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 incline in chronic illnesses towards the end stage of life. As a result a rise in patients with more complex healthcare requirements could be expected.
Palliative care advocates a holistic, problem-based approach for patients facing terminal disease 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 evaluate 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.
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 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 live (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 mean that pressure will be put on palliative health and social care capacity in order to adapt to these changing demographics (NCPC, 2010).
Palliative care is defined by The World Health Organisation (WHO) as:
‘â€¦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.’
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) describes 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.”
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 facing end of life.
There is sufficient evidence demonstrating that exercise can improve reduced mobility which is so prevalent among the elderly. In a high intensity strength training program of 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.
A fundamental core value of palliative care is to allow the older person to feel empowered facing 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. 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).
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 has been forecasted 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.
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).
It can be predicted that physiotherapy services will be required over a prolonged period as a result of the older person facing more long term, chronic debilitating diseases. This emphasizes the need for palliative care teams to draw upon more physiotherapists to ensure the needs of the older person are met during the end of life.
Although changing demographics may suggest that 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. They further go on to emphasize that a predominant problem in accessing physiotherapy services as part of palliative care is a lack of experienced physiotherapists available CSP (2004). With an increase in ageing population and the changes in demographic trends of long term chronic conditions, a shortage of physiotherapists within palliative care teams will reduce the effectiveness of care packages provided.
It is recognised worldwide that physiotherapy in palliative care is a specialty with physiotherapists required to have years of 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)
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. However, physiotherapists are only infrequently incorporated into specialist palliative care teams (CSP, 2004). In order for physiotherapists to be able to meet the demands of changing demographics of the ageing population it is essential that the role of the physiotherapist within palliative care is defined. Although NICE Guidelines on Supportive and Palliative Care (NICE, 2004) set aims relevant to the physiotherapeutic profession, whilst NICE (2011) guidelines on Palliative Care also state that physiotherapists are able to provide specialist skills, there is a lack of specific mention of physiotherapists and the role contributed. Proposals, such as NICE guidelines on Palliative Care (2011) and recommendations by WHO (2011) emphasis the importance of a multidisciplinary approach to palliative care however mentions of specialist palliative care teams are restricted to doctors, nurses and careers. 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 has been 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 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 specialised palliative care teams. This will allow for the development and production of a recognised clinical career structure for physiotherapists working in palliative care and thus to keep up with the changing demographics of ageing populations.
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).
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. Whilst it has also been found that the older person, specifically with dementia, have been shown to demonstrate greater progress and benefits when treated in a familiar setting such as the home setting rather than the clinical setting (Brissette, 2004).
However as stated by Kumar and Jim (2011), 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 will be required to expand, with more physiotherapists being readily available to treat the older person in outpatient and home settings.