National Cancer Action Team. Rehabilitation Care Pathway Brain CNS

Transcription

1 National Cancer Action Team Rehabilitation Care Pathway Brain CNS

2 Rehabilitation Care Pathway Brain CNS Diagnosis & Care Planning Drop Down Pathways Dysphagia Mobility/ loss of function Intervention D1 Assessment a Carry out pre-treatment assessment including impact of co-morbidity on treatment interventions b Undertake functional and neurological assessment to improve quality of life including mobility, exercise tolerance, functional task, balance, vestibular and upper limb function & allocation of appropriate outcome measures c Undertake risk assessment for falls & manual handling d Undertake respiratory status assessment & management accordingly e Undertake seating & positioning assessment f Undertake wheelchair assessment D2 Cognitive & Psychological Factors a Carry out assessment of mood & depression b Help with cognitive function D3 Communication a Undertake speech & language assessment b Provide preventative treatment c Assist with consent as the patients advocate D4 Exercise & Well Being a Maintain restorative exercise & health promotion as possible pre-operatively D5 Information/Support a Assess information needs for patients & provide suitable verbal & written advice b Provide family & carer support & education as required c Provide contact details for relevant AHPs D6 Nutrition a Provide nutritional screening b Assess nutritional requirements & status, current nutritional intake (including use of supplements such as OTC, health food & prescribable products), patients circumstances & possible future treatments. Ability to act on dietetic advice should be considered 2

3 Rehabilitation Care Pathway Brain CNS c Provide practical dietetic advice including written information tailored to individuals needs, diagnosis, prognosis & circumstances d Where necessary consider alternative methods of nutrition support including education & support for patient, carers & Health Professionals D7 Referral/Liaison a Refer on to community & social services b Attend MDT as core members D8 Respiratory Function a Identify patient with or without pre-existing respiratory disease if patient is to be referred for surgery b Assess respiratory status c Commence chest physiotherapy to suit individual requirements d Optimise physical & respiratory fitness prior to surgery D9 Work, Leisure & Activities of Daily Living a Provide functional safety advice including aids and equipment, postural management, behavioural management, handling and falls risk management and seating (refer to mobility and loss of function pathway) b Carry out access visit c Assess levels of fatigue & advise as necessary (refer to fatigue care pathway) Treatment Drop Down Pathways Dysphagia Communication Fatigue & energy management Pain Mobility & loss of function Intervention T1 Assessment a Undertake functional and neurological assessment to improve quality of life. Include motor and sensory impairment, mobility, exercise tolerance, balance, upper limb function, abnormal muscle tone with posture or management and the provision of splints where necessary b Negotiate goals with patient & allocate appropriate outcome measures 3

4 Rehabilitation Care Pathway Brain CNS c Undertake assessments for vestibular problems, joint range and deformities, seating & positioning (refer to fatigue care pathway) d Undertake wheelchair assessment e Undertake psycho-social assessment post-op f Undertake home risk assessment, giving consideration to safety & discharge planning g Follow World Health Organisation International Classification of Functioning Framework T2 Cognitive & Psychological Factors a Assess psychological needs of patients, families & carers & refer or advise appropriately b Assess & plan anxiety management programme in order to provide confidence for patient &/ or carers in management of condition c Help with sleep management d Help patients to explore their feelings around body image, self esteem & sexuality e Suggest relaxation techniques f Undertake assessment of mood (depression) T3 Communication a For Awake craniotomy patients, provide intraoperative language assessment T4 Equipment Provision a Undertake equipment & adaptation assessment T5 Exercise and Wellbeing a Provide neurological rehabilitation to help improve normal muscle tone, balance, mobility and functional activities b Provide advice and education to family & carers about how to manage mobility & functional activities c Provide ongoing monitoring of function throughout radiotherapy/ chemotherapy stages T6 Information/Support a Offer support & advice to carers b Offer spiritual care MDT approach c In negotiation with the patient set treatment & goal planning d Provide keyworker role as required 4

5 Rehabilitation Care Pathway Brain CNS T7 Nutrition a Provide nutritional screening b Assess nutritional requirements & status, current nutritional intake (including use of supplements such as OTC, health food & prescribable products), patients circumstances, possible future treatments. Ability to act on dietetic advice should be considered c Provide practical dietetic advice including written information tailored to individuals needs, diagnosis, prognosis & circumstances d Where necessary consider alternative methods of nutrition support including education & support for patient, carers & Health Professionals e Provide ongoing monitoring & support to the patient, family & carers f Liaise with catering department regarding provision of appropriate food & drinks for the individual patient, including texture modification where relevant T8 Referral/Liaison a Make onward referral to and communicate with rehabilitation or palliative care services b Attend weekly MDT meetings & refer patients back to MDT if appropriate c Provide strategic planning & case management d Ensure there is MDT liaison for symptoms monitoring and affect on functional status and quality of life. T9 Respiratory a Assess respiratory status including tracheostomy care, mobility, muscle power & general physical fitness pre operatively b Teach patient breathing exercises as indicated c Teach patient methods for secretion clearance, supported cough & provide ongoing chest physiotherapy to achieve optimal respiratory status & aid clearance of secretions T10 Voice & Swallowing a Undertake tracheostomy assessment & care T11 Work, Leisure, Activities of Daily Living a Provide vocational rehabilitation and advice on return to work as appropriate b Offer rehabilitation of functional activities of daily living & cognition c Provide ongoing monitoring & support to maintain patient s independence in all activities of daily living d Provide advice on energy conservation techniques in activities of daily living (refer to fatigue pathway) 5

