曹昭懿主任 國立臺灣大學物理治療暨研究所主任 國立臺灣大學物理治療暨研究所教授

1. 復健與安寧緩和照護
Palliative
Care
曹昭懿

2. Goals
• To
cure
some-mes
• To
relieve
o0en
• To
comfort
always

3. Pallia-ve
Care
• Goal:
achievement
of
the
best
quality
of
life
for
pa-ents
and
their
families
• Focus
on
func-onal
consequence
of
the
disease
and
its
treatment,
including
physical
and
psychological
aspects
• Func-onal
reserve
and
maximize
func-on

4. How?
• Structure:
mul-disciplinary
team
• Process:
reitera-ve,
ac-ve,
educa-onal,
problem-­‐solving
process
– Assessment
à
Goal
seHng
à
interven-on
à
re-­‐
assessment
• Outcome
–
maximize
the
par-cipa-on
in
pa-ent’s
social
seHng
– Minimize
the
pain
and
distress
of
pa-ents
and
carers

5. Where?
• Hospital
• Hospice/specialist
pallia-ve
seHng
• Day
care
center
• Community

6. What?
• Disease
related:
brain
tumor…
• Treatment
related:
chemotherapy
induced,
radiotherapy
induced…
• Symptoms,
e-ology
of
the
symptoms

7. Symptoms
• Func-onal
limita-on
• Pain
• Breathless/Dyspnea
• Cancer
related
fa-gue
(CRF)
• Mental
Health:
communica-on

9. Assessment

10. Pa-ent
Family
Centered
• Pa-ent
family’s
expecta-on
– Expected
ac-vity
– Physical
ability
– Environmental

11. Ques-ons
• Pa-ent
– What
are
the
most
important
things
prevented?
– What
brings
you
the
most
pleasure?
– What
do
you
most
like
to
do
tomorrow
if
you
can?
• Caregiver
– What’s
the
most
concerned
in
caring
for
the
physical
needs
of
the
pa-ent?
– What
are
you
allowing
the
pa-ent
to
do
independently?

12. RED
FLAGS
OR
YELLOW
FLAGS
l Complete blood count
l Anemia
l Neutropenic
l Thrombocytopenic
l Neural impairments
l Skeletal impairments
l Cardiovascular or pulmonary system

13. PHYSICAL
FUNCTIONING
l Strength, ROM, muscular and cardiopulmonary
endurance, pain
l Eastern Cooperative Oncology Group (ECOG) scale
l Karnofsky Performance Status scale (KPS scale)

14. ECOG
performance
status
Grade ECOG
0 Fully active, able to carry on all pre-disease performance
without restriction
1
Restricted in physically strenuous activity but ambulatory and
able to carry out work of a light or sedentary nature, e.g., light
house work, office work
2 Ambulatory and capable of all selfcare but unable to carry out
any work activities. Up and about more than 50% of waking
hours
3 Capable of only limited self care, confined to bed or chair more
than 50% of waking hours
4 Completely disabled. Cannot carry on any selfcare. Totally
confined to bed or chair
5 Dead
Oken, et al. Am J Clin Oncol 1982;5:649-655

15. KPS scale
Able to carry on normal
activity and to work; no
special care needed.
100 Normal no complaints; no evidence of disease.
90 Able to carry on normal activity; minor signs or symptoms
of disease.
80 Normal activity with effort; some signs or symptoms of
disease.
Unable to work; able to
live at home and care for
most personal needs;
varying amount of
assistance needed.
70 Cares for self; unable to carry on normal activity or to do
active work.
60 Requires occasional assistance, but is able to care for most
of his personal needs.
50 Requires considerable assistance and frequent medical
care.
Unable to care for self;
requires equivalent of
institutional or hospital
care; disease may be
progressing rapidly.
40 Disabled; requires special care and assistance.
30 Severely disabled; hospital admission is indicated although
death not imminent.
20 Very sick; hospital admission necessary; active supportive
treatment necessary.
10 Moribund; fatal processes progressing rapidly.
0 Dead

