A Snapshot of Inpatient Cancer Rehabilitation

Megan B. Nelson & Ying Guo

Published online: 15 September 2013# Springer Science+Business Media New York 2013

During my cancer rehabilitation fellowship training, cancer pa-tients graciously provide me with mental, emotional, and educa-tional snapshots of their lives. I learn from them daily as theyimmerse themselves in a unique setting surrounded by dedicatedinpatient cancer rehabilitation team members. Our cancer pa-tients have various diagnoses: some are considered cured, someare in remission, some are undergoing palliative care, and someare waiting for news from “the scan” to know which box they fitin. No matter which box that is for each patient, physiatristsassess their functional needs and generate overall therapy plansamid their oncologic care, comorbidities, and psychosocialchallenges.

One particular day of inpatient rounds stands out in my mindas it epitomizes the difficulties many cancer patients face. Likein photography, when only one moment of many is captured,this article serves as a snapshot of cancer rehabilitation. Includedare fewer patients thanwere seen that day because of finite space(like the borders of a photograph), but hopefully, there is no filterfor hope despite the despair that was beneath it all.

Patient 1 is new to our service. He has recurrent glioblas-toma and had been admitted for a second resection because ofworsening symptoms, including seizures and left side weak-ness. His wife is at his bedside saying, “We’re ready for 3 h oftherapy today!” Her jovial mood seems like the right start tothe day for us. “We’ve already been in this spot once, and we

knowwe have lots of work to do,” she says as her husband liessleeping catching the last moments of rest. The patient and hisfamily own a construction company, so his home renovationalready includes wheelchair accessibility, and social and fam-ily resources are high. I feel the humor and love in the room,and I know our job is made easier by this patient’s support.

Another new patient on our list today is a few doors down thehallway. Patient 2 has a complex history, with multiple endocrineneoplasia (MEN) type 2B and multiple tumor resections. How-ever, her cancer did not cause this admission. Instead, it wassudden-onset cervical cord compression and myelopathy. Initial-ly, a malignancy was in the differential diagnosis, but a patho-logical examination revealed a disc protrusion, which required anemergent anterior cervical discectomy and fusion. She has asignificant pre-morbid leg-length discrepancy from a prior legfracture, and physical therapy for this issuewas halted because ofthis sudden admission. She liveswith her elderlymother and son,who unfortunately also hasMEN type 2B. Her son is present; heis tall and lanky with obvious deformities, including a visiblylarge mass hanging from the side of his neck. While discussingtheir family and home dynamics, the patient comments on hermother: “She is in her 70s, but really healthy. I used to drive tomy appointments, but now she drives me,” as the patient’smounting physical difficulties limit her function. Another obsta-cle is the three stairs to enter her home, providing one of manygoals to tackle during her inpatient rehabilitation stay.My attend-ing asks, “Are you planning to build a ramp to get into yourhome?” She answers quickly: “Yes, we are working on it.” Onexamination, her left leg is about 10 cm shorter than the right andweaker. She asks, “Will I be able to control my bowel? I hadcontrol before surgery.” She has been having a bowel movementeveryday with the help of a suppository, but nursing bedsidereports consistently state “incontinent.” Despite her upper andlower extremity weakness, judging from the physical examina-tion findings, she can probably transfer to a bedside commodewith some assistance. “We will start training your bowel, and

We certify that no party having a direct interest in the results of the researchsupporting this article has or will confer a benefit on us or on any organizationwith which we are associated, and if applicable, we certify that all financialandmaterial support for this research (e.g., NIH or NHS grants) and work areclearly identified in the title page of the manuscript.

M. B. Nelson :Y. Guo (*)Department of Palliative Care and Rehabilitation Medicine,The University of Texas M. D. Anderson Cancer Center, 1515Holcombe Boulevard, Houston, 1515 Holcombe Boulevard-Unit1414, Houston, TX 77030, USAe-mail: yguo@mdanderson.org

J Canc Educ (2013) 28:676–678DOI 10.1007/s13187-013-0547-0

tonight, after you receive a suppository, we will get you to thebedside commode.”The patient’s face shows excitement becauseincontinence in bed has been deleterious to her confidence. “Wewill ask the [occupational therapist] to practice commode trans-fers today.” Just then, the occupational therapist, Kerri, and hertwo students walk in and the work begins. Kerri later texted,“Commode transfer at minimal assistance level.” I write an orderfor nursing to transfer her to the commode after a suppositoryevery night for bowel training. The patient has challenges beyondher cancer diagnosis, yet she smiles and says, “I’m ready to getstarted.”