6 Rehabilitation Care Pathway Brain CNS Post Treatment Drop Down Pathways Dysphagia Communication Fatigue & energy management Mobility problem/ loss of function Intervention PT1 Assessment a Undertake functional assessment and provision of advice/equipment b Carry out executive functioning assessment & treatment c Carry out assessment of mood & depression and effect on function d Carry out home assessments (refer to fatigue pathway) PT2 Cognitive & Psychological Factors a Discuss sexuality & body image b Assess & plan anxiety management programme in order to provide confidence for patient & carers in management of condition c Provide cognitive rehabilitation PT3 Information/Support a Provide spiritual care MDT approach b Provide ongoing monitoring & support to the patient, family & carers PT4 Nutrition a Carry out nutritional screening b Assess nutritional requirements & status, current nutritional intake (including use of supplements such as OTC, health food & prescribable products), patients circumstances, possible future treatments & ability to act on dietetic advice should be considered c Provide practical dietetic advice including written information tailored to individuals needs, diagnosis, prognosis & circumstances d Where necessary consider alternative methods of nutrition support including education & support for patient, carers & Health Professionals e Refer to locality based dietetic service (directly or via MDT as indicated) PT5 Referral/Liaison a Attend AHP meetings at review clinics b Refer on to appropriate rehabilitation services and AHP co-ordination 6

7 Rehabilitation Care Pathway Brain CNS PT6 Work, Leisure & Activities of Daily Living a Manage seating & offer postural advice b Provide vocational rehabilitation c Re-assess function & repeat outcome measures to compare with baseline d Provide neurological goal-orientated rehabilitation to improve function &/ or quality of life e Manage side effects of long term steroid use f Provide compensatory & restorative treatment strategy g Maintain functional therapy h Address loss of role & re-education i j Implement memory strategies Help with activities of daily living assessment & rehab Monitoring & Survivorship Drop Down Pathways Dysphagia Breathlessness Fatigue & energy management Mobility/ loss of function Intervention M1 Assessment a Complete holistic initial assessment including social, psychological, function, cognitive & perceptual areas b Undertake driving assessment c Carry out full holistic neurological assessment d Undertake environmental assessment, risk assessment & manage appropriately e Undertake MDT assessment/ review & allocate key lead/ key worker M2 Cognitive & Psychological Factors a Carry out assessment of mood/ depression & self esteem b Assess & plan anxiety management programme in order to provide confidence for patient &/ or carers in management of condition 7

8 Rehabilitation Care Pathway Brain CNS c Undertake cognitive assessment & retraining d Carry out psychological assessment and assist with psychological adjustment and goal-setting related to loss of function e Help patients to explore their feelings around sexuality/ body image & self esteem f Provide spiritual care MDT approach M3 Communication a Review/ reassess speech and language skills (also considering cognitive impairment) M4 Exercise & Well Being a Promote health & advise on exercise M5 Information/Support a Review goal planning b Design treatment plan (individualised) c Provide ongoing monitoring & support to the patient, family & carers d Repeat outcome measures e Be aware of rare disease understand prognostic f Advocate ongoing (not contract) carer g Patient/ lead to support/ educate h Work roles: - support other colleagues specialist advisory role M6 Mobility a Splint to prevent deformities and control pain b Carry out wheelchair assessment (seats/ sitting) c Provide carer retraining manual handling (refer to mobility pathway) M7 Nutrition a Carry out nutritional screening b Assess nutritional requirements & status, current nutritional intake (including use of supplements such as OTC, health food & prescribable products), patients circumstances, possible future treatments & ability to act on dietetic advice should be considered c Provide practical dietetic advice including written information tailored to individuals needs, diagnosis, prognosis & circumstances d Where necessary consider alternative methods of nutrition support including education & support for patient, carers & Health Professionals e Respond to individual/ support group information needs regarding appropriate diet on completion of treatment 8

9 Rehabilitation Care Pathway Brain CNS M8 Referral/ Liaison a Refer to community/ primary care teams & specialist neuro/ cancer teams if available. They should also be referred to these teams throughout the pathway as care will transfer between community and acute settings dependant upon the patient s overall management. They may go home between treatments and there should be a smooth flow between acute/community teams to reflect this. b Follow common assessment framework - refer on to other Healthcare Professionals for further assessment c Formal handover from Acute primary care d Ensure MDT/AHP co-ordination e Allocate key lead AHP professional rehab coordinator f Provide links to Support Groups (professionally lead) M9 Work, Leisure & Activities of Daily Living d Establish treatment plans & realistic goals with patient & carers including priorities for intervention e Assist with lifestyle review and changes f Help with feeding, eating, self-care, washing, dressing, access & sign posting g Be aware that younger patients life changes are significant h Manage somnolence as a side effect of radiotherapy and be aware of impact on patient s physical i Carry out environmental adaptations j Support patients to re-engage in graded social activities k Provide vocational rehab & return to work assessment l Advise on maintaining role at work or re-engaging in work place m Help with leisure/ hobbies & creativity needs a Assess home environment where appropriate in relation to treatment plan b Maintain awareness of wider issues of cancer prognosis & impact of surgery on self image c Provide ongoing monitoring & support to maintain patient s independence in all activities of daily living 9

