3 Ways to Deliver Freedom to Patients in Palliative or Hospice Care

Practice in hospice and palliative care requires a shifting of both focus and application of our therapy knowledge and skills. A large majority of our patients in this practice niche will decline towards the end of life.

How can we use therapy intervention to maximize the person’s mobility, function, and comfort with disease progression?

1. Remain Engaged

As long as people live, they will try to move around and maintain normalcy. A positive model for the end of life is to retain as much independence a possible, and relinquish activities only when there is no alternative.

As physical, occupational, or speech therapists, we are experts in teaching patients and their family caregivers the best ways to achieve ADLs, mobility, and communication, whatever the condition. We must recognize and accept ongoing needs for therapy in the transition from active health until death.

2. Rehabilitate in Reverse

‘Rehabilitation in Reverse’ is one of five practice patterns useful in seeing how we can provide skilled therapy intervention over time to someone whose function is declining due to a terminal illness.1

Rather than a traditional therapy trajectory of increasing activity to a long-term goal of improvement, we must adapt short-term goals of improved safety and function with each new intervention during decline. For example, with balance and weakness, first introducing a cane, then progressing to a walker, then needing caregiver training to assist, then perhaps transfers only to a wheelchair, then transfers with physical assist, and eventually bed mobility and care needs. At each level, new body movement, skills, and assist must be instructed to assure a safe transition for both patient and caregiver to achieve hospice goals of self determined life closure and dying at home.


3. Adjust Biomechanics and the Environment

Adjusting the environment to changing strength and function is essential. While efforts can be made to maximize strength and proper body mechanics for transitions from sitting to standing, eventually this can become extraordinarily difficult.

Elevating sitting surfaces to maximal safe heights can preserve both energy and independence. This might include recommending placement of blocks or a platform under a favorite chair to prolong independent mobility or raising adaptive commode and bath seat heights. Walker heights traditionally are set with 15 to 30 degrees of elbow flexion, which works well with adequate UE strength. As the body is failing, often UE muscle mass, strength, and cardiac output decline. Conversely, lowering walker height to allow complete UE extension reduces effort (exercise pulse) and preserves energy (resultant increased endurance), again allowing independence for longer as the body’s ability wanes.2

Adapting for Independence

Putting these strategies together can maximize the person’s ability to remain active in the things they enjoy despite disease progression toward the end of life.

  1. Briggs R. Clinical Decision Making for Physical Therapists in Patient-Centered End-of-Life Care. Topics in Geriatric Rehabilitation. 2011; 27(1): 10-17).
  2. Hambrook GW, Simoneau GG, Bachschmidt RA, Harris, GF. Biomechanical effect of changes in walker height and position on sagittal plane elbow dynamics for rehabilitation purposes. Engineering in Medicine and BiologySociety, 1998: Proceedings of the 20th Annual International Conference of the IEEE. 1998; 5:  2686-2688.