Effectiveness Of Occupational Therapy In Palliative Care - Research Paper Example

Current and future practice issues for occupational therapy in relation to the chosen client group in palliative care Introduction This paper identifies client group as those patients suffering from life limiting conditions. Life limiting conditions are associated with the impairment, incapacity, debilitation and death (Moody, Beckie & Long, 2000). According to Moody such conditions are not to be interpreted as a natural and inevitable ending. What is so significant about occupational therapy and palliative care is that the professional practitioner adopts a friendlier and more understanding approach in taking care of the patient. In other words he becomes a catalyst in transforming the patient from acute awareness of their life limiting conditions – e.g. cancer, HIV, kidney disease, heart disease, lung disease and so on – to a more hopeful mental condition. Life limiting conditions might create such concerns and fears among patients, thus leading to a lack of social intercourse and communication. Such patients also display stressed conditions. Occupational therapist has been called upon to identify, diagnose and devise treatment plans in conformance with modern hospice environments that demand a greater degree of professionalism and an equally great amount of practical experience (Thomson, 2000). The underlying assumptions point towards a formidable palliative care regime. Such palliative care regimes have come up in response to otherwise demanding patient care environments. In other words identified client groups such as those with life limiting conditions need to be classified under much stricter palliative care concepts rather than institutional dispensations. There are two different ways in which those participants in client group are selected. Random selection can be adopted as a better method which would enable the students randomly participates in the process. Secondly non-random selection can be adopted in order to obtain a particular point of view of the participants. Subject to the above criteria the adolescence of the client group will be involved in explorations and studies to find out ways and means to improve the existing occupational standards and performance. In this respect the following reasons for the members’ participation must be noted. Potential members of the client group would be required to serve as participants in therapeutic sessions. Designing and planning processes would enhance the occupational therapist’s contribution to the development of both the process of treatment and engagement. This would be of immense help in the future because there would be many positive outcomes with client group’s participation in occupational therapy sessions. Palliative care refers to dynamic occupational therapy settings in hospices where professional therapists are involved in providing a variety of services within the occupational therapy sphere (Wilkie, Kampbell & Cutshall, 2000). Palliative care as defined for the purpose of this paper includes services rendered within the hospice environment where the patient is absorbed in the day-to-day affairs of the hospice. As a result, the professional therapist’s freedom of practice is enhanced and further there is a process of alleviation and mitigation. Alleviation of the hospice inmate’s psychological pain and concern is a primary aim of palliative care (Craik, Chacksfield & Richards, 1998). The hospice setting attenuates the inmate’s psychological tendency to entertain negative feelings. In other words the hospice settings invariably support the patient’s attitudinal shifts away from acute perception of terminal conditions to a perception of well – being, though temporary. 2. Life limiting conditions and palliative care settings According to World Health organization (WHO) there are four categories of life limiting conditions ordered according to severity (http://www.stoppain.org). Certain life limiting or threatening conditions or illnesses that can be treated though not with success. Certain life limiting ailments or conditions that can be treated with a degree of intensity to prolong life and normal activity though premature death might not be ruled out. Progressive degeneration conditions that aren’t amenable to curative intervention or treatment and can only be ameliorated through palliative care extending over a number of years (Sepúlveda, Marlin, Yoshida & Ullrich, 2002). Life limiting conditions that cannot be reversed though might not be progressive making the patient susceptible to complicated health conditions and finally might lead to premature death. Current research on the subject of occupational therapy and palliative care identifies life limiting conditions as having a decisive impact on both the professional therapist’s capacity to cope up with process related issues and the role that they play as transforming agents or catalysts (Creek & Lawson-Porter, 2007). Life limiting conditions thus acquire a significant place in the palliative care delivery system based on the hospice as against the hospital. In other words the hospice defined as an informal, friendly and long-term stay establishment is a regenerative phenomenon. The importance of its physical environment isn’t emphasized as much as its non-physical nature (Yerxa, 1990). This is all the more obvious when one looks at palliative care provision against the backdrop of hospice management. Life limiting conditions can be identified with some barriers which would directly impact on the health and well being of the patient. Such conditions could be regarded as lifelong diseases and they