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SAN DIEGO — The aging of the U.S. population, burgeoning focus on quality end-of-life care and new Medicare conditions of participation have led the way to a new practice area for physical therapists — hospice.

Members of the American Physical Therapy Association’s oncology section offered an educational session highlighting this area of opportunity for PTs at the Combined Sections Meeting in San Diego in February.

“We’re on the map now, formally,” said Karen Mueller, PT, PhD, Northern Arizona University and Northland Hospice and Palliative Care, Flagstaff, Ariz. Therapy from a qualified PT must be made available to hospice patients, according to the Medicare rule change made in 2008.

Because hospice is such a new area for PTs, practice guidelines are sparse. In a 12-patient study conducted by Mueller, hospice patients were most interested in functional training from PTs. This was followed by edema control, family education and advice on equipment modifications.

“We reduced pain fairly significantly,” Mueller said of her study participants. “They’re safer, they’re more efficient and they’re more comfortable.” Sleep quality also was greatly improved, she said.

Massage, mindfulness-based stress reduction and yoga were used, which were effective for both pain and sleep disturbance. “I’m not suggesting we get our patients into more extreme postures, but some of the stretching and deep breathing can be helpful,” Mueller said.

Mueller approaches hospice patients with an unobtrusive manner.“The phrase that has worked for me over the past few years is, ‘Maybe I have a tip or hint that might help you and maybe I don’t,’” she said. “The simpler I make it, the more families are apt to open up.”


Practice Settings
In 2008, 39% of U.S. deaths occurred in a hospice setting, Mueller said. “If you’re interested in working in hospice, you may find yourself in several settings,” Mueller said. Private homes, independent living facilities, assisted living facilities, skilled nursing facilities, inpatient hospice facilities, prisons and perinatal settings are a few examples.

Hospice team members include the physician, nurse (who is the case manager), social workers, home health aides, pastoral care counselors, volunteers, OTs, speech therapists and bereavement counselors.

Patients are admitted to hospice with a life expectancy of six months. “I’ve had patients I’ve treated one or two days, then I’ve had patients with, for example, ALS I’ve treated for one or two years,” Mueller said.

Hospice patients are usually older (83.5%) and white (81.9%). Just more than half are female. Cancer is the top diagnostic category at 38.3%, though it is declining, with an average length of stay of 45.6 days, Mueller said. Debility is the second most-common diagnosis, at 15.3% and increasing. The average length of stay is 76.1 days. Heart disease is third, at 11.7% and declining. Dementia is fourth, at 11.1% and increasing.

Mueller believes PT treatment can, in fact, prolong survival by offering “the life-sustaining benefits of being comfortable, being pain free ... living as well as you possibly can.”

Care Plans
In hospice, the focus is on giving care, not finding a cure, said Jo Ellen Thomson, PT, St. Luke’s Hospice, Bethlehem, Pa. The emphasis is on the patient and family, not the disease, she said. The priority is on pain and symptom management.

“There’s minimal to no evidence-based research to say what you do in this situation, so you really use your experience,” Thomson said.

PTs can consult on issues such as injury prevention, but this is a hands-on position, Thomson stressed. “I thought I would be doing more evaluation than treatment, but it’s turned out to be equal.”

Education the PT provides to a hospice patient and his or her family can include caregiver safety, environment modifications, mobility, complementary and alternative medicine techniques, and equipment selection.

There are unique psycho-social considerations with hospice patients, Thomson said. For example, patients often resist transition to a hospital bed. “For a lot of these people, acceptance of a hospital bed means it’s their death bed,” Thomson said. “It’s their choice.” A “cradle bed” made of foam is one alternative, she said.

“One phrase I’ve used a lot is, ‘Can we try this for a week?’” she said. “Once you get your foot in the door and they realize how much you can offer ... they’ll use you.”

Pain may come from tumor growth, metastasis, spinal cord compression, disease progression, chemotherapy and radiation. Treatment may include exercise, positioning, edema management, massage, heat and cold, and relaxation techniques.

There are other considerations. “Energy conservation cannot be stressed enough with what we have to do with this population,” Thomson said.

Psychological distress is always a factor in hospice patients. “Another thing we’re paying a lot of attention to is people who were involved in wars,” Thomson said. “People are reliving atrocities they have been through.”

Hospice may not be for everyone, but it offers some benefits over other areas of PT practice. These include no OASIS coding, no case admissions, no discharge summaries and unique problem-solving opportunities, Thomson said.

“For me, I find it very rewarding and I feel privileged when they say there’s one more thing they want to do before they die and I can help provide that for them,” Thomson said.

Natasha Emmons is national news editor for Today in PT.