is forecast to increase, the inclusion of non-cancer related diseases within palliative care is essential (Gott and Ingleton, 2011). In correlation with recommendations from WHO (2011) guidelines, in order to meet the care needs of the older person, the dimensions of palliative care need to be expanded to encompass a broader range of conditions. This will require understanding from healthcare staff at all levels.
It is recognised worldwide that physiotherapy in palliative care is a specialty with physiotherapists required to have several years experience before they become involved in palliative care (CSP, 2004; WHO, 2011).
Specialist palliative care is defined by the NCPC as a multidisciplinary approach, providing a variety of specialist services to patients facing end of life, either as a result of the ageing process or terminal illness. There is compelling evidence to demonstrate that compared to conventional care, specialist teams improve satisfaction and identify dealing more with patient and family needs, whilst they can also reduce the overall cost of care by reducing the time patients spend in acute hospital settings (House of Commons Health Committee, 2004)
Specialist palliative care teams encompasses hospice care, including services such as inpatient services, day care and community care as well as a range of advice, education, support and care (NICE, 2011). Given that a common problem presented by the older person is a functional decline in mobility, a major barrier preventing the older person from accessing palliative care services are difficulties leaving the home. Worryingly, physical inactivity has been demonstrated to correlate to an increase in premature deaths of patients under palliative care services, therefore it is essential that provisions are put in place for patients unable to access palliative care services (Pate et al, (1995); Bryan et al, (2007).
One option is the proviso of palliative care physiotherapy in the community setting. There is an advantage for the older person to receive physiotherapy in their home setting as not only does it provide familiarity but it grants patient centred holistic care. It has also been found that the older person, specifically with dementia, (have been shown to) demonstrates greater progress and benefits when treated in a familiar setting such as the home setting rather than the clinical setting (Brissette, 2004). However studies by Kumar and Jim (2011), found that the scope of physiotherapy practice is influenced by the ratio of qualified physiotherapists to the population. Therefore in order to meet the needs of the older person under changing demographics, the scope of physiotherapy services within palliative care need to be evaluated to ensure that physiotherapists are readily available to treat the older person in both the clinical and home settings.
Although more physiotherapists will be required in order to meet the demands of the older person, the CSP (2004) highlights that in current clinical practice there is already a shortfall of physiotherapists working within palliative care. It is further emphasized that a predominant problem in accessing physiotherapy services as part of palliative care is a lack of experienced physiotherapists available (CSP, 2004). A short fall of physiotherapists within palliative care teams will reduce the effectiveness of care packages provided.
Further detracting from the effectiveness of specialist care packages provided to the older person in palliative care is the underutilization of physiotherapists into specialist palliative care teams (CSP, 2004). It is the ability to call upon a broad range of health professionals in specialist palliative care teams that provides care responsive to the older patient’s individual needs. Therefore, in order for physiotherapists to be able to meet these demands it is essential that the role of the physiotherapist within palliative care is clearly defined. Although NICE (2004) guidelines set aims relevant to the physiotherapeutic profession, whilst the updated NICE (2011) guidelines clearly state that physiotherapists are able to provide specialist skills, there is still a lack of specific mention of physiotherapists and the role they can contribute. Proposals, such as NICE guidelines on Palliative Care (2011) and recommendations by WHO (2011) emphasis the importance of a multidisciplinary approach to palliative care but the mention of specialist palliative care teams is restricted to doctors, nurses and careers. So although guidelines recommend rehabilitation to be available to all patients, the role and effectiveness of the physiotherapist is not highlighted.
The NHS Cancer Plan (2000) outlines palliative care guidelines to ensure patients receive the right healthcare services and support, as well as receiving the best, most holistic treatment. However in contradiction to this it was found by Montagnini, Lodhi and Born (2003) that in the palliative care setting, rehabilitation interventions are often overlooked and underutilized, despite patients demonstrating high levels of functional disability.
This has raised concerns, as by excluding the attributes of specialist physiotherapists from specialist palliative care teams this will be detrimental to patient care (CSP, 2004). More research is therefore required to identify the value and effectiveness of physiotherapy intervention for the older person under palliative care. Furthermore, it is essential that palliative care core guidelines are not just limited to medical teams and that physiotherapists are also recognised and identified as core members of the care teams. This will allow for the development and production of a recognised clinical career structure for physiotherapists working in palliative care and thus keep up with the changing demographics of ageing populations.
Discussions of ageing and palliative care assume that ageism is an important factor limiting access to palliative care for the older person. The TLC model of Palliative Care, Jerant et al., (2004) argues that palliative care is viewed as a terminal event rather than a longitudinal process. He argues that this can result in unnecessary distress to the elderly patient suffering from chronic, slowly progressive illnesses (Jerant et al., 2004). The TLC model further goes on to recognise that palliative care of the older person is essential to relieve the physical and emotional complications that often accompany chronic long term end of life diseases and the illnesses associated with ageing (Jerant et al., 2004). Therefore, regardless of whether death is imminent, palliative care should be a major focus throughout the ageing process, with physiotherapy services being readily available to improve symptom control (Jerant et al., 2004). With the older person facing more long term, chronic debilitating illnesses alongside the physical effects of ageing, it can be predicted that it will be crucial for physiotherapy services to be utilized over a prolonged period of time, regardless of their age.
In order for physiotherapists to keep up with the changing demographics of ageing populations, more research is required to identify the value of physiotherapy intervention for patients in palliative care and to identify the stage of ageing process that it’s necessary for the older person to receive intervention. It’s essential that the value of the physiotherapist and role is identified, established and incorporated into clinical guidelines in order to be able to provide the older person with patient centered holistic care. Whilst it is also essential that palliative care services focus on meeting the needs of the older person in the home setting as well as the clinical setting, through community services.
Furthermore, it can be predicted that a shortage of physiotherapists will detract from the ability to provide patient centered care therefore services need to be evaluated to ensure a sufficient number of staff within specialist palliative care teams.
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