may have some risk exacerbating factors such as poverty, parental divorce, divorce, living in violent neighborhoods and so on. In the first instance limited income levels of patients can be considered as a risk factor behind the prolongation of sufferance. In other words there must be a thorough examination of the impact of social disabilities on life limiting conditions. Social, economic and psychological factors would be thoroughly examined in order to apply a more appropriate conceptual and theoretical contingency model/framework (Dowling & Hutchinson, 2008). Currently available literature on the conceptual and theoretical contingency models of the life limiting condition prevalence and their cause and effect analysis on the society at large are pathetically inadequate. While the degree of convergence/divergence between and among the variables has been metrically presented as higher, there is very little analysis on the related subject social impairment and lack of social mobility. Thus consequences for the society, the affected individual and the family ought to be investigated. The psychological conceptualization of life limiting conditions and palliative care also underline the importance of cognitive societal biases and prejudices to such an extent so that independent researchers on the subject hold the common view community perspectives on palliative care have much more than what they show on the surface. Thus societal attitudes haven’t undergone the more desirable transformation needed to serve as a catalyst of change in palliative care environments, including hospitals and homes (Nolen-Hoeksema, Larson & Bishop, 2000). The available literature on societal attitudes towards palliative care has amply demonstrated the fact that attitudes in the society towards individuals have not been shifting in the right direction. For instance number of deaths in palliative care environments like hospices has been exaggerated by many. In the UK a majority of deaths has been attributed to life limiting conditions of which cancer and heart disease are the leading causes. Out of 500,000 deaths per annum in the UK, the greatest percentage occurs in hospitals (Ryan, 2000). This figure can be as high as 58%. On the other hand only 4% die in hospices. Health education and health promotion among patients with life limiting conditions must be centered on motivation. Motivation is an important factor that contributes to the therapist and client relationship ending in a successful counseling process in a palliative care setting (Alaeddini, Julliard & Shah, 2000). Various degrees of motivation can be determined depending on the nature of referral. Self-referred patients are the most motivated ones because their motivation is an intrinsic one empowered by self-determination and will to change. However, patients who are referred by family, and especially those who aren’t sure are more reserved to engage in the counseling process (Haley, LaMonde & Han, 2001). This reticence is caused by the external pressure. These patients are not motivated by a desire to change. They are persuaded by family members, friends and so on. However, patients motivated by anothers achievement are likely to be strongly motivated, even though they may not fully understand the process of intervention by the occupational therapist. Another factor that determines the relevance and success of the health professional’s or therapist’s intervention in creating awareness of gradual termination is the nature of the problem presented by the patient. In other words, the problems and concerns of patients must be amenable to modification by intervention. Usually, these are common concerns and problems among patients who are experiencing life limiting conditions. Though occupational therapeutic intervention can help people who have a variety of concerns, it is likely to be unsuccessful if used as stand-alone treatment in some cases (Carey, Love, Nehill & Wein, 2006). People struggling with severe attitude related problems or with cognitive mental disorders and those who oppose therapeutic interventions, or those who exceedingly externalize the cause of their problems are more likely to pose a challenge for the therapist and the subsequent intervention process, by rendering it inefficient. This can be due to a lack of understanding palliative care or other professional or social help resources. Thus palliative care education has much more in common including the therapeutic intervention planning with persuasion. The professional therapeutic intervention plans need to be put in place with a view to educating patients so that a degree of increased awareness about the complex implications of life limiting conditions would help the patient to adjust to his environment better, thus increasing the level of tolerance towards palliative care. 3. Assessment Assessment criteria in palliative care settings need to be developed in conformance with category constructs and theoretical constructs. Category constructs and theoretical underpinnings that underlie each category construct in treatment planning in palliative care environments have to be delineated in order to understand the extent and the nature of the impact created by different procedural techniques adopted by the therapist and the intervention process. In this analysis a controversy that exists in between the definitions of therapeutic intervention and psychotherapy ought to be cleared, viz. therapeutic intervention in palliative care settings and psychotherapy have been treated by many researchers as identical concepts. This is part of a recent general trend to identify occupational therapeutic intervention