10 Rehabilitation Care Pathway Palliative & EOL Palliative Care Drop Down Pathways Anorexia/cachexia Breathlessness Communication Dysphagia Fatigue Lymphoedema Pain Mobility & loss of function Spinal cord compression Intervention P1 Assessment a Carry out comprehensive social assessment b Undertake functional assessment c Undertake assessment of cognitive & psychological ability d Undertake holistic needs assessment e Provide ongoing assessment of quality of life, anxiety & depression, psychological & social needs as appropriate f Provide ongoing assessment and feedback to multidisciplinary team about symptoms such as pain, breathlessness, fatigue, depression, low mood g Agree patient centred goals P2 Cognitive & Psychological Factors a Assess & assist in management of anxiety & refer on to appropriate specialist b Provide anxiety management, relaxation & structured sleep strategies c Manage mood through compensatory strategies & engagement in meaningful occupations d Retrain and/or educate as necessary in order to help patient with cognitive & perceptual dysfunction e Identify psychological needs & provide psychological support to patients & carers P3 Communication a Assess communication skills and capacity to make informed decisions b Assess ability to communicate/ convey needs relating to pain, care, place of death & drawing up will c Educate patient, carers and healthcare professionals on optimal communication methods for individual patient d Implement communication strategies to optimise communication function e Trial, prescribe and train in use of communication aids if required 10

11 Rehabilitation Care Pathway Palliative & EOL P4 Exercise & Physical Well Being a Assess current function, mobility, muscle power, fatigue and general weakness b Apply restorative or compensatory therapy interventions where appropriate c Advise on pacing, relaxation and controlled exercise d Provide exercise classes to maintain/improve physical and psychological functioning and quality of life taking into account variations in health status P5 Equipment Provision a Provide aids/ equipment to support daily living & self management techniques to optimise management of activities of daily living P6 Fatigue a Assessment and intervention as appropriate with energy conservation techniques, goal planning, pacing, diet, exercise and anxiety management b Ensure treatable causes of fatigue are ruled out by referral to other disciplines P7 Information/ Support a Ensure good communication and coordination between the various care settings and professions b Be involved in discussions on preferred priorities and place of care c Provide education & support to patient, family & carers d Provide information prescription & leaflet with links to charities & support groups e Enable informed decision making with regards to treatment & management f Consider ethical issues & goals of treatment to improve quality of life P8 Mobility a Assess mobility including function, strength, sensation, joint range, coordination and potential risks (refer to mobility and loss of function pathway) b Stabilise/immobilise unstable areas using braces, splints and positioning c Help patient to optimise function & assess risk assisting with activities for the treatment of physical dysfunction, impaired motor, sensory & self maintenance skills d Carry out wheelchair assessment & prescription including associated pressure relieving cushions e Assess for specialist & complex seating and/ or positioning in bed f Carry out manual handling training & assessment g Assess the need for and provide hoists at home 11

12 Rehabilitation Care Pathway Palliative & EOL P9 Nutrition a Implement nutritional screening at each outpatient visit/ inpatient admission & refer on to dietitian as appropriate b Assess nutritional status & consider nutritional requirements if appropriate formulating a nutritional care plan for the patient c Assess factors affecting nutritional intake & barriers to optimising nutritional intake & quality of life d Provide practical nutritional advice including written information tailored to individuals needs, prognosis & circumstances e Consider modified consistency diet for palliative stents f Implement dietary adaptations to optimise nutrition related symptom management g Advise on symptom management, taste changes, nausea, vomiting, mouth care etc to help improve quality of life and liaise with palliative/ medical/ nursing team regarding pharmacological management of symptoms h Work with family on understanding of & anxiety about eating & drinking i Provide dietetic monitoring & follow up including discharge planning of enterally fed patients where appropriate P10 Pain Management a Identify pain issues and apply non pharmacological pain management techniques (refer to pain pathway) P11 Referral/ Liaison a Refer on to other members of the team if appropriate b Signpost to other supportive care services as required dependent on need c Liaise with multi-disciplinary team and allocate key worker d Issues relating to sexual function and expression should be referred to the most appropriate local specialist P12 Respiratory a Maintain optimal respiratory function b Provide non-pharmacological management of breathlessness (refer to breathlessness pathway) P13 Skin Care a Manage sensory impairment and tissue viability, lymphoedema and lymphorrhoea as appropriate (refer to lymphoedema pathway) 12

13 Rehabilitation Care Pathway Palliative & EOL P14 Swallowing a Assess swallow function and monitor regularly for change b Manage any dysphagia via compensatory strategies and/or direct intervention (refer dysphagia pathway) P15 Work, Leisure & Activities of Daily Living a Discuss lifestyle adjustment including roles, loss & self esteem b Assess impact illness has on occupational pursuits c Help patient to manage lifestyle including investigating meaningful hobbies, leisure, occupational pursuits and driving d Undertake environmental and functional assessment e Assess and support patient to carry out personal care and domestic activities f Provide aids/ equipment to support daily living, & self management techniques to optimise independent activities of daily living End of Life Drop Down Pathways Anorexia/cachexia Breathlessness Communication Dysphagia Fatigue Lymphoedema Pain Mobility & loss of function Spinal cord compression Intervention E1 Assessment a Carry out comprehensive social and functional assessment b Assess functional & cognitive ability c Assess & assist in management of anxiety & refer on to appropriate specialist d Undertake holistic needs assessment 13

14 Rehabilitation Care Pathway Palliative & EOL E2 Cognitive & Psychological Factors a Identify psychological needs b Undertake pre bereavement work with family c Apply spiritual care taking multi-disciplinary team approach d Provide ongoing psychological support with regards to adjusting to loss, deteriorating function, grief response e Assist in management of low moods f Apply sleep and relaxation techniques g Apply restorative or compensatory therapy interventions E4 Equipment Provision a Provide mobility aids for safe moving & handling if appropriate and manage deteriorating function E5 Fatigue a Assessment and intervention as appropriate with energy conservation techniques, goal planning, pacing, diet, exercise and anxiety management (refer to fatigue care pathway) b Ensure treatable causes of fatigue are ruled out by referral to other disciplines E3 Communication a Assess communication skills and capacity to make informed decisions b Assess ability to communicate/ convey needs relating to pain, care, place of death & drawing up will c Educate patient, carers and healthcare professionals on optimal communication methods for individual patient d Implement communication strategies to optimise communication function e Trial, prescribe and train in use of communication aids if required E6 Information/ Support a Ensure good communication and coordination between the various care settings and professions b Provide education & support to carers c Provide information prescription d Consider sudden events, scenario planning e Identify and help to facilitate preferred place of care (preferred place of dying) where this is home f Attend case conferences when complex discharge is apparent g With the MDT/key worker, identify the dying process and implement Liverpool Care Pathway ensuring that unnecessary and invasive treatment is avoided 14

