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Contact:
Amy Edwards
Professional Affairs Officer
Organisation:
College of Occupational Therapists
106 - 114 Borough High Street Southwark London SE1 1LB United Kingdom
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Case study:
16 October 2011
Occupational therapy: co-ordination of care
Key points
- This case study shows the occupational therapist’s role when the person is reaching the last days of life
- The occupational therapist was able to recognise that there was a sudden and rapid deterioration in the person’s condition, that his wife would struggle to care for him without additional support and that urgent input from the wider team was needed.
Phillip* was 65 years old. Glioblastoma had been diagnosed 18 months previously and had been treated with surgery, radiotherapy and chemotherapy. Initially results had been good but there had been a recurrence three months ago that required further surgery. He was currently receiving palliative chemotherapy.
A referral to the district nurses had been made the previous week but, to date, no care package had been arranged or equipment provided, apart from a hired wheelchair.
The occupational therapist team received an urgent referral from the hospice one Friday following a phone call from Phillip’s wife Susan reporting decreasing mobility.
Phillip had previously been very active and was finding it hard to accept either his deteriorating condition or the need for assistance so specialist occupational therapy input was felt to be appropriate. He had last been seen by the palliative care team nurse two weeks previously.
The occupational therapist visited Phillip at home on the following Monday. Susan reported that he now needed assistance to mobilise and was very slow. He was coming downstairs daily with assistance. She had to assist him with all personal care.
Phillip was noted to have a dense right hemiplegia with no functional use in his right arm or hand. He was able to bear weight on his right leg but was unable to lift his foot or step and was walking with a shuffling gait. He required assistance to transfer out of bed and to mobilise a few steps to the en-suite bathroom. Severe speech problems were noted (dysphasia); he was only able to say a few words.
Phillip was due to attend chemotherapy the next day. Susan felt it was the chemotherapy that was making him so weak but she hoped this would improve. Phillip was obviously not keen to accept equipment – the occupational therapist explained that none of the equipment needed to be fixed and that it could be removed if he wasn’t happy with it.
Susan felt she now needed some input from formal care services but wasn’t sure how to go about this. Options of social services, continuing care or private care were therefore discussed.
The occupational therapist recommended the provision of equipment – next day delivery was requested – and an urgent referral to the community physiotherapist for an assessment for walking aids.
The occupational therapist visited again late on Thursday afternoon with the physiotherapist from the neurology service. Equipment had been delivered the previous day and the physiotherapist had assessed for, and provided, the walking aid. On arrival it was clear that Phillip’s condition had deteriorated significantly since the previous visit just three days before.
Susan reported that he had not received his chemotherapy on Tuesday as a deep vein thrombosis (DVT) was diagnosed. The district nurse had visited that morning and referred Phillip to social services for care. In addition the speech therapist had assessed his swallow and, as it was becoming a problem, advised use of thickened fluids. He had been unable to walk on the day of the review visit and needed full assistance from the occupational therapist and physiotherapist to get back to bed safely.
Susan started the visit by saying that the DVT was the cause of his inability to stand and it should improve with anti-coagulant therapy. The occupational therapist asked if they had considered admission to the hospice, especially in view of the lack of community care. They also discussed other options for care, including private care, and the fact that carers would be unable to assist Phillip on the stairs. He might now need a hospital bed downstairs.
On reflection Susan requested an admission “for a few days to treat Phillip’s DVT and get him back on his feet” and to set up care. The occupational therapist spoke to the hospice medical team who recommended liaising with the hospital oncology team since Phillip was still receiving chemotherapy and might need more active treatment.
Susan contacted the hospital clinical nurse specialist who agreed to discuss with the oncologist whether admission should be to the hospice or to the hospital. The occupational therapist suggested that the deterioration in Phillip’s condition was unlikely to be due to the DVT since his arm, speech and swallow were also affected. The deterioration may have been due to chemotherapy or to disease progression and there was a possibility that his mobility might not improve.
The occupational therapist asked if the family had ever discussed where Phillip would want to be cared for when his condition deteriorated. The answer was no. The occupational therapist also suggested that admission to the hospice was likely to be for more than a few days. The occupational therapist then liaised with the hospice team advising that Phillip might need admission the next day if he did not go to hospital.
He was admitted to the hospice on Friday and the medical team explained to the family that he was now dying. His family was seen by the occupational therapist in the hospice on Monday and Tuesday – just over a week after the initial referral. The family was grateful for admission to the hospice as the pressure was taken off them. They now fully understood that Phillip was dying and were happy he was in the hospice.
Phillip died on Tuesday night.
*All names have been changed to protect confidentiality
Author
Barbara Littlechild, occupational therapist
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