with psychotherapy and is of extreme relevance here. This paper would instead place emphasis on a synthesis between the therapist’s efforts in the palliative care setting and prolongation of terminal condition (Reeves, Freeth,  McCrorie & Perry, 2002). In other words there should be some strictly definable measurable criteria for the assessment of the impact of palliative care interventions in patients with life limiting conditions. The currently available adjustment measures adopted by individual hospices have been of varying degrees of success though. In the absence of supporting techniques the therapist’s task both in intervention design and planning becomes difficult. Next a treatment plan ought to be well balanced with all specificities in it. Interventions give meaning to the previous steps and signify the essence of intervention regimes. The nature and type of interventions are presented in two steps. First, in the theoretical framework it is indicated as to which will be the most appropriate theoretical basis for a particular therapeutic process. In the second step, the therapist determines tools and strategies that are required by the specific theoretical postulate. A single theoretical basis is rarely used during the sessions. Typically different theoretical bases and their respective strategies are used in order to achieve different objectives at different stages of the therapy process. Although a concrete and valid reference system has not been yet developed guidelines have been established by research that vouches for a high probability of effectiveness in approaching specific problems through specific theoretical models (Acquaviva, 1998). Despite the benefits of palliative care there are also some concerns about the probable outcomes of such care for patients with life limiting conditions. In the first instance there are some limitations and controversies along with positive outcomes associated with the clinical validity and compatibility of the palliative care interventions and systems. The competence of therapists in articulating intervention regimes is often questioned. Another important issue is the relative competence of the palliative care staff in providing advice to the patient with a life limiting condition (Dysart &Tomlin, 2002). Postmodern viewpoints, on therapeutic interventions in occupational therapy in palliative care settings like hospices, are varied and complex. 4. Implications and policies Palliative care related implications arising from both formal and informal environments such as hospices and homes require much greater attention. In the first place palliative care practice and intervention in the informal setting where strictly defining the hospice is no more than a conducive environment for the transformation of the patient with a life limiting condition, is much less amenable to a broader interpretation (Maddocks & Rayner, 2003). For example, palliative care has been variously interpreted to include even alternative medical treatment processes. But nevertheless such broader interpretations cannot be accommodated within the function based definitions of the concept. Hospices and homes are not so much regulated as hospitals are and therefore the care delivery environment in the hospice and the home tends to be informal (Tuffrey-Wijne, Hogg & Curfs, 2007). Where informality is greater, it is possible that palliative care is subject to some constraints. Despite the WHO’s broader definitions of occupational therapy and palliative care, there is very little that therapeutic regimes in palliative care settings can do to create a degree of broader acceptance (http://whqlibdoc.who.int). A major area of criticism includes that palliative caregivers have to be trained in clinical diagnosis and treatment delivery skills. In other words despite the fact that palliative caregivers are highly competent to deliver the kind of service, their knowledge of parallel areas of competence has to be enhanced in keeping with exigencies of time and the space (Weber & Grohmann, 2004). 5. Palliative care intervention methodology Thus by implication those patients suffering from such life limiting conditions have to be convinced that their conditions can be ameliorated through palliative care intervention. Intervention methodology and palliative care practice are not always compatible. Therefore it is essential to understand that occupational therapy in the hospice setting must be treated as an evolving concept or a paradigm. Palliative care practice and intervention methodology on patients with life limiting conditions can be divided into three sub categories as follows. a) Occupational therapy related methodology While occupational therapeutic interventions in hospice settings have been advocated on two specific fronts – clinical support and education in creating awareness among clients of dual diagnosis – there have been parallel efforts too to identify and define the various needs and pressures with life limiting conditions in both formal and informal contexts. Health policies adopted by the NHS largely focus on curative aspects of treatment and care. Therefore palliative care practices have received less attention (Walker, Drummond, Gatt & Sackley, 2000). This in turn produced a wider spectrum of positive outcomes including those associated with tangible and intangible benefits. While a more positive correlation was established between benefits and intervention outcomes, there were also some bottlenecks that evolved with the very practice techniques. For instance as a corollary of the new developments individual and institutional freedom enjoyed by health professionals increased