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Mucinous tumours of the ovary or Borderline Ovarian Tumours (BOTs) are a broad type of neoplastic disorders that include invasive mucinous ovarian carcinoma, mucinous tumours of low malignant potential (borderline), and benign mucinous cystadenoma among others (Louis, Gupta, Gouda, & Gupta, 2013; Black et al., 2016). BOTs comprise 15-20% of all epithelial ovarian malignancies but differ significantly from ovarian carcinomas in terms of lower FIGO state, the distribution of tumour histotypes, excellent overall prognosis, higher infertility rate, younger age distribution, and lower frequency of BRCA mutations (Kurman & Shih, 2016).
