Palliative care applicable to all serious health related suffering. Palliative care is the active total care applicable from the time of diagnosis, aimed at improving the quality of life of patients and their families facing serious life limiting illness, through the prevention and relief of suffering from pain and other physical disability.

1. PALLIATIVE CARE
Dr. Adarsh Kumar Srivastav
MPT (Neuro)
Research Fellow
MMIPR MM(DU)
© Dr Adarsh Kumar
Srivastav_Palliative care

2. • “All people have a right to receive high-
quality care during serious illness and to a
dignified death free from overwhelming
pain and in line with their spiritual and
religious needs.”
© Dr Adarsh Kumar
Srivastav_Palliative care

3. What is palliative care?
• WHO (1) has defined palliative care as:
“…an approach that improves the quality of
life of patients and their families facing the
problem associated with life-threatening
illness, through the prevention and relief of
suffering by means of early identification and
impeccable assessment and treatment of pain
and other problems, physical, psychosocial
and spiritual.
© Dr Adarsh Kumar
Srivastav_Palliative care

4. Palliative care:
• affirms life and regards dying as a normal
process;
• intends neither to hasten nor to postpone
death; [and]
• uses a team approach to address the needs
of patients and their families, including
bereavement counselling if indicated.
© Dr Adarsh Kumar
Srivastav_Palliative care

5. “How people die remains in the memory
of those who live on.”
© Dr Adarsh Kumar
Srivastav_Palliative care

6. “You matter because you are you, and you matter to the end of your life.
We will do all we can not only to help you die peacefully, but also to
live until you die.”
Cicely Saunders (1)
© Dr Adarsh Kumar
Srivastav_Palliative care

7. • A core value for palliative care has been to
enable people to make choices about their
end-of-life care and place of death.
© Dr Adarsh Kumar Srivastav_Palliative care

8. Proponents of palliative care rehabilitation point
to three key areas of commonality:
•Emphasis on enhancing quality of life in the context of
serious illness;
• Importance of an integrated focus on mind, body, and
spirit;
• And delivery in a model of collaborative partnership
between patients, families, and the interdisciplinary care
team.
© Dr Adarsh Kumar
Srivastav_Palliative care

9. Restorative vs. Palliative
Rehabilitation
• Rehabilitation therapy is divided into three categories,
each addressing a range of functional activities:
1. Physical therapy (PT) is concerned with gross
functional mobility, defined as a change in body
position, and includes any physical states or limitations
that affect the ability to change position.
Another term used for gross functional mobility is
“transitional movements.”© Dr Adarsh Kumar
Srivastav_Palliative care

10. 2. Occupational therapy (OT) is the area of
rehabilitation that includes Activities of Daily
Living (ADLs), including self-care and home
management.
3. Speech therapy deals with tasks involving
the oral-pharyngeal-laryngeal function, as
well as cognitive components involved in the
process of communication.
Traditional rehabilitation medicine focuses on
maximizing quality of life and function based
on a patient’s physical limitations.
© Dr Adarsh Kumar
Srivastav_Palliative care

11. • The Rehabilitation restorative approach
to rehabilitation fosters the patient’s
independence and autonomy by offering
new ways to perform ADLs and/ or direct
a caregiver. Treatment is often focused on
healing as well.
• In the case of permanent disability,
emphasis is placed on helping the patient
and family cope with and adapt to the
new limitation caused by a stroke, spinal
cord injury, or amputation.
© Dr Adarsh Kumar
Srivastav_Palliative care

12. • In palliative rehabilitation, this standard
restorative continuum is reversed.
• Rather than working to return to a pre-
morbid level of function, palliative care
patients are supported as they face the
prospect of disease progression
accompanied by functional decline over
time.
© Dr Adarsh Kumar
Srivastav_Palliative care