but only to replace the converse parallel that prevailed before, i.e. the professional straightjacket. Assessment frameworks and processes in hospice settings and treatment planning occupy a very important place due to the fact that the relationship between the therapist and the patient is a continuous one with each successive stage of the process of follow up. The methodology of assessment is also a bilateral one in that therapists happen to increase their awareness of the patient’s life limiting condition and then focus attention on the nature of intervention (Jonhsen, Petersen, Pedersen & Groenvold, 2009). According to modern critics such processes help the therapist to understand the patient with specific stress on the internal and external parameters of intervention and treatment. In the same vein it helps the patient to understand and be involved in the treatment process as characterized by an inescapable mutually reinforcing relationship between the two. b) Palliative care related methodology NHS policy direction has suffered from a very short-sighted approach though. Despite its laudable efforts there have been numerous delays and uncertainties in identifying and addressing the requirements of a systematic development plan for professional palliative care intervention methodologies in health care environments, like hospices. The consequences of this lack of policy direction could be seen in how patients with life limiting conditions have been subject to a variety of institutional and treatment mishaps. But nonetheless recently many researchers have suggested the significance of evidence-based palliative care interventions with pre-designed metrics of success measurement (Teno, Byock & Field, 1999). As at present those commissioning bodies that have been set up by trusts are responsible for the putting in place of evaluation criteria. These criteria serve as standards for the NHS Executive’s policy evaluation efforts. Palliative care related methodology constructs have been designed and developed with focus on quantitative paradigms. In such situations quantitative approaches play an important role in assessment related methods or techniques. Standardized inventories or metrics are divided into categories based on the variability they are designed to measure (Grov, Dahl, Moum & Fossa, 2005). Metrics that measure the patient’s ability to cope up with certain extreme situations are intended to size up individual capacities that in turn measure intelligence, achievement, and aptitudes. These metrics provide information regarding academic strengths and weaknesses as well as to indicate the level of learning of a patient relative to a specific life limiting condition (Hinkel, 2005). c) A synthesis of both Even though therapists might not be competent to prescribe medication, there are a number of reasons for which therapists should be familiar with the medications frequently used to treat life limiting conditions and their effects. First, at the point when the palliative care process starts the patient may have already been taking some medication, which might give an idea not only of the present and past status of the patient, but would help the therapist to avoid unwarranted outcomes. Knowing what a medication can or cannot do and knowing its side effects helps the therapist to monitor closely the patient’s progress, so he is able to decide whether to send the patient for a medication evaluation or not (Jack, Hillier, Williams & Oldham, 2003). During treatment planning, and often during therapy sessions, the therapist recommends adjunct services to improve the efficiency of the therapeutic process. A wide range of adjunct services are available to improve social life and personal growth in general for the patient, and especially for those people who are in need (García-Pérez, et al, 2009). Both the occupational therapist and palliative caregiver are involved in this process of providing adjunct services. Finally, the last step in treatment planning is the prognosis. Considering the generally accepted prognosis for a specific life limiting condition, and taking into account the personal resources and motivation of the patient, the prognosis may be terminologically established as follows: very good, good, fair, poor or guarded. However, seeking for a treatment plan with an optimistic prognosis by establishing realistic goals and valid interventions increases the likelihood of the desired outcome of the palliative care and occupational therapy process. Therefore the needs of the patient are the most important determinant in when, how and which adjunct services will be used in addition to pure palliative care. 6. Occupational therapy in palliative care contexts Formal institutional settings aren’t identifiable to palliative care settings in hospices where the client group tends to be cared for rather than treated by the occupational therapist. In such situations the model of care or the framework of care tends to be a holistic one with little else being left out for a secondary process of intervention. In other words as the founder of the UK’s modern Hospice Movement, Dame Cicely Saunders, once said “it’s intended to promote a good death”. Here a clear distinction between guidance and intervention is of importance to the analysis. Guidance refers to a systematic process of helping individuals to decide on the relative merits of available choices. On the other hand intervention is primarily focused on helping the individual to make changes in the process of treatment. While guidance is more or less akin to helping individuals to make choices, occupational therapists’ intervention helps them to