Lymphoedema and oedema in palliative care patients.

Oedema and lymphoedema commonly occur in patients receiving palliative care. Community nurses frequently manage both in the home or must decide to refer for medical or specialist lymphoedema assessment. This article describes the types of oedema seen in palliative care and assists in clinical reasoning around the type of oedema presented and when to refer onwards. The treatments for palliative care oedema and lymphoedema are described, including how to adapt for complex cases and for patient comfort. Genital swelling, abdominal swelling, head and neck oedema and lymphorrhoea are also discussed.

Association between attendance at a specialist palliative care day unit and improvement in patient symptoms and quality of life.

BACKGROUND: Specialist palliative day care is an area of palliative care which has a notable scarcity of research. Evidence is needed on the role of palliative day care to improve patients' quality of life and symptom management, while recognising the different patient cohorts that use the service. AIM: To determine the symptoms and quality of life of the patient cohort that are affected by the completion of a full therapeutic cycle (8 to 9 weeks) at a specialist palliative care day unit (SPCDU). METHOD: A retrospective cohort study was carried out from January 2016 to December 2017. Patient related outcome measures (PROMs) were collected as part of routine clinical paperwork at admission and discharge, and these were used to determine symptoms and quality of life pre-attendance and on completion of an 8 to 9 week therapeutic cycle at the SPCDU. RESULTS: Descriptive analysis demonstrated improvement across the many symptoms that were analysed. Quality of life analysis also established improvement. Statistically significant difference was achieved in several areas. Total physical symptoms (p value=.009) confirmed the positive impact attendance at SPCDU has on physical symptoms. Specific symptoms which displayed a statistically significant difference included: poor appetite (p value=.002), weakness (p value=.03) and the anxiety felt by family/friends (p value=.029). The quality of a patient's life also displayed statistically significant difference (p value=.000). CONCLUSION: This study demonstrates that attendance at a SPCDU may positively impact a patients' symptoms and quality of life. A more uniform national approach to specialist palliative day care delivery, alongside multi-setting research, may further bolster the image of palliative day care. This will improve referrals to and occupancy of SPDCUs and benefit the palliative patient in the community.

Pilot Study: The Effectiveness of Complex Decongestive Therapy for Lymphedema in Palliative Care Patients with Advanced Cancer.

BACKGROUND: Complex decongestive therapy (CDT) is a regimen of physical treatment for lymphedema. Its effectiveness is unknown in advanced cancer patients. This study evaluates effectiveness of CDT in this population. METHOD: This is a prospective observational cohort study for 18 months of advanced cancer patients with lymphedema, who received three or more CDT interventions. Measurements were taken before the first (T1), third (T3), and sixth (T6) treatments as follows: limb volume using circumferential measurements, quality of life (QOL) using qualitative questions, skin quality using a locally developed scale measuring color, thickness, and texture. The treating physiotherapists collected data. Analysis was carried out using Microsoft Excel and SPSS. RESULTS: Twelve patients, age range 42-73 years (median 69.5) were included. Survival from last recorded treatment ranged from 3 to 262 days (median 40). At T3 (n = 21 limbs), volume reduction was significant (Wilcoxin Signed Rank Test Z = -2.5, p = 0.01, r = 0.5). At T6 (n = 13 limbs), volume reduction was significant (Z = -2.4, p = 0.013, r = 0.66). At both time points, there were significant reductions in abnormal skin thickness and surface, but not color. Improvements occurred independent of volume changes. QOL changes included better function, improved limb aesthetics, and less pain and tightness. CONCLUSION: For the first time, this study shows that CDT is effective for a cohort of palliative cancer patients with limited survival. Improvements in limb volume, skin quality, and lymphedema-related QOL were recorded. Valid skin and QOL measures need to be developed. Larger, blinded trials need to be conducted to determine which patients benefit from CDT.

Assessment, treatment goals and interventions for oedema/lymphoedema in palliative care.

BACKGROUND: Little is known about the treatment of oedema in palliative care patients. AIM: To outline the assessment, goals, and interventions for patients with oedema. METHOD: A 6-month chart review of a specialist physiotherapy-led oedema service was carried out. RESULTS: Of the sample group (n=63), 28.6% of patients had lymphoedema, 15.9% had non-lymphatic oedema, 46% had mixed oedema and 9.8% had lymphorrhoea; 58 patients (92%) had cancer. The most common interventions were providing education (100%, n=63), using compression garments (58%, n=37), bandaging (51%, n=32), exercise (38%, n=24), lymphatic massage and kinesio-taping (35%, n=22 each). Treatment regime differed depending on the type of oedema present. Treatment goals were pragmatic: the most common were to maintain skin quality (54%, n=34), reduce limb volume (52%, n=32), and improve quality of life (48%, n=30). CONCLUSION: Palliative care oedema can be treated using manual methods, including compression and massage. Goals differ from other oedema populations. Research is hampered by lack of suitable measures to record skin changes and quality of life.

