Functional goals and outcomes of rehabilitation within palliative care: a multicentre prospective cohort study.

Abstract

Background: Rehabilitation is an integral component of palliative care. An understanding of functional goals can help tailor interventions and support the evaluation of services. This study examined the nature and timescale of functional goals in palliative care, attainment of goals following personalised rehabilitation, responsiveness relative to health-related quality of life across, and factors associated with goal achievement.

Methods: Prospective, observational cohort study of adults with advanced progressive illness from 10 UK hospices referred for rehabilitation assessment. Urgency of care needs and functional status were assessed using the palliative Phase of Illness (stable, unstable, deteriorating) and Australia-modified Karnofsky Performance Status (AKPS, ≥ 60,60 - 50, ≤ 40) respectively. Health-related quality of life was assessed using EuroQoL 5-Dimension 5-Level (EQ-5D-5 L) utility score. Functional goals were set collaboratively with patients using SMART goal statements, mapped onto the WHO International Classification of Functioning, Disability and Health (ICF). Goal Attainment Scaling (GAS) was used to evaluate achievement against an anticipated outcome using a T-score. Ordinal logistic regression was sued to identify factors associated with goal achievement.

Results: 364 patients (54% female, mean (SD) age 68 (14) years, 71% cancer, 71% stable Phase, median AKPS 60) took part. They set a median (range) of 2 (1-4) goals; 645 in total. Goals had a median (range) timeframe of 28 (1-196) days and spanned 13/30 ICF domains; most frequently mobility, general tasks and demands, mental functions, community, social and civic life, and self-care. The majority focused on activity (51%) and participation (20%). Following personalised rehabilitation, GAS T-scores improved overall (mean (SD) change 8.9 (13.4)) and for each subgroup by Phase and AKPS (all p < 0.01). EQ-5D scores improved overall, but not for those with a deteriorating Phase or AKPS ≤ 40. Living alone or receiving multiple interventions increased the likelihood of goal achievement, whereas being wheelchair or bedbound, receiving a generic exercise intervention, or having goals rated as very difficult reduced it.

Conclusions: Functional goals in palliative care typically focus on optimising activity and participation in the short term. Progress towards personalised goals can be achieved through personalised rehabilitation, including among people with deteriorating health or largely confined to bed. Goal Attainment Scaling can help direct and evaluate rehabilitation interventions in this setting.