I am a home care physical therapist with a client recently admitted to an AFC post-hospital discharge. This patient recently experienced rapid physical decline and falls because of a diagnosis of metastatic cancer. He was referred to home care PT and upon evaluation he expressed a desire to work with rehab to regain his strength and safety with mobility. Initially he responded well to treatment; walking safely and making other functional gains. He was then rehospitalized due to a rapid significant decline. Upon return to the AFC, I received a resumption of care order. I am not quite sure how long to continue rehabilitative care. What do you think?

          The situation you describe is not unusual for today’s clinician to encounter. Geriatric patient populations will invariably include patients with terminal diagnoses. The question you are posing really revolves around quality of life and care philosophy issues. All clinicians should examine their approach to these type of delicate clinical situations in preparation to make appropriate and supportive care decisions with and for the patient.
            Geriatric patients currently receiving home care are routinely discharged from therapy services upon enrollment in a hospice program. The underlying clinical premise of hospice care is to support the patient during the end of life transition. General rehab principles and modalities often clash with comfort-based hospice programming goals. It is uncomfortable and inappropriate to urge or coerce hospice enrollees to participate in standard rehab activities. The occasional hospice patient we treat in our practice has requested rehab services as a basic quality of life issue. Physical therapy programming for the hospice patient revolves specifically on safety training of patient and caregivers and instruction of a home exercise program that can be performed by and for the patient that is tailored to tolerance.
            Though your patient remains a Medicare certified home health client, it is easy to wonder how his recent declines and subsequent hospitalizations are related to his terminal diagnosis. It may very well be that these setbacks stand in stark contrast to a normal decline seen in rehab patients for a variety of other reasons. The natural inclination to relate his recent regressions to his cancer diagnosis would prompt questions regarding the appropriateness of a hospice referral. Specific communication should occur with the patient’s physician. It must include 1) the clinical basis of the declines 2) the patient’s goals and attitudes 3) the need for a hospice information visit.
            Continuing with further rehab services would occur after the physician identifies that the patient is safe to continue rehab without concern for the diagnosis. Secondly, the patient should state in no uncertain terms his eagerness to resume therapy to obtain functional goals. Once this has been determined, you should create a new plan of care based on your resumption of care assessment. In no way do any of these points restrict the use of a hospice information visit if the physician deems it necessary or appropriate.

Teri N. Thompson and Arnie Cisneros are physical therapists with more than 35 years of combined home care experience. They are co-owners of Home Health Strategic Management of East Lansing, MI; providing clinical service management and home care consulting expertise. They also lecture and provide OASIS, HHRG, OBQI and P4P training at seminars nationally.