Palliative Care Edema: Patient Population, Causal Factors, and Types of Edema Referred to a Specialist Palliative Care Edema Service.

BACKGROUND: Edema in palliative care patients is a common symptom, however, the research base for all aspects of its care is extremely poor. OBJECTIVE: To evaluate a specialist palliative care edema service in order to report on the patient population referred, the types of edema encountered, and the causes of edema. DESIGN: Prior to study, three different edema types were described for evaluation: lymphedema, nonlymphatic edema, and a combination of the two. Retrospective chart evaluation was completed from August 2013 through January 2014. SUBJECTS: Patients with edema assessed by the specialist palliative care physiotherapy edema service. RESULTS: Sixty-three cases were included, comprising 10.5% of all new palliative care referrals during the study period. Ninety-two percent (n = 58) had a diagnosis of cancer and 57% (n = 36) were female. Age ranged from 45-97 years. The most common edema type was a mixed edema (46%, n = 29), followed by lymphedema (27%, n = 18) and nonlymphatic edema (16%, n = 10). Lymphorrhea occurred in 9.5% of cases. The most common reasons for edema, based on clinical opinion, were blocked lymphatics (33%) and dependency from immobility (27%). The most common site for edema was in the lower limbs (89%, n = 56). The time lapse from the last treatment to death ranged from 1-225 days. Having a mixed edema type or lymphorrhea was a relatively poor prognostic sign. CONCLUSIONS: This is the first study to describe in detail the occurrence of edema in palliative care patients. Edema may be present for many months prior to death making the search for effective treatments imperative.

A profile of hospice-at-home physiotherapy for community-dwelling palliative care patients.

AIM: To profile a specialised palliative care physiotherapy service to community-dwelling patients. DESIGN: Retrospective audit. SETTING: Milford Care Centre, Limerick, Ireland. PARTICIPANTS: Patients referred to hospice-at-home physiotherapy during September 2010-February 2011. OUTCOME MEASURE: Edmonton Functional Assessment Tool (EFAT-2). RESULTS: 165 patients were referred, of whom 90% had cancer. Nurses referred 120 (73%). Referrals appeared to be increased by the presence of physiotherapists in the nursing bases. No asssessment was conducted for 55 referrals (33%), mainly owing to clinical deterioration. The remaining 110 patients were assessed, with 47 (43%) being contacted within 2 days of referral (mean 4 days, standard deviation 4.2, range 0-21 days). Physical function ranged from 0-18 (median 7, mode 4) on the EFAT-2 scale. The most commonly used treatments were exercises and advice/education. CONCLUSION: Referrals to the at-home physiotherapy service are heavily dependent on nurses and their understanding of the physiotherapy role. Patients tended to be relatively high functioning and tolerated numerous interventions.

Physical function in hospice patients and physiotherapy interventions: a profile of hospice physiotherapy.

OBJECTIVE: There is a dearth of international research on hospice physiotherapy. This study aims to profile hospice physiotherapy in an Irish setting in order to inform practice internationally. DESIGN: The study design consisted of a retrospective chart audit over 6 months. SETTING: The study took place at a specialist palliative care inpatient unit (hospice) in Limerick, Ireland. PARTICIPANTS: All patients were discharged (through death or discharge onwards) from January to June 2010. OUTCOME MEASURE: The Edmonton Functional Assessment Tool (EFAT-2) was used as an outcome measure. RESULTS: Sixty-five percent were referred for physiotherapy; 58% (n=144) were assessed and treated. A wide range of patients was referred (mean functional score 11, range 1-23, SD 5). Rehabilitation activities were widespread: 48% with more than one functional score recorded made improvements; 53% of physiotherapy patients were eventually discharged home; 47% of physiotherapy patients died, of whom 52% received physiotherapy in the last week of life. The median physiotherapy program lasted 11 days (range 1-186, SD 22) whereas the median number of treatments was four (range 1-99, SD 10). The most common interventions were gait re-education (67%), transfer training (58%), and exercises (53%). One third of treatment attempts were unsuccessful because of the unavailability/unsuitability of patients. Challenges for physiotherapists included frequent suspension of treatment and large functional fluctuations in patients. CONCLUSION: There was a high referral rate to physiotherapy in this hospice. Functional changes in hospice patients were mapped, showing that physiotherapy involved both rehabilitative and quality of life/supportive measures. The most common treatments were physical activity interventions.