Our next patient has been on our rehabilitation service for2 weeks. He has renal cell carcinoma, with metastases to theleft acetabular bone and pelvis. His hospitalization startedover a month ago, when he underwent a left internalhemipelvectomy because of unremitting and progressive painover 2 years. Postoperatively and for approximately 6 months,he has only been able to apply minimal pressure on his leftfoot, allowing for soft tissue healing. He is a retired farmer inhis late 60s who has always been independent and in charge ofhis world. His wife is usually at his bedside with an anxiousand worried appearance. Her recently fractured humerus givesher an additional concern, knowing that her physical strengthwill be needed to help her husband when they return home.Once discharged, they will fly back to Kansas which takes 3–4 h; thus, his goals include improved sitting tolerance andendurance and his long hospitalization and postoperativecomplications have impaired both. Despite our daily emphasison sitting longer, the patient tolerates only 2 h out of bed. Hisother concerns include his neurogenic bowel and bladder,which developed postoperatively. Our rehabilitation care planincludes a daily bowel program and teaching him how to self-catheterize his bladder, both have provided him with a grow-ing sense of independence and allowed uninterrupted therapyby eliminating frequent urgent trips to the bathroom andunexpected accidents. After reporting these successes, herevisits his familiar question: “When will I be able to walk?”We again explain the healing process: when the scar tissue ismore solid, he will be allowed to put more weight on his leftleg. This statement must have brought realization of the con-tinued long recovery ahead, and he starts to cry, with tearsrolling down his cheeks. I quickly find the tissue box andreassure him that his feelings are normal. “It’s so hard lying inbed and needing so much help.” His wife is not present thismorning, which may explain his release of emotions without aconcern about worrying her. We emphasize the progress hehas made and that when he can sit longer, his quality of lifewill continue to improve. He nods his head as tears still flow.We stand there in silence feeling his pain and emotion andknowing he just needs a presence. The tears later calm, and hesays, “You all go on. I know you are busy. I am all right. I willbe all right.”We ask if he will feel comfortable with Tony, our

chaplain, coming to speak with him. Hewelcomes the offer. “Iknow Tony. I like Tony.”

As we enter the next patient’s room, I think to myself, Theemotional load seems quite heavy today, but I am unpreparedfor more. Patient 4 is a man of Asian descent in his late 20s.He has metastatic myxoid spindle cell sarcoma that originatedfrom a left shoulder mass that grew over years. He has under-gone extensive oncologic treatment, but he unexpectedly de-veloped rapid-onset paraplegia and extensive leptomeningealdisease. He is aware of his poor prognosis. His rehabilitationgoals are extensive, including training in wheelchair mobility,transfers from various surfaces, management of his neurogen-ic bowel and bladder, skin protection, and education of him-self and his family, and all of this must occur in truncated timebecause of the severity of his disease. When we enter theroom, his two sisters are at his bedside. We ask about his pain,and he replies, “The pain and numbness used to be at mybellybutton, but now it’s inching up my chest, and it’s like abelt around my chest.” We remind him of the plan: “Wecontacted your oncologist, and we will transfer you back tooncology tomorrow for more chemotherapy.” The hope is tolengthen his survival duration. He gives a fake smile and says,“Can I have a few days to think about it?” Before transferringto our rehabilitation service, hospice care had been arrangedfor him; however, we were told the plans had suddenlychanged because of his request for more treatment. He askshis sisters in their native language to give him privacy with us,and they hesitate but leave the room. He softly says, “My timeis near. I am not ready to go to a nursing home, but I am afraidof hospice. I want to do therapy and showmy family that I amnot stuck in bed and dying. I want them to have peace and noregret they are not here to take care of me [the sisters werescheduled to return to their homes in California soon]. I reallydon’t want chemotherapy or anything that is only going toprolong my life now.” He is persistently stoic, but he divulgesthe truth of his pain: “The pain is very bad. But I don’t wantthem [family] to see and worry. I knowmy time is short now.”I recall his spinal MRI: the leptomeningeal lesions are diffuse,and it is obvious that his assessment is correct. His acceptanceof life’s events is amazing for someone so young. Unfortu-nately, his oncologic decline is occurring rapidly, and his levelof neurologic impairment is quickly progressing, with loss ofupper extremity control seeming imminent. Today, he realizeshis personal goals are shifting dramatically. He does not wantto return home and be a “burden” on his family, but he isunsure of the best next step. After a long conversation, withbravery never leaving him, he decides he wants to learn moreabout the comfort care that is offered at the end of life. Withinhours, he is transferred to the inpatient palliative care unit. Iam impressed with the attending physician’s emotional com-posure as mine waivers. I take time to gather myself, and weproceed to the next patient’s door.

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In one morning’s rounds in an inpatient cancer rehabilita-tion unit, I am exposed to the many facets and complexities ofpatients’ lives: the loss of physical function, the oncologytreatment plans, the social support, the financial and emotionalstrain, the social and cultural barriers, and the dignity andrespect every patient deserves. Although the diagnoses andclinical presentations vary [1], these cancer patients had onething in common—they had experienced a loss of functionthat had severely affected their quality of life. The purpose ofinpatient cancer rehabilitation is to restore or maximize theirfunctional status. These snapshots are meant to serve as a lens,looking into the journey of cancer patients and shining a lighton the importance of cancer rehabilitation as part of holistic

care. Cancer patients have a diverse array of physical, emo-tional, social, financial, and spiritual needs that require thehelp from an integrated team of oncologists, physiatrists,palliative professionals, rehabilitation professionals, nurses,chaplains, social workers, and case managers.

Reference

1. Shin KY, Guo Y, Konzen B, Fu J, Yadav R, Bruera E (2011) Inpatientcancer rehabilitation: the experience of a national comprehensivecancer center. Am J Phys Med Rehabil 90:S63–S68

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