15 Rehabilitation Care Pathway Palliative & EOL E7 Mobility a Carry out risk assessment to optimise comfort (refer to mobility and loss of function pathway) b Prevent complications of inactivity c Provide seating, position & manual handling advice for patient & carers E8 Nutrition a Influence organisational approach to provision of food b Assess patients nutritional status, history & recent history & oral intake c Address concerns expressed by patient and their family regarding food and fluids. d Implement dietary adaptations to optimise nutrition related symptom management e Address feeding & hydration issues with patient, carer & relatives, MDT in conjunction with palliative care/ medical team f Advise & encourage on mouth care strategies to reduce the use of artificial hydration g Make decisions with multi-disciplinary team around ethics for feeding & feeding withdrawal E9 Referral/ Liaison a Multi-disciplinary team liaison/ referral to other specialist professions b Address & support symptom control & quality of life issues as appropriate on an individual basis in conjunction with Palliative Care MDT, carers, patients & relatives c Ensure appropriate withdrawal of intervention in liaison with multi-disciplinary team d Show awareness of advance of symptoms, need for further palliative/ surgical intervention such as paracentesis, stenting & debulking & how this further affects quality of life E10 Respiratory a Apply breathing strategies (refer to breathlessness pathway) b Carry out respiratory & airway management 15

16 Rehabilitation Care Pathway Palliative & EOL E11 Skin Care a Assess positioning & provide simple massage/movement/comfort measures b Identify soft tissue viability & refer on as necessary c Assess & manage sensory changes and advise on suitable clothing d Manage ascites as appropriate e Manage lymphorrhoea (refer to lymphoedema pathway) E13 Work, Leisure & Activities of Daily Living a Undertake environmental and functional assessment b Manage deteriorating function c Assess and support patient to carry out personal care and domestic activities d Provide aids/ equipment to support daily living, & self management techniques to optimise independent activities of daily living E12 Swallowing a Assess swallow function and monitor regularly for change b Manage any dysphagia via compensatory strategies and in accordance with patients wishes (refer to dysphagia pathway) 16

17 Rehabilitation Care Pathway Brain CNS Professional intervention matrix The rehabilitation interventions listed in the care pathways can either be carried out by a single profession or could be carried out by a number of professions. There is the potential for different professions to be involved in delivering some of the interventions for a number of reasons. Unique skills are required which are within the scope of a single allied health profession ie videofluoroscopy is only carried out by Speech and Language Therapists The intervention listed may be approached in different ways. For example P9b (Assess the factors affecting nutritional intake and barriers to optimising nutritional intake and quality of life) could involve: the Dietitian focusing of nutritional intake and physiological barriers. the Occupational Therapist focusing on cutlery, seating position and equipment that may help during feeding and the Physiotherapist looking at postural stability and physical capacity SALT Speech and Language Therapists OT Occupational Therapy Other Other professions including Clinical Nurse Specialists, Lymphoedema Practitioners 17

18 Rehabilitation Care Pathway Brain CNS AHP Intervention Number Physio D1 (a/ b/ c/ d/ e/ f) D4 (a) D5 (a/ b/ c) D7 (a/ b) D8 (a/ b/ c/ d) D9 (a/ c) T1 (a/ b/ c/ d/ e) T4 (a) T5 (a/ b) T6 (a/ c/ d) T8 (a/ b/ c/ d) T9 (a/ b/ c) T11 (a/ b/ c/ d) PT3 (a/ b/ d) PT5 (a/ b) PT6 (a/ b/ c/ d/ e/ f/ g) M1 (c/ e) M4 (a) M5 (a/ b/ c/ d/ e/ f/ g/ h) M8 (a/ b/ c/ d/ e/ f) M9 (a/ b/ c/ d/ e/ f/ g h/ i / j/ k) P1 (a/ b/ c/ d/ e/ f/ g) P2 (a/ e) P4 (a/ b/ c/ d) P5 (a) P6 (a/ b) P7 (a/ b/ c/ d/ e/ f) P8 (a/ b/ c/ d/ e/ f/ g) P9 (a/ b) P10 (a) P11 (a/ b/ c) P12 (a/ b) P13 (a) P15 (d/ e/ f) E1 (a/ b/ c/ f) E2 (a/ b/ c/ d/ e/ f) E3 (a/ b/ c/ d) E4 (a) E5 (a/ b) E6 (a/ b/ c/ d/ e/ f/ g) E7 (a/ b) E9 (a/ b/ c/ d) E10 (a/ b) E11 (a/ b) E13 (b/ d) OT D1 (a/ b/ c/ e/ f) D2 (a/ b) D5 (a/ b/ c) D7 (a/ b) D9 (a/ b/ c) T1 (a/ b/ c/ d/ e/ f/ g) T2 (a/ b/ c/ d/ e/ f) T4 (a) T5 (a/ b) T6 (a/ b/ c/ d) T8 (a/ b/ c/ d) T11 (a/ b/ c/ d) PT1 (a/ b/ c/ d) PT2 (a/ b/ c) PT3 (a/ b) PT5 (a/ b) PT6 (a/ b/ c/ d/ e/ f/ g/ h/ j) M1 (a/ b/ c/ d/ e) M2 (a/ b/ c/ d/ e) M5 (a/ b/ c/ d/ e/ f/ g/ h) M6 (a/ b/ c) M8 (a/ b/ c/ d/ e/ f) M9 (a/ b/ d/ e/ g/ i/ k/ l/ m) P1 (a/ b/ c/ d/ e/ f/ g) P2 (a/ b/ c/ d/ e) P3 (a) P4 (a/ b/ c/ d) P5 (a) P6 (a/ b) P7 (a/ b/ c/ d/ e/ f) P8 (a/ b/ c/ d/ e/ f/ g/) P9 (a/ b/ c/ h) P10 (a) P11 (a/ b/ c) P12 (b) P13 (a) P15 (a/ b/ c/ d/ e/ f) E1 (a/ b/ c/ f) E2 (a /b/ c/ d/ e/ f/ g) E3 (a/ b/ c/ d/ e) E4 (a) E5 (a/ b) E6 (a/ b/ c/ d/ e/ f/ g) E7 (a/ b/ c) E8 (c/ e) E9 (a/ b/ c/ d) E11 (a/ b/ c/ d) E13 (a/ b/ c/ d) 18