13. • The clinical goals of geriatric palliative
rehabilitation are to maintain as much functional
independence as possible, provide emotional
support to patient and family members, mitigate
uncomfortable or distressing symptoms, and
reduce the caregiver burden of serious illness.
• Strategies to accomplish these goals are pursued
in a step-wise manner during the progression
from the early to late stages of a serious illness
as follows: © Dr Adarsh Kumar
Srivastav_Palliative care

14. 1. Preventive 2. Restorative 3. Supportive 4. Palliation
Preventing the
symptoms and
complications of
the underlying
disease process.
The patient is
expected to be free of
restrictive disease or
symptoms for an
appreciable time, and
the goal is to regain as
much as possible of
the function and
strength that may
have been lost due to
disease process or
treatment side effects.
Where persistent
residual disease is
expected, the focus
of rehabilitation is
to maintain
function at new
baseline for as long
as possible.
For patients with
advanced disease,
rehabilitation aims
to increase
functional
independence,
reduce pain and
discomfort,
maximize quality
of life, and reduce
the burden of care
for family
members.
© Dr Adarsh Kumar
Srivastav_Palliative care

15. • Core principles of palliative rehabilitation
practice include patient and caregiver
education and communication, realistic
and individualized patient-centered goals
for care, continuity of care, and
supporting the whole family throughout
the disease trajectory.
© Dr Adarsh Kumar
Srivastav_Palliative care

16. PATIENT BENEFITS
• Palliative rehabilitation, can alleviate a patient’s
fears of being a burden on caregivers reduces
feelings of helplessness, increase the patient’s
sense of competence and control, and contribute to
an improved mood and sense of well-being.
• Studies indicate that rehabilitation contributes to
improved function and quality of life for cancer
patients. Improved functional status as a result of
rehabilitation may also help improve cancer
patients’ tolerance of burdensome treatments such
as chemotherapy or radiation.
© Dr Adarsh Kumar
Srivastav_Palliative care

17. • Palliative rehabilitation can help identify and manage
shifting care priorities and goals in the face of advancing
illness:
• Early in disease, the goal is preserving function and reducing
dependency.
• As illness progresses, priorities will include safety,
environment assessment, assisted mobility, fall prevention
measures, transfer techniques, and instruction and use of
assistive devices; emphasis remains on vocational
adjustment, psychological support, and enhancing patient’s
sense of mastery and control.
© Dr Adarsh Kumar
Srivastav_Palliative care

18. • When the patient is closer to the end of
life, the focus will shift to quality of life
and maximal comfort for the patient (e.g.,
bed positioning to preserve skin integrity,
pain relief techniques, attention to
hygiene, gentle massage).
© Dr Adarsh Kumar
Srivastav_Palliative care

19. Referral for Palliative
Rehabilitation
• Palliative rehabilitation emphasizes realistic and achievable
goals of care, strategies to control pain and distressing
symptoms, and helping patients and caregivers adjust to
the discouraging loss of independence and function while
maximizing quality of life for both patient and family.
• Rehabilitation programs typically begin with light activity
and gradually progress to moderate activity under the
supervision of a trained practitioner
© Dr Adarsh Kumar
Srivastav_Palliative care

20. • Rehabilitation programs must be individualized to each
patient’s limitations and goals.
• After therapists discuss the risks and benefits with
patient and family, the parameters of the prescription or
recommendations may be liberalized.
© Dr Adarsh Kumar
Srivastav_Palliative care

21. • As the patient progresses through the disease
trajectory, therapies become gradually less
aggressive or demanding.
• When the patient is closer to the end of life,
emphasis will shift to quality of life and
comfort, including pain-relief techniques
such as desensitization, gentle massage,
healing touch, vibration, visualization, and
relaxation.
© Dr Adarsh Kumar
Srivastav_Palliative care

22. PALLIATIVE REHABILITATION
THERAPIES
Symptom or Disability Prescription and
Possible Interventions
Benefits/Comments
Lymphedema Manual lymphedema
decompression (MLD)
Congestion
decompression
techniques/
physiotherapy
(CDT/CDP)
Compression
stockings/garments and
instruction
in donning/doffing
Preserve motion and
function
Minimize and prevent
disfigurement
Psychosocial adjustment
Foster
emotional well-being
Prevent
secondary infection
© Dr Adarsh Kumar
Srivastav_Palliative care

