The barn door: Physical therapy in hospice
By Fran Moore, PT
Physical therapy is added to a hospice patient’s plan of care for many different reasons.
Sometimes I get referred to see a hospice patient because he has had several falls at home. Don’t tell anybody, but I secretly wonder if adding therapy at that point is like closing the barn door after the horse is out. Maybe a therapist could have rearranged the barn before the horse even got near the door. Maybe?
OK, horse and barn analogies aside, I’m often struck by the fact that a physical therapy evaluation might have benefitted a hospice patient and his caregivers long before it was added to the plan of care. But hindsight is always 20/20.
Sorting out the hospice team
Signing on to hospice is a huge decision for many patients and their families. Patients and loved ones are usually overwhelmed with all of the information they must absorb at the start of hospice care. Just remembering the names of all of the hospice team members and their roles can be challenging – not to mention trying to juggle everyone’s schedule, as they try to find the best time to visit the patient at home. It can take patients and caregivers several weeks to settle into this new routine. And every week is crucial when we are talking about the end of life.
A physical therapist’s point of view
As a physical therapist who attends our agency’s weekly hospice meetings, I often feel like a little kid in the back row trying to sneak a peek at a new patient when his case is presented during those meetings. The team discusses the patient’s medical and social history. The plan to control the new patient’s pain takes precedence as his case is reviewed. The medical director asks pertinent questions to determine if the patient is an appropriate candidate for end of life care. The patient’s case is evaluated by the team using evidence-based standards of care, and the patient’s function is assessed using standardized assessments. My mind begins to wander as questions are asked: “Can he eat a full meal?” “Can he walk?” “What is his functional assessment score?”
I wonder what the home looks like when I hear the reports of his function. Is it a row house? Is it cluttered? Are there pets? Is the bathroom door wide enough to handle a wheeled walker – even if he doesn’t need one right now? I wonder how he will handle it when he can no longer get up out of a chair without help. Will his decline be gradual, or will it be sudden?
Ask about physical therapy
Although physical therapy is now mandated to be available for every hospice patient, it is not automatically added at the start of hospice care for many valid reasons. Patients may have no mobility problems when they sign on to hospice. Or their disease may be so advanced that they are already bedbound with no goal of getting out of bed, and hopefully, little risk for falling out. Or the patient may not think he needs physical therapy at that time.
What will a physical therapist do?
Too often, though, a person’s risk for falling can be predicted long before a fall happens. A physical therapy evaluation soon after the start of care can reveal safety risks in the home or in the way that the patient moves. Maybe the patient has a bum knee from an old injury that can affect which direction he usually leans when he’s fatigued. Maybe his wife has a bad back, and she won’t be able to pull him up out of the chair when he reaches for her as he gets weaker.
A physical therapy “treatment” session may be very different with a hospice patient than it is with an otherwise healthy orthopedic patient. The entire session may be spent with the therapist demonstrating and teaching safe ways to move.
Sometimes tips provided by therapy are so simple that the family member says “Why didn’t we think of that!” My response is usually, “You had a lot more important things to think about.” But a physical or occupational therapist can do much to improve the quality of a patient’s life while he is in hospice. And one of the most important things that we can do is to provide instructions and information to prevent a patient from falling.
Accidents do happen. And we all feel badly when they do. But, when the dust settles a bit as a patient gets used to the new hospice team, and when you have time to think about the situation at hand, you might want to think about asking for a physical therapy evaluation – before the horse gets out of the barn.