19 Rehabilitation Care Pathway Brain CNS AHP Intervention Number Dietetic D1 (a) D5 (a/ b/ c) D6 (a/ b/ c/ d) D7 (b) T1 (b) T6 (a) T7 (a/ b/ c/ d/ e/ f) T8 (a/ b/ c/ d) PT3 (b) PT4 (a/ b/ c/ d/ e) PT5 (a/ b) PT6 (c) M1 (e) M5 (a/ b/ c/ d/ e/ f/ g/ h) M7 (a/ b/ c/ d/ e) M8 (a/ b/ c/ d/ e/ f) M9 (d) P1 (d/ e/ f/ g) P2 (a/ e) P5 (a) P6 (a) P7 (a/ b/ c/ d/ e/ f) P9 (a/ b/ c/ d/ e/ f/ g/ h/ i) P11 (a/ b/ c) P15 (a/ b/ c) E1 (b/ c) E2 (a/ b/ c/ d/ e/ f) E3 (a/ b) E6 (a/ b/ c/ d/ e/ f/ g) E8 (a/ b/ c/ d/ e/ f/ g) E9 (a/ b/ c/ d) E11 (d) SALT D1 (a) D2 (a/ b) D3 (a/ b/ c) D5 (a/ b/ c) D6 (d) D7 (b) T1 (b) T2 (a/ e/ f) T3 (a) T4 (a) T6 (a/ d/ e) T7 (c/ d/ f) T8 (a/ b/ c/ d) T9 (a) T10 (a) PT1 (d) PT2 (c) PT3 (b) PT4 (b) PT5 (a/ b) PT6 (b/ c/ d/ f/ h/ j/ k) M1 (e) M2 (a/ b/ c) M3 (a) M5 (a/ b/ c/ d/ e/ f/ g/ h) M7 (c/ d/ e) M8 (a/ b/ c/ d/ e/ f) M9 (d) P1 (b/ d/ e/ f/ g) P2 (a/ e) P3 (a/ b/ c/ d/ e) P7 (a/ b/ c/ d/ e/ f) P9 (a/ c/ g/ h) P11 (a/ b/ c) P14 (a/ b) P15 (a/ b) E1 (b/ c/ f) E2 (a/ b/ c/ d/ e/ f/ g) E3 (a/ b/ c/ d/ e) E6 (a/ b/ c/ d/ e/ f/ g) E8 (c/ d/ e/ f/ g) E9 (a/ b/ c/ d) E12 (a/ b) Other D1 (a) D5 (a/ b/ c) D7 (b) T1 (b) T6 (a/ d) T8 (a/ b/ c/ d) T11 (a) PT3 (b) PT5 (a/ b) PT6 (b/ c) M1 (e) M5 (a/ b/ c/ d/ e/ f/ g/ h) M8 (a/ b/ c/ d/ e/ f) M9 (d) P1 (d/ e/ f/ g) P2 (a/ e) P7 (a/ b/ c/ d/ e/ f) P8 (h) P11 (a/ b/ c) P13 (a) E1 (a/ b/ c) E2 (a/ b/ c/ d/ e/ f) E3 (a/ b/ c/ d) E6 (a/ b/ c/ d/ e/ f/ g) E9 (a/ b/ c/ d) E11 (a/ e/ b) E13 (b) 19

20 National Cancer Action Team Rehabilitation Care Pathway Breast

21 Rehabilitation Care Pathway Breast Diagnosis & Care Planning Drop Down Pathways Breathlessness Lymphoedema Pain Fatigue & energy management Intervention D1 Assessment a Undertake risk assessment to determine patients at risk of developing post-operative problems such as high levels of anxiety, history of chronic pain, existing musculoskeletal conditions b Undertake general assessment that monitors and records weight, height & waist as a bench mark to enable any weight gain or loss to be monitored c Undertake cognitive assessment d Undertake assessment of specific symptoms and/or side effects affecting independent functional status, activities of daily living, lifestyle, fatigue & self esteem D2 Cognitive & Psychological Factors D3 Exercise & Well Being a Provide advice about exercise including shoulder specific exercises, pre-op maintenance & general exercise programme to increase or maintain independence D4 Information/Support a Provide carer support & education b Provide information on posture, wound infection, lymphoedema, cording (axillary web syndrome), postop scar management sensation changes, post-op timeline & complications & any other risk factors c Provide information on maintenance techniques to take forward d Provide access to education/ information leaflet on role & scope of rehabilitation staff & referral procedure D5 Mobility a Carry out mobility assessment including provision of equipment & making environmental adaptations as indicated a Manage relaxation & anxiety providing treatment as appropriate 2