16. GOAL
SETTING
l Patient and family need
l Achievable within one week
l Compensatory approach is concerned

17. 確認現有的資源及優勢-1
病患本身及家屬
1. 是否認清疾病進展對功能的影響？
2. 期望，是否好高騖遠？
3. 達成病患的目標需要花多少時間或介入的
次數？
4. 病患的家庭支持系統好嗎？家屬願意配合
嗎？照顧者是固定的嗎？

18. 確認現有的資源及優勢-2
病患本身及家屬(續)：
5. 病患現有的身體功能，有哪些可以安全的
參與於活動當中？
6. 病患現有的輔具有哪些？合適嗎？可以維
修或修改嗎？有輔具資源可運用嗎？
7. 病患使否有身障手冊？可爭取到哪些社會
福利資源？
8. 後續的安置問題
尊重病人自主權

19. 確認現有的資源及優勢-3
照顧團隊的考量：
1. 對於病患的期望或需要，緩和病房團隊成
員覺得可行嗎？
2. 可以給予怎樣的配合及幫助？(護理師、社
工、志工、宗教師)
3. 如何以最有效率、節省人力、物力成本的
方式提供服務呢？

20. 確認現有的資源及優勢-4
• 和病患、家屬及團隊共同擬訂計畫後一起
解決問題。
★
病患的參與可以減少其對疾病的絕望
★
增進和病患、家屬和醫療者間的關係
★
提升病患的生活品質和減輕照顧者的負擔

21. PALLIATION
l Managing symptoms
l Improving mobility
l Slowing functional decline
l Maintaining QOL
l 6-week structured PA: significant decrease in
fatigue increase in physical performance
emotional functioning (Oldervoll et al, 2005, 2006 )
l 50 patients, home-based PA, walking
(Lowe, et al. Support Care Cancer 2010;18:1469-75)

22. INTERVENTION—FUNCTION
l Strength training, ROM exercise, muscular and
cardiopulmonary endurance training, pain
management
l Activity modification
l Assistive devices
l Environmental adaptation

23. CASE
1
l BC, bone meta with spine compression fracture
l Sit, dinner with family
l Pain, weakness, contracture of knee, poor
endurance

24. INTERVENTION—PAIN
l Somatic pain
l Neuropathic pain
l Visceral pain
l Total suffering

25. INTERVENTION—PAIN
(I)
l Medication: mouth, clock, the ladder

26. INTERVENTION—PAIN
(2)
l PT measures
l Exercise and movement
l Graded and purposeful activity
l Postural re-education
l Massage
l Manual techniques
l Pain control modalities: TENS, heat cold

27. PAIN
AND
FUNCTION
(Rehabilita-on
in
cancer
care,
2008)

28. (Rehabilita-on
in
cancer
care,
2008)

29. Interven-on—dyspnea
• Medical
interven-on
• Alter
the
physiological
mechanisms
• Alter
the
central
percep-on
of
dyspnea

30. (Rehabilita-on
in
cancer
care,
2008)

31. Helpful
Posi-ons
• High
side
lying
• SiHng
upright
in
a
chair
with
feet,
back
and
arms
supported
• Forward
lean
siHng
with
arms
res-ng
on
pillows
on
a
table
• Standing
relaxed,
leaning
forward
with
arms
res-ng
on
a
support
such
as
a
windowsill
• Standing
relaxed,
leaning
backwards
against
a
wall
with
the
legs
slightly
apart,
chest
forward
and
relaxed,
arms
hanging

32. Central
Percep-on
• Fear,
anxiety,
distress
• Safe,
relaxa-on
(including
physical
interven-on)
• Overbreathing
• Communica-on
and
Understanding
(empathy)

33. Fa-gue:
Screening
Assessment
• Age
5-­‐6
y/o:
not
-red,
-red
• Age
7-­‐12
y/o:
1-­‐5
scale
– 1-­‐2:
mild
– 3:
moderate
– 4-­‐5:
severe
• Age
12
y/o:
0-­‐10
scale
– 0-­‐3:
none
to
mild
– 4-­‐6:
moderate
– 7-­‐10:
severe

34. Non
to
Mild
• Not
-red
in
age
5-­‐6,
scores
1-­‐2
in
age
7-­‐12,
or
scores
0-­‐3
in
age12
• Educa-on
– Ac-ve
treatment
– Post
treatment
– End
of
life
• General
strategies
to
manage
fa-gue
– Ac-ve
treatment
– Post
treatment
– End
of
life

