Case study:

16 October 2011

Occupational therapy: Delivery of high quality care in different settings

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Key points

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Joan* was 54 when she was admitted to hospital with a four-week history of constipation. It was discovered that she had had a breast lump for eight months. On examination she was found to have pleural effusions and was in a high state of anxiety. She was extremely fatigued, had no appetite and could only manage to walk a few steps.

Breast cancer with lung and bone metastases was diagnosed and her prognosis was poor. She was given chemotherapy but was unable to tolerate it and by this time she was unable to get out of bed.

Three weeks later Joan was transferred to the hospice. On admission she was treated for shortness of breath and given mouth care, and the medication for her constipation was adjusted. Anxiety remained the overriding problem.

Following holistic assessment by the team, the main problems noted were body image, anxiety, spiritual concerns, practical issues (Joan wished to make a will) and mobility.

Discussions also took place with her husband, David, around his concerns. Over the next four weeks Joan was given complementary therapy, was seen by the hairdresser, received communion, made a will and gradually gained confidence in the staff.

Joan then began physiotherapy. Following assessment, work began on a daily basis with the rehab assistant working on gentle exercise and re-establishing her confidence in moving.

The occupational therapist and the physiotherapist worked together with Joan to improve her ability to transfer independently and eventually she moved from using the hoist to using the standing aid. She was encouraged to attend day care and to begin relaxation to alleviate some of her anxiety.

Discussions took place with Joan and David about returning home. The occupational therapist accompanied them on a home visit and an agreement was made around downstairs living and the equipment required. They also agreed to a package of care with two carers calling three times a day.

Joan was discharged home with a follow-up visit by the occupational therapist to ensure that David could assist safely with transfers and use the portable ramps which had been provided to enable Joan to go outdoors.

She attended day care to continue with her physical rehabilitation and address her ongoing psychological needs, which centred on her anxiety. Staff at the day centre gave lots of positive reinforcement and listened actively to her concerns.

Joan had been reluctant to attend any hospital appointments because of her anxiety about the disease. Time was spent with her before the first hospital appointment to allow an open discussion around her fears about the prognosis. David was also given support, especially when he needed to return to work.

Over the next nine months Joan continued to make progress and achieve her goals. Her anxiety levels reduced with anxiety management, her confidence increased and physically she progressed to being independently mobile using a wheeled walking frame.

Liaison with the social services’ ccupational therapists resulted in a permanent ramp for access and a stair lift installed at home. Her next goal was to use the bath with equipment and to return to sleeping upstairs which, with assistance from the occupational therapist, she was able to do.

Joan was finally discharged from day care 12 months after diagnosis. She attended for a review eight weeks after discharge and did not require any further intervention at that time. She died peacefully at home two months later.

*All names have been changed to protect confidentiality

Author
Ann Norris, occupational therapist

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