Hospice care is an extremely important element of the modern health care system. Owing to the development of science and medicine, the life expectancy of patients with severe chronic diseases is extended, and the moment of death is postponed . Hospice care understood as a comprehensive set of medical and rehabilitation services is a relatively new solution, while apart from controlling pain and other symptoms related to the disease, it is also important to improve the functioning and quality of patients' lives . Physiotherapy is becoming a very important component of hospice care.
Consideringour study, as expected, the average functional level of ADL and IADL of the examined patients before the beginning of rehabilitation in the home hospice was low. There was a high average pain intensity and a high risk of falling. Moreover, a high incidence of depression and poor quality of life, especially in the psychological domain was recorded. After the completion of the intervention program, a very positive result was found associated with a significant improvement in hospice patients in virtually all assessedareas, in particular in the scope of performing basic everyday activities. Even thought, some improvements have been assumed hypothetically, we did not expect such a large increase and a positive physical and emotional response in hospice patients.
As the disease progresses, hospice patients experience a high level of loss of activity and mobility disorders, and then dependence on others in the performance of daily activitiesas a result. They have serious problems in carrying out everyday life activities, which greatly deteriorate their physical and mental functioning . Restriction of daily activities, i.e. washing, dressing, moving, eating meals and controlling urine and stool excretion causing dependence on other people, reduces the subjective assessment of the quality of life of hospice patients . Most people admitted to the hospice indicate severe and moderate dependence in terms of simple and complex activities of everyday life and limited mobility .
The population of palliative patients is diverseregarding functional performance. Some patients are still able to cope with daily activities, while others are weak and bedridden. As for the hospice patients, disability and dependence is associated with many factors, such as pain, neurological and musculoskeletal problems, disorders of internal organs, fatigue and exhaustion associated with drug therapy, comorbid diseases and poor mental condition.
Considering our study, the most common identified problems of patients in the home hospice before the beginning of the physiotherapy program were lack of independence in bathing and showering and transferring – functional. Other activities that involved the greatest and even total restrictions were dressing and toilet hygiene (getting to the toilet, cleaning oneself, and getting back up). The identified areas with the highest level of restriction are characteristic for hospice and palliative patients . In most cases, hospice patients frequently receive basic medical care without special rehabilitation programs . As for our study, the performed intervention and observation confirmed a significant improvement in the performance of basic daily activities after the end of the program. Most patients, despite their poor mental and physical condition, noticed an improvement in the area of their functioning as the rehabilitation process progressed and they reported an increase in their motivation for further therapy. Most hospice patients expressed a desire to stay physically independent during the illness. With reference to Cole’set al.study, it was stated that rehabilitation can improve both motor and cognitive functions in patients with disabilities resulting from impaired cancer or its treatment . Improving ADL is an important factor in delaying death and improving quality of life . Speaking of the study of Park et al., they observed that ADLis an important predictor of mortality in elderly people with severe disease. Observation of hospice patients not subjected to rehabilitation interventions shows a more dynamic decline in function and approaching death, the faster the worse the functional state of the patient . ADL assessment plays a role in decision making regarding the treatment and rehabilitation of weak, elderly patients [40, 43]. We have proved in our study that considering patients with chronic illnesses in the home hospice, a method of achieving functional improvement is the use of an individualized physiotherapeutic program including appropriately selected physical and functional exercises. There are reports confirming that properly selected physical activity improves the comfort of life and extends its duration in elderly, chronically ill people .
With reference to our study, we found a high incidence of depression and poor quality of life (especially in the psychological domain) of patients in the home hospice before starting the physiotherapy program. The emotional and functional state are associated with the sense and assessment of quality of life . It was proved in studies that there was a significant correlation between the occurrence of depression and worse mobility, performance of daily tasks, and more frequent pain or anxiety . We demonstrated in our study an improvement in the mental state and quality of life of patients in a home hospice subjected to physiotherapeutic intervention. Pop et al. confirmed in their study that the rehabilitation of patients under palliative care resulted in a significant improvement in their quality of life. Our results confirm that there is a need to provide palliative patients with optimal rehabilitation regardless of their clinical status before rehabilitation .
The possibility to change body position and its transfer is the starting point for performing various everyday activities. Therefore, gait and body balance assessment, followed by planning adequate physiotherapeutic intervention that is adequate to the possibilities, are extremely important. Any improvement recorded in these activities reduces the risk of falling and the subsequent poor health consequences and prognosis resulting from it . Considering our study, we noted large problems in gait and body balance in hospice patients, and thus a high risk of falling. However, the introduced intervention proved a significant improvement in gait and balance parameters as well as a reduction in the risk of falling. Other reports confirm positive results after using individually selected gait, balance and muscle strengthening exercises in older and chronically ill patients [49, 50].
As a rule, patients under hospice care reveal severe limitations in performing various activities, which means that high-sensitivity instruments are necessary to assess functional performance. A comprehensive patient’s assessment is also required for both diagnostic assessmentof the patientas well as the assessment of improving effects. The International Classification of Functioning, Disability and Health (ICF) of the World Health Organization provides a normalised, standard language and a comprehensive framework for describing health and health-related conditions, and therefore it was used in this study. The deployment of qualifiers consistent with ICF scale for the assessment of individual categories assigned to individual items of the ADL and IADL scales allowed the researchers to evaluate responsively the problem before rehabilitation and observed a significant improvement in case of overwhelming majority of patients from a total dependency (qualifier 4) towards significant problems (qualifier 3), which meant that a completely dependent patient was able to participate actively in the performance of these activities, which greatly facilitates the care and nursing of caregivers. What is more, in most cases, improvement was even greater (qualifier 2), which meant that the patient required assistance in carrying out the activity rather than a complete replacement. In many cases, it was possible to achieveeven a return to full (qualifier 0) or almost full independence (qualifier 1). Therefore, it is worth mentioning that the use of the ICF scale to assess individual items of the ADL and IADL scales also letthe researcher specify in detail which activities required care and which only assistance, as well as which of them the patient was able to perform alone without the help of another person. In addition, a very important advantage of ICF was the ability to present results in various areas of human functioning in a universal language, which gave the opportunity to compare data of researchers using different measuring tools.