identify what strategic options are available to them and at what opportunity costs etc (Howe,  2001). This in turn helps them to change their own decisions. There are both a priori and a posteriori elements in this approach. Though advantages outweigh disadvantages in therapeutic sessions, priorities might be overlooked by individuals if they happen to change decisions without the help of a therapist. Professional guidance is part of the help process provided by health professionals such as therapists. All the processes analyzed above are necessary for efficient palliative care intervention. However occupational therapy though which particular one carries more weight than which particular one is rather difficult to establish. Theoretical model building done on the modern models is more appropriate here because the underlying paradigm constructs for the evaluation of the relative importance of designing ad implementing therapeutic intervention sessions have received a broader perspective-based analysis (Elsayem, et al, 2004). In this context the following conclusions have been drawn and the subsequent recommendations have been presented with a view to enlarging the scope of discussion on the subject. The relative significance of occupational therapy sessions has to be considered against this backdrop and the subsequent category constructs in techniques of intervention and treatment planning will enable the occupational therapist to build up a contingency model of intervention based on palliative care and therapeutic intervention. Thus a broader definition of occupational therapy involves a multitude of procedural, professional, design, planning and implementing conceptualizations that would be more feasible in this context (Walling, et al, 2008). The above mentioned correlation between the therapeutic effect and the subsequent calibration of the client’s performance can be highlighted with specific reference to occupational performance on an individual basis. However the calibration effort can be the most difficult because individual performances might vary as reflected through level of response and individual well being. This is specially so when a particular group is subject to a verity of moral influences. For example a series of denotations and connotations apply to social attitudes. Learning outcomes apart such palliative care environment related causal factors towards amelioration of conditions would have little or no impact at all if the patient routinely performs some selected tasks. Against this backdrop of occupational therapy, a medium level of concentration and logical reasoning can be adopted to identify some therapy programs which would include a variety of attention shifting exercises (Letizia, Shenk & Jones, 2000). Occupational therapy is one such alternative available to the average patient with life limiting conditions in formal clinical setting or an informal non-clinical setting. These professionals provide a variety of services in an equally diverse and complex set of circumstances. Their actual practice begins with patients whose life limiting conditions permit their direct involvement in occupational therapy environments. Occupational therapy includes those borderline interventionist techniques that could be used with maximal impact by simultaneously adopting some unorthodox approaches such as taking the client group on camping and telling them how to practice self reliance. Thus there are some logical steps or a sequence of activities to be followed. These activities will improve the interaction and communication with the client group members and other family members in the home environment (Hearn & Higginson, 1998). Occupational therapeutic intervention for the patient with life limiting conditions would be of immense help to realize the ultimate outcome, i.e. death. But nevertheless it would be understood in a new light. This kind of logical reasoning would necessarily be associated with both productivity and leisure thus producing a well meant equilibrium between emotional response and health related well being. Conclusion In retrospection occupational therapeutic practice for client groups with life limiting conditions would provide some learning outcomes that could be influenced partially or wholly by using alternate intervention techniques. For example an occupational therapy activity for such patients is not only logical but also sheds light on some hitherto unknown aspects of palliative care intervention in hospice settings. In other words occupational therapy in general and palliative care in particular help patients with life limiting conditions such as cancer and heart disease to entertain a new paradigm of thought on the final outcome of the terminal condition. Arguably palliative care in particular and occupational therapy in general have been of immense benefit to client groups with life limiting conditions such as cancer, heart disease and HIV. Professional involvement of the palliative caregiver in the hospice setting as against the professional in a hospital setting invariably stands out as a newer paradigm for attention. In other words occupational therapy has come a long way despite the myths and brickbats to achieve its current position of being looked at seriously by patients with life limiting conditions. Death is inevitable but according to occupational therapy the feeling can be much less distressing to the patient if they were subject to the kind of social and mental well-being. In other words even when death is certain there can be some relief that the death comes with a change in one’s conditions. 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