22 Rehabilitation Care Pathway Breast D6 Nutrition a Provide information on healthy lifestyle, diet, weight control D7 Referral/Liaison a Attend MDT and liaise as appropriate D8 Respiratory Function a Identify patients with pre-existing respiratory disease if patient is to be referred for surgery b Assess respiratory, functional & mobility status of all patients c Commence chest physiotherapy to optimise physical & respiratory fitness prior to surgery D9 Work, Leisure & Activities of Daily Living a At presentation of a functional impairment or comorbidity which affects functional independence provide access to an oncology trained staff b Assess levels of fatigue & advise as necessary (refer to fatigue care pathway) c returning to activities of daily life Treatment Drop Down Pathways Lymphoedema Pain Fatigue & energy management Anorexia & cachexia Intervention at each treatment stage T1 Pre-operative a Undertake assessment which includes range of movement, muscle tone, skin condition, home assessment, occupation, driving, any pre-existing problems that may be exacerbated by surgery b Teach post-op exercises including graded shoulder exercises c Measure and record pre-op limb circumference if patient is undergoing axillary surgery d Undertake pre-op respiratory assessment e Help patient cope with altered body image 3

23 Rehabilitation Care Pathway Breast f Re-educate on pain, precautions to take with activities of daily living (no heavy activities), general well being & fitness, sensation changes, scar massage, wound infection & healing, haematoma signs & symptoms, postural awareness, returning to driving, lymphoedema (refer to lymphoedema pathway), seroma, cording (axillary web syndrome) signs & symptoms T2 Post-surgery a Teach post-op exercise regime to include arm, shoulder & abdominal exercises b Undertake assessment of activities of daily living c Monitor respiratory function post-operatively and treat as necessary d Help patient cope with altered body image e Provide advice on early active movement and tissue massage to reduce scar formation f Provide post-op advice and re-educate on pain, precautions to take with activities of daily living (no heavy activities), general well being & fitness, sensation changes, scar massage, wound infection & healing, haematoma signs & symptoms, postural awareness, returning to driving, lymphoedema (refer to lymphoedema pathway), seroma, cording signs & symptoms & how to treat this using soft tissue techniques g Give advice on moving & handling h Educate on soft tissue healing process i Help patient to resume activities of daily living and assess as required j Provide moving & handling advice if required k Carry out 3 6 week post-op check up including measurement of limb circumference, progress of exercises, planning for radiotherapy & treatment of cording T3 During Chemotherapy a Assess & treat to monitor symptoms during cancer treatment b Manage anxiety c Provide treatment for cording d Treat shoulder problems & provide exercise class e Provide advice on pacing & energy conservation (see fatigue pathway) f Refer for dietary advice as appropriate g Manage phlebitis h Discuss body image i Give advice on the potential for peripheral neuropathy j Discuss with patient about altered body image & impact on participation in activities of daily living, lifestyle management/ roles, sexuality & self esteem 4

24 Rehabilitation Care Pathway Breast T4 During Radiotherapy a Teach stretching exercises at start of treatment (class) b Advise on general exercise c Provide help getting back to work & advise on pacing to resume activities d Assess potential for cording and massage scar as appropriate. Be aware of skin care e Help patient to resume activities of daily living f Help patient manage anxiety g If patient showing signs of fatigue advise & treat accordingly (refer to fatigue and energy management pathway) Exercise & Well Being h Introduce general exercise programme to increase/ maintain independence i Assess for lymphoedema & provide treatment as appropriate (refer to lymphoedema pathway) T5 Stage I II III for surgery, radiotherapy & chemotherapy Nutrition a Consider co-morbidities b Provide nutritional support for loss of appetite c Advise on alternative diets & nutritional supplements d Provide healthy eating/ weight control advice e Give expert guidance on bone management Metastases f Provide nutritional support for loss of appetite g Provide healthy eating advice h Follow expert guidelines for bone management i Influence organisational approach to provision of food j Carry out general assessment monitoring record weight, height & waist Information/ Support j Provide carer support & education 5

25 Rehabilitation Care Pathway Breast Post Treatment Drop Down Pathways Lymphoedema Fatigue & energy management Communication Intervention PT1 Assessment a Assess & manage cancer treatment effects where any functional or co-morbidities affecting functional independence are identified. b Assess & manage late effects from oncology treatment PT2 Cognitive & Psychological Factors a Manage menopausal symptoms b Manage anxiety & tailor to patients activities of daily living & lifestyle management c Assess patients for needs such as psychological support & other support groups d Assess & plan anxiety management programme in order to provide confidence for patient &/ or carers in management of condition PT3 Communication a Treat speech or language impairment PT4 Exercise & Well Being a Introduce general exercise programme to increase/ maintain independence b Provide general rehabilitation & exercise on prescription c Help patient resume activities of daily living d Advise on scar management e For patients with lymphoedema refer to lymphoedema pathway PT5 Mobility a Manage shoulder & chest wall problems PT6 Nutrition a Promote healthy eating & discuss alternative diets b Help patient manage weight c Carry out general assessment monitoring & recording weight, height & waist 6

26 Rehabilitation Care Pathway Breast PT7 Voice & Swallowing a Treat hoarse voice b Treat for swallowing difficulty PT8 Work, Leisure & Activities of Daily Living a Support patients to re-engage in graded social activities b Advise on maintaining role at work or re-engaging in work place c Help patient return to work. Discuss pacing to resume activities, task analysis, work simplification and energy conservation to resume activities d Establish treatment plans & realistic goals with patient & carers including priorities for intervention Monitoring & Survivorship Drop Down Pathways Lymphoedema Fatigue & energy management Communication Intervention M1 Assessment a Assess & manage late effects from oncology treatment as symptoms present b Assess pre-existing functional status to establish a base line measurement. Pre-empt the impact of treatment modalities &/or surgery/ post operative precautions on functional status & plan treatment sessions/referrals accordingly. c Assess for & access compensatory &/or adaptive techniques / aids / equipment. d Assess patient s current goals, purpose, roles & quality of life priorities to provide a base line measurement. e Assess lifestyle management skills, self esteem & coping strategies to establish a base line measurement & goal setting 7