35. Non
to
Mild:
Ac-ve
Treatment

36. Non
to
Mild:
Post
Treatment

37. Non
to
Mild:
End
of
Life

38. Moderate
to
Severe
• Tired
in
age
5-­‐6,
scores
3-­‐5
in
age
7-­‐12,
or
scores
4-­‐10
in
age12
• Educa-on
– Fa-gue
is
not
an
indicator
of
disease
progression
– Self-­‐monitoring
of
the
fa-gue
level
– Expected
the
end-­‐of
life
symptom
and
the
fa-gue
intensity
may
vary
• Primary
evalua-on
• Interven-ons

39. Primary
Evalua-on

40. Interven-ons:
Ac-ve
Treatment

41. Interven-ons:
Post
Treatment

42. Interven-ons:
End
of
Life

43. Ac-vity
Enhancement
(I)
• Fa-gue:
**
– during
cancer
treatment
– following
cancer
treatment
• Aerobic
capacity:
– 11/22:
significant
difference
between
interven-on
and
control
group
– 3/22:
significant
pre-­‐post
difference
– 8/22:
non
significant
difference
• Quality
of
life:
-­‐-­‐
• Anxiety:
-­‐-­‐
• Depression:
-­‐-­‐
Cramp
et
al,
2008

44. Ac-vity
Enhancement
(II)
• ↑func-onal
capacity
so↓effort
in
ac-vi-es
• 15~45min/session
(no
more
than
I
hour)
• 1-­‐5
sessions/week
• 3~32
weeks,
average:
12
weeks
• 25~80%
age-­‐predicted
HRmax
(220-­‐age)
• walk,
bicycle,
ergometer,
treadmill,
yoga,
tai-­‐chi,
mul-dimensional
(aerobic+stretching+resistance
exercise)
• group/individualized,
supervised/home-­‐based
,
mixture
of
supervised
and
home-­‐based

45. Psychosocial
Interven-ons
• Educa-on:
– energy
conserva-on
and
ac-vity
management
to
balance
rest
and
ac-vity
– planning,
delega-ng,
priori-zing,
pacing,
res-ng
• Support
group
• Individual
counseling
• Comprehensive
coping
strategy
• Stress
management
training
• Behavioral
interven-on

46. Sleep
Therapy
• S-mulus
control
– go
to
bed
when
sleepy,
get
out
of
bed
a0er
20
min
of
wakefulness
– Have
a
rou-ne
bed-me
and
rising
-me
• Sleep
restric-on
– avoidance
of
long
or
late
day
naps
– Limi-ng
total
-me
in
bed
• Sleep
hygiene
– caffeine
and
exercise
avoidance
near
bed-me
– comfortable
sleep
surroundings
(dark,
relaxing…)
– soothing
ac-vi-es
at
bed-me
(music,
…)

47. 癌末頻死症狀
• 進行性惡化徵候
– 肌力下降、體重下降、神智混亂昏睡、時空感
消失、注意力越來越差、皮膚顏色變化(濕冷、
斑駁)、四肢發冷末端發紺、脈搏減弱、血壓逐
漸降低。
• 臨終脫水
– 不再進食及喝水。是一預備死亡的自然過程，
大部分患者不會感到不適。
• 死亡咯咯聲(death
rattle)
– 喉頭及支氣管內分泌物無法排出，隨呼氣及吐
氣上下移動發出聲音。

48. 癌末頻死症狀
• 臨床的躁動不安
– 症狀包含：躁動、翻身/打滾、呻吟、意識不清、
肌肉痙攣
– 亦與下列症狀重疊：瞻妄、臨終痛苦(常因未完
成遺願而造成)
• 臨終大量出血
– 腫瘤在大血管周圍進而浸潤到血管壁，血管壁
破裂後，造成大量血液流出，好發於頭頸部腫
瘤、骨盆腔內的腫瘤合併陰道直腸廔管患者。

49. Thank
you
for
your
anen-on!
Any
Sharing?

50. 考題
• 病人的疼痛應先試物理治療，一個月沒效
再開始用強效止痛劑 （X）
• 病人無法經由訓練提升功能時，則應停止
物理治療 （X）
• 病人可以選擇不接受治療 （O）