Clinical Training Recommendations for Physical Therapy Practitioners Caring for Patients with Serious Illness

These training recommendations will help physical therapy practitioners address the unique needs of patients living with serious illness.

Assess the Needs and Concerns of Patients

• Assess the impact of serious illness on patient and caregivers’ quality of life, well-being, participation in daily life, meaningful activities (e.g. ADLs, functional mobility, strength, joint mobility, fall risk, fatigue and pain management, environmental constraints) and necessary adaptation.
• Assess patient’s physical, mental, social, cultural, and spiritual well-being at all stages of illness and use appropriate assessment tools specific to rehabilitation.
• Identify the impact of medical treatments and medications on balance, bodily functions, alertness, self-monitoring skills, and awareness of self and safety.
• Assess patient for durable medical and/or adaptive equipment needs.
• Review caregiver needs (physical, psychosocial), resiliency, and potential resources.
• Know what palliative care is, and how and when to request a consult.

Strengthen the Clinician-Patient Relationship and Understand Goals of Care

• Identify social supports that enable the patient to participate in meaningful activities.
• Facilitate conversations with patients to understand what matters most to them now that they have a diagnosis of a serious illness; participate in shared decision-making that is aligned with patients’ values and preferences to create a PT care plan that reflects these goals.
  • May include desired location for future care (e.g. home vs. extended care facility)
• Support patients and caregivers to prioritize and problem-solve barriers to participation in daily life and meaningful activities, as well as enhancing safety in and outside the home.
• Identify how culture, race, gender, sexual orientation, and context (e.g., social determinants of health) influence patient and family decision-making in the context of a serious illness, and deliver responsive, unbiased care matched to needs and priorities.
• Educate clinical colleagues on the role of physical therapy for patients with serious illness, and when consults are appropriate.

Manage Pain and Symptoms

• Assess the functional impact of common symptoms associated with serious illness on safety, function, and participation in daily life (e.g., impact of weakness or severe pain on ability to participate in daily life and meaningful activities), and alert team members about:
  • Pain
  • Nausea and vomiting
  • Constipation and diarrhea
  • Dyspnea
  • Fatigue
  • Depression
  • Anxiety
  • Delirium, agitation
  • Balance/dizziness (especially regarding positional change
  • Safety risks
  • Cognition (e.g. attention to task)
  • Caregiver needs and/or concerns re: function
• Prescribe an appropriate exercise/physical activity program utilizing clear principles (e.g. FITT – Frequency, Intensity, Time, and Type) and educate patient and caregiver on when and how to progress and regress as necessary based on patient presentation.
• Utilize non-pharmacological pain and symptom management techniques (e.g. TENS, massage, exercise, positioning) in relationship the implications of appropriate exercise dosing to optimize quality of life.
• Modify physical therapy examination and treatment based on pain, fatigue, and symptom limits to avoid negative effects and exacerbation of conditions.
• Use principles of trauma-informed care, specifically in the context of serious illness (e.g. cancer-related post-traumatic stress).

Prevent Crises and Plan Ahead

• Identify and assess the feasibility, acceptability, and safety of the care plan with the patient (e.g. recommending appropriate home modifications).
• Collaborate in discharge planning and level of care.
• Identify sources of distress (physical, psychosocial, spiritual), and collaborate with colleagues to provide support when needed.
• Provide patient and caregiver education in:
  • Patient transfers (body mechanics)
  • Self-care
  • Communicating patient needs to care team
  • Safety, including safe use of assistive devices, bed rails, commodes, and environmental modifications and their benefits and burdens
  • Energy conservation and pacing
  • Planning for future patient decline and increased caregiving needs (e.g. procuring and educating on walkers and wheelchair before need arises)
  • Community resources to support living with serious illness
• Assess patient’s environments (e.g., home, community, social, cultural) and provide recommendations that are appropriate, feasible, and anticipatory.

Complete the Learning Pathway, Foundational Skills for all Physical Therapists, to acquire these skills.

Assess the Needs and Concerns of Patients

• Determine patient and/or caregivers’ level of knowledge about their illness and refer to primary team for additional information when appropriate.
• Assess for distress related to function, safety, and participation in daily life; invite dialog on these issues and alert appropriate team members.
• Assess for common factors affecting safety, function, and participation in daily activities that may be complicated by serious illness, and collaborate with the treating team for effective management, including:
  • Social risk factors:
    • Presence of caregiver and their capacity
    • Caregiver burden and support
    • Racism and other cultural factors that influence care
    • Access to housing, food, and transportation
    • Financial security or strain (e.g., ability to pay for equipment or environmental modifications)
  • Polypharmacy and its impact on function
  • Emotional, social, psychological, cultural, and spiritual sources of distress (e.g., existential distress)
  • Physical symptom distress (pain, weakness, dyspnea, dizziness, pelvic floor dysfunction, etc.)
  • Communication barriers (e.g., vision, hearing, dental issues, health literacy)

Strengthen the Clinician-Patient Relationship and Understand Goals of Care

• Review goals of care conversations and be confident and competent to provide goal-concordant physical therapy.
• Assess for, and be responsive to, individual or cultural practices related to serious illness and end of life.
• Conduct skilled conversations with patients and families about:
  • Serious news (e.g., discussing activity cessation in response to medical or functional changes)
  • Prognosis (changes in function, participation in daily life, and level of care needed)
  • Anticipated functional decline and strategies for maintaining autonomy
  • Patient/family expectations (future needs for equipment or support)
  • Financial strain
• Provide education about:
  • Coping with serious illness and its impact on participation in daily life and function
  • ADLs
  • Safety (e.g., transfers)
  • Non-pharmacological strategies for managing pain and anxiety
  • Adaptations to daily life and meaningful activities, including gradation of activity to facilitate participation
  • Environmental modifications (home set-up for safety and independence)

Manage Pain and Symptoms

• Educate patients and caregivers on the often-fluctuating nature of pain and symptoms and functional performance across the illness trajectory, including preparation for safe ADL and functional participation when fluctuations occur.
• Contextualize treatment and/or interventions to incorporate the values, meaning, and priorities of each individual patient to provide person-centered, family-focused, and culturally congruent care
  • Know side effects of current and future medical treatments, medications on function, and plan accordingly.
  • Employ mindfulness and active listening strategies/tools to address pain and symptoms.
• Advocate for the increase of palliative care services for underserved or marginalized populations.

Prevent Crises and Plan Ahead

• Identify barriers to engaging routine and important life events within the patient’s capacity and desires (e.g. discuss risks/benefits of a family beach outing and assist in planning).
• Develop a proactive plan in the event of changing abilities or needs, falls, changes in functional and cognitive ability, or compromised ability to participate in daily life and/or meaningful activities.
• Educate patients and caregivers on the often-fluctuating nature of symptoms and functional performance including preparation for safe ADL and functional participation when fluctuations occur.
• Assess caregiver’s ability to provide continued care; discuss necessary transitions of care if warranted.
• Facilitate in conversations with patients and families about what to expect in the future (“rehab in reverse”/decline with dignity).

Thank you to the following clinicians for their review of these recommendations: Chris Wilson, DScPT, DPT, GCS