27 Rehabilitation Care Pathway Breast M2 Cognitive & Psychological Factors a Complete holistic initial assessment including social, psychological, functional, cognitive & perceptual areas b Assess & plan anxiety management programme in order to provide confidence for patient &/ or carers in management of condition c Help patients to explore their feelings around body image, self esteem & sexuality d Offer up to level 2 psychological support throughout assessment and treatment e Identify psycho-social needs to establish a base line measurement & promote psychological adjustment & well being f Teach relaxation techniques as part of anxiety management g Provide ongoing physical & psychological functional assessment in relation to activities of daily living M3 Exercise & Physical Well Being a Ensure access to physical rehabilitation to optimise physical status, health & wellbeing b Teach general exercise programme to increase & maintain independence c Advise on general fitness programmes and prescribe exercise as appropriate d Continue to provide appropriate treatment for lymphoedema (refer to lymphoedema pathway) M4 Information/ Support a Provide carer support & education b Help patient integrate into society M5 Nutrition a Carry out general assessment monitoring & recording weight, height & waist b Advise on healthy eating, fatigue, weight maintenance & alternative diets M6 Referral/ Liaison a Refer to support groups, expert patient programmes, Living With Cancer course b Provide a crucial link between home & hospital rehabilitation & refer early as appropriate 8

28 Rehabilitation Care Pathway Breast M7 Work, Leisure & Activities of Daily Living a Provide vocational rehabilitation as indicated b Assess home environment where appropriate in relation to treatment plan c Establish treatment plans & realistic goals with patient & carers including priorities for intervention d Advise on maintaining role at work or re-engaging in work place e Support patients to re-engage in graded social activities f Optimise a patient s quality of life through review of participation in activities of daily living & goal setting g Help maintain occupational activities that are meaningful to the patient, taking into account the influence of culture, religious beliefs & practices h Work with the patient to assess what priorities & roles are most important to them including social, leisure & spiritual i Work with the patient to achieve lifestyle management 9

29 Rehabilitation Care Pathway Palliative & EOL Palliative Care Drop Down Pathways Anorexia/cachexia Breathlessness Communication Dysphagia Fatigue Lymphoedema Pain Mobility & loss of function Spinal cord compression Intervention P1 Assessment a Carry out comprehensive social assessment b Undertake functional assessment c Undertake assessment of cognitive & psychological ability d Undertake holistic needs assessment e Provide ongoing assessment of quality of life, anxiety & depression, psychological & social needs as appropriate f Provide ongoing assessment and feedback to multidisciplinary team about symptoms such as pain, breathlessness, fatigue, depression, low mood g Agree patient centred goals P2 Cognitive & Psychological Factors a Assess & assist in management of anxiety & refer on to appropriate specialist b Provide anxiety management, relaxation & structured sleep strategies c Manage mood through compensatory strategies & engagement in meaningful occupations d Retrain and/or educate as necessary in order to help patient with cognitive & perceptual dysfunction e Identify psychological needs & provide psychological support to patients & carers P3 Communication a Assess communication skills and capacity to make informed decisions b Assess ability to communicate/ convey needs relating to pain, care, place of death & drawing up will c Educate patient, carers and healthcare professionals on optimal communication methods for individual patient d Implement communication strategies to optimise communication function e Trial, prescribe and train in use of communication aids if required 10

30 Rehabilitation Care Pathway Palliative & EOL P4 Exercise & Physical Well Being a Assess current function, mobility, muscle power, fatigue and general weakness b Apply restorative or compensatory therapy interventions where appropriate c Advise on pacing, relaxation and controlled exercise d Provide exercise classes to maintain/improve physical and psychological functioning and quality of life taking into account variations in health status P5 Equipment Provision a Provide aids/ equipment to support daily living & self management techniques to optimise management of activities of daily living P6 Fatigue a Assessment and intervention as appropriate with energy conservation techniques, goal planning, pacing, diet, exercise and anxiety management b Ensure treatable causes of fatigue are ruled out by referral to other disciplines P7 Information/ Support a Ensure good communication and coordination between the various care settings and professions b Be involved in discussions on preferred priorities and place of care c Provide education & support to patient, family & carers d Provide information prescription & leaflet with links to charities & support groups e Enable informed decision making with regards to treatment & management f Consider ethical issues & goals of treatment to improve quality of life P8 Mobility a Assess mobility including function, strength, sensation, joint range, coordination and potential risks (refer to mobility and loss of function pathway) b Stabilise/immobilise unstable areas using braces, splints and positioning c Help patient to optimise function & assess risk assisting with activities for the treatment of physical dysfunction, impaired motor, sensory & self maintenance skills d Carry out wheelchair assessment & prescription including associated pressure relieving cushions e Assess for specialist & complex seating and/ or positioning in bed f Carry out manual handling training & assessment g Assess the need for and provide hoists at home 11