23. Symptom or
Disability
Prescription and Possible
Interventions
Benefits/Comments
Ambulation training
Musculoskeletal
pain
Isometrics
Passive range of motion (PROM)
and/or Assistive/
Active range of motion (A/AROM)
physical
therapy
Progressive resistive exercises
(PRE)
Joint preservation techniques
Restriction release
Assistive devices evaluation as
appropriate
Modalities such as collator packs,
ultrasound,
cold laser
Increased autonomy and
dignity
May require orthopedic
clearance if there are
bony
metastases
Modalities that enhance
blood
flow must be restricted
from
areas of tumor
Skin breakdown Bed mobility:
Supine-to-sit, roll, scoot, positioning
Instruct caregivers in “back school”
techniques: bed height,
positioning/posture
Increased autonomy and
dignity
Caregiver education
leading to
improved care
© Dr Adarsh Kumar
Srivastav_Palliative care

24. Symptom or Disability Prescription and Possible
Interventions
Benefits/Comments
Dyspnea Airway clearance techniques: cough,
autogenic and postural drainage,
paced and pursed lip breathing,
chest percussion, vibration
Better function, quality
of life Decreased
anxiety
Dysphagia, poor PO
intake, cachexia
Communication
difficulties
Swallow/Barium Swallow
evaluation
Modified consistency, discussion of
artificial nutrition for select
diagnoses
Explore supplements, appetite
stimulants, medication adjustments
for motor neuron disease
Speech therapy, Oromotor skills
(e.g., tongue coordination,
pocketing, chin tuck)
Auditory, visual, reading
comprehension
Prognostic value; may
help guide decision-
making Determine
appropriate calorie
intake Improved
family understanding
of benefits and
burdens of artificial
nutrition
© Dr Adarsh Kumar
Srivastav_Palliative care

25. Symptom or Disability Prescription and Possible
Interventions
Benefits/Comments
Anxiety/depression Relaxation, visualization,
massage therapy, Reiki,
healing touch
Mood is frequently
improved
with improved physical
function and
independence
ADLs:
Self-care
Transfers
Home safety
Assistive device
evaluation and training
Adaptive techniques
Energy conservation
techniques
Home modifications
Increase feelings of self-
worth
Independence is
frequently
enhanced with improved
functional status
© Dr Adarsh Kumar
Srivastav_Palliative care

26. © Dr Adarsh Kumar
Srivastav_Palliative care

27. Euthanasia is legal in India from 2011, by
Supreme court, Delhi
© Dr Adarsh Kumar
Srivastav_Palliative care

28. “Palliative care is an urgent
humanitarian need worldwide.”
© Dr Adarsh Kumar
Srivastav_Palliative care

29. • Because of the nature and duration of
chronic illness during old age, the timing
of initiation of palliative care differs from
what is usually appropriate in a younger
population.
• The content of the palliative approach to
patient care differs not in kind but in
emphasis in the geriatric patient.
© Dr Adarsh Kumar
Srivastav_Palliative care

30. Markers for Initiation of Palliative
Care in Geriatrics
Disease-independent markers Disease-specific markers
•Frailty
•Functional dependence
•Cognitive impairment
•Symptom distress
•Family support needs
•Symptomatic congestive
heart failure
•Chronic lung disease
•Dementia
•Stroke
•Cancer
•Recurrent infection
•Degenerative joint disease
causing functional
impairment and chronic pain© Dr Adarsh Kumar
Srivastav_Palliative care

31. • Codes of professional ethics in medicine
identify the following driving purposes
and conditions of practice:
• to cure;
• to care;
• to be trustworthy; and
• to contribute to the well-being of society.
© Dr Adarsh Kumar
Srivastav_Palliative care

32. Thank you
© Dr Adarsh Kumar
Srivastav_Palliative care