What therapeutic intervention should the client expect from therapist
The therapeutic intervention a client should expect from an occupational therapist in an oncology service should be one that complies with government legislation, plans, standards and guidelines.
The Governments plans for the National Health Service (NHS) are set out in several reports such as:
– the Calman-Hine Cancer Report (1995),
The New NHS – Modern and Dependable (1997)
and The NHS Cancer Plan (2000), which provide information to service users regarding the quality of the services they should expect.
Client’s should also expect occupational therapists to adhere to the Code of Ethics and Professional Conduct for Occupational Therapists, which is ‘a public statement of the values and principles used in promoting and maintaining high standards of professional behaviour in occupational therapy’ (COT 2000). ‘Cancer’ is a general term used when referring to a malignant growth of tissue in any part of the body. Cells that become cancerous have an abnormal increase in their growth rate, which can result in the development of a tumour or growth.
Malignant tumours can destroy the normal tissues surrounding them and if left untreated can spread via the lymphatic and circulatory systems, resulting in possible metastases forming away from the primary tumour. Many primary tumours have a predictable route of spread and since many of them have few early signs and symptoms, they may not be detected until they have formed metastases (Turner et al 1996). The range of services available to individuals with cancer has changed considerably over the last five years.
Emphasis of care is now provided within a multidisciplinary teamwork approach, which incorporates the valuable skills of occupational therapy. Occupational therapists need to assess and consider the physical, functional, psychological and social needs of their clients and utilise their core skills together with the skills of the multidisciplinary team to maximise the independence and quality of life of the patient with cancer and their carers. Read the answer on what is not a physical security measure for your home?
The College of Occupational Therapists Position Statement (1994) provides a comprehensive list of the unique core skills that clients can expect from occupational therapists, which include the: – use of purposeful activity and meaningful occupation as therapeutic tools in the promotion of health – ability to enable people to explore, achieve and maintain balance in the daily living tasks and roles of domestic care , leisure and productivity – the ability to assess the effect of, and then to manipulate, physical and psychosocial environments to maximise function and social Integration – ability to analyse, select and apply occupations as specific therapeutic media to treat people who are experiencing dysfunction in aily living tasks, interactions and occupational roles.
The treatment process and core skills of the occupational therapist should be based on a problem solving approach. This involves: – gathering and analysing information, assessing, defining and establishing the problem, prioritising, planning and preparing for treatment, setting aims and goals, identifying suitable solutions, providing treatment, evaluating outcomes, continuation of treatment, discharge or reviewing (Turner et al 1996, Cooper 1997). The case in context for this assignment concerns a client named Mary.
When analysing the information gathered following Mary’s referral to occupational therapy, it was determined that she was sixty-four years of age and has recently moved into a bungalow in this area with her husband in order to live closer to her daughter. Her past medical history shows that she was diagnosed with breast cancer in her right breast three years ago. The treatment given at that time was surgical removal and mastectomy of the right breast combined with radiotherapy and chemotherapy treatments.
Mary’s present medical condition shows she has recently undergone surgery to remove several axilliary nodes under her left arm and a mastectomy of her left breast following the discovery of a lump in her left axilla three weeks ago. She presently has oedema in her left upper arm and is also receiving radiotherapy and chemotherapy treatments. According to Cooper (1997) it is important for occupational therapists to establish a good rapport with their clients to aid intervention. When approaching new clients for the first time and establishing rapport, an explanation of the occupational therapists role should be provided.
This should enable the client to ‘understand the nature, purpose and likely effect of the proposed intervention’ as stipulated in section 2 of the Code of Ethics and Professional Conduct for Occupational Therapists (COT 2000). On reflection and analysis it would be impossible for the client to provide informed consent to his/her treatment if this was not carried out. An initial interview carried out with Mary can provide information concerning her social situation, accommodation and the internal layout; mobility, stairs, transfers, bed, chair, toilet, bath, personal ADL, domestic ADL, cognition and communication.
After the initial interview Mary could be asked to complete the Canadian Occupational Performance Measure (COPM) and identify and set her aims and goals of treatment and together with the therapist choose activities that will enable her to achieve them. COPM is a tool, which can be used to provide standards and outcome measures. It has been chosen to use because it is client centred and promotes rapid identification of treatment priorities and can specify problems across all performance areas; therefore problems which are not important or relevant to the client need not be dealt with.
The concentration of both client and therapist is thereby focussed on the problem solving process and the relevance of therapy is clear and outcome measures are inbuilt (Hagedorn 1997). However, a critique of the COPM could be that it does not measure the effectiveness of such aspects as: – quality of life and of dying, bereavement outcome, control of pain and relief of anxieties and fears for patient and family. According to Higginson (1995) these are important aspects to include in outcome measurement in palliative care settings.
However, this deficiency could be remedied by occupational therapy staff devised their own written standards of care, auditing tools and outcome measures that could be used alongside COPM. This could include questionnaires for clients to complete concerning their views on, and satisfaction with, the above mentioned aspects of care they have received. The various approaches and models selected for use throughout intervention with Mary indicate an eclectic approach was applied in order to draw selectively upon various schools of thought when addressing Mary’s variety of needs.
The ‘Biomechanical’ approach could be used which provides a graded programme of exercise based on kinesiological principles that will help with restoring function and also, the provision of equipment and orthoses that will help overcome residual disability. The ‘Humanistic Client-Centred’ approach, which is a holistic, flexible and can deal with psychological, developmental and physical dysfunction of the client and also with deteriorating and terminal conditions can be applied in conjunction with the ‘Biomechanical’ approach (Cooper 1997).
The ‘Rehabilitation Model’ can be applied to help restore, retrain or provide aids, appliances, environmental adaptations or assistance from others. The Canadian Model of Occupational Performance can be used as it is strongly centred on the occupational therapy process and occupational performance and it involves the client, is flexible, practical and promotes occupational therapy to others. Other factors that have influenced the choice of this model are its suitability to use with cancer patients because one of its fundamental elements of intervention includes a focus on the area of the client’s spirituality.
The occupational therapist can offer the client ‘the opportunity to explore existential themes such as suffering, guilt, forgiveness, joy, freedom or loneliness’ (Hagedorn 1997, p125). This may help the client pass through her stages of grief and adapt more quickly to her circumstances. Grief is a normal psychological response to any significant loss, which may include loss of function, reduced body image due to loss of a breast and also loss of roles (Cooper 1997). The occupational therapist will need to carry out observational assessments of Mary’s functional abilities and a home visit assessment may also be required.
The home visit should be planned promptly with the client and her carer. After the necessary assessments are completed the occupational therapist can then provide information regarding equipment and provision of home-care or counselling services and make referrals for the provision of these as necessary. Information concerning surgery such as mastectomy may be required by the client and may include – post-surgery complications, exercises, pain and coping with disfigurement. Surgery such as a mastectomy can lower a woman’s self-esteem and can be seen by her as reducing her physical, social and sexual desirability.
According to Turner et al (1996) it can aid intervention when occupational therapists respect the clients spiritual, cultural and religious needs and beliefs and how illness may effect how the clients’ communities view and accept them. The holistic approach of the occupational therapist can help address these issues by allowing time for the individual to discuss her feelings about herself and her new situation, providing a prosthesis and advice on adapted clothing, hair and make-up.
By encouraging Mary to maintain her roles, hobbies and leisure interests, she will be able to retain a feeling of purpose and security in that which is familiar to her. Information can be provided to Mary concerning cancer care groups in her area or other groups she may be interested in such as Age Concern or day centre facilities. Mary could be concerned and worried about her daughter June who has recently discovering a lump in her breast. The occupational therapist may need to consider that June may possibly require surgery herself and may not be able to assist with her mother’s care when she returns home, as was previously expected.
It may be possible however, if Mary agrees, to provide home-care once she is discharged home and the occupational therapist will need to liase with the Social Worker regarding this issue. Mary may experience nausea, vomiting, reduced energy, initiative and motivation, which can all hinder intervention. The occupational therapist can provide treatments aimed at controlling these, which could include progressive muscular relaxation training and education concerning stress management and energy conservation techniques (Cooper 1997).