31 Rehabilitation Care Pathway Palliative & EOL P9 Nutrition a Implement nutritional screening at each outpatient visit/ inpatient admission & refer on to dietitian as appropriate b Assess nutritional status & consider nutritional requirements if appropriate formulating a nutritional care plan for the patient c Assess factors affecting nutritional intake & barriers to optimising nutritional intake & quality of life d Provide practical nutritional advice including written information tailored to individuals needs, prognosis & circumstances e Consider modified consistency diet for palliative stents f Implement dietary adaptations to optimise nutrition related symptom management g Advise on symptom management, taste changes, nausea, vomiting, mouth care etc to help improve quality of life and liaise with palliative/ medical/ nursing team regarding pharmacological management of symptoms h Work with family on understanding of & anxiety about eating & drinking i Provide dietetic monitoring & follow up including discharge planning of enterally fed patients where appropriate P10 Pain Management a Identify pain issues and apply non pharmacological pain management techniques (refer to pain pathway) P11 Referral/ Liaison a Refer on to other members of the team if appropriate b Signpost to other supportive care services as required dependent on need c Liaise with multi-disciplinary team and allocate key worker d Issues relating to sexual function and expression should be referred to the most appropriate local specialist P12 Respiratory a Maintain optimal respiratory function b Provide non-pharmacological management of breathlessness (refer to breathlessness pathway) P13 Skin Care a Manage sensory impairment and tissue viability, lymphoedema and lymphorrhoea as appropriate (refer to lymphoedema pathway) 12

32 Rehabilitation Care Pathway Palliative & EOL P14 Swallowing a Assess swallow function and monitor regularly for change b Manage any dysphagia via compensatory strategies and/or direct intervention (refer dysphagia pathway) P15 Work, Leisure & Activities of Daily Living a Discuss lifestyle adjustment including roles, loss & self esteem b Assess impact illness has on occupational pursuits c Help patient to manage lifestyle including investigating meaningful hobbies, leisure, occupational pursuits and driving d Undertake environmental and functional assessment e Assess and support patient to carry out personal care and domestic activities f Provide aids/ equipment to support daily living, & self management techniques to optimise independent activities of daily living End of Life Drop Down Pathways Anorexia/cachexia Breathlessness Communication Dysphagia Fatigue Lymphoedema Pain Mobility & loss of function Spinal cord compression Intervention E1 Assessment a Carry out comprehensive social and functional assessment b Assess functional & cognitive ability c Assess & assist in management of anxiety & refer on to appropriate specialist d Undertake holistic needs assessment 13

33 Rehabilitation Care Pathway Palliative & EOL E2 Cognitive & Psychological Factors a Identify psychological needs b Undertake pre bereavement work with family c Apply spiritual care taking multi-disciplinary team approach d Provide ongoing psychological support with regards to adjusting to loss, deteriorating function, grief response e Assist in management of low moods f Apply sleep and relaxation techniques g Apply restorative or compensatory therapy interventions E4 Equipment Provision a Provide mobility aids for safe moving & handling if appropriate and manage deteriorating function E5 Fatigue a Assessment and intervention as appropriate with energy conservation techniques, goal planning, pacing, diet, exercise and anxiety management (refer to fatigue care pathway) b Ensure treatable causes of fatigue are ruled out by referral to other disciplines E3 Communication a Assess communication skills and capacity to make informed decisions b Assess ability to communicate/ convey needs relating to pain, care, place of death & drawing up will c Educate patient, carers and healthcare professionals on optimal communication methods for individual patient d Implement communication strategies to optimise communication function e Trial, prescribe and train in use of communication aids if required E6 Information/ Support a Ensure good communication and coordination between the various care settings and professions b Provide education & support to carers c Provide information prescription d Consider sudden events, scenario planning e Identify and help to facilitate preferred place of care (preferred place of dying) where this is home f Attend case conferences when complex discharge is apparent g With the MDT/key worker, identify the dying process and implement Liverpool Care Pathway ensuring that unnecessary and invasive treatment is avoided 14

34 Rehabilitation Care Pathway Palliative & EOL E7 Mobility a Carry out risk assessment to optimise comfort (refer to mobility and loss of function pathway) b Prevent complications of inactivity c Provide seating, position & manual handling advice for patient & carers E8 Nutrition a Influence organisational approach to provision of food b Assess patients nutritional status, history & recent history & oral intake c Address concerns expressed by patient and their family regarding food and fluids. d Implement dietary adaptations to optimise nutrition related symptom management e Address feeding & hydration issues with patient, carer & relatives, MDT in conjunction with palliative care/ medical team f Advise & encourage on mouth care strategies to reduce the use of artificial hydration g Make decisions with multi-disciplinary team around ethics for feeding & feeding withdrawal E9 Referral/ Liaison a Multi-disciplinary team liaison/ referral to other specialist professions b Address & support symptom control & quality of life issues as appropriate on an individual basis in conjunction with Palliative Care MDT, carers, patients & relatives c Ensure appropriate withdrawal of intervention in liaison with multi-disciplinary team d Show awareness of advance of symptoms, need for further palliative/ surgical intervention such as paracentesis, stenting & debulking & how this further affects quality of life E10 Respiratory a Apply breathing strategies (refer to breathlessness pathway) b Carry out respiratory & airway management 15

35 Rehabilitation Care Pathway Palliative & EOL E11 Skin Care a Assess positioning & provide simple massage/movement/comfort measures b Identify soft tissue viability & refer on as necessary c Assess & manage sensory changes and advise on suitable clothing d Manage ascites as appropriate e Manage lymphorrhoea (refer to lymphoedema pathway) E13 Work, Leisure & Activities of Daily Living a Undertake environmental and functional assessment b Manage deteriorating function c Assess and support patient to carry out personal care and domestic activities d Provide aids/ equipment to support daily living, & self management techniques to optimise independent activities of daily living E12 Swallowing a Assess swallow function and monitor regularly for change b Manage any dysphagia via compensatory strategies and in accordance with patients wishes (refer to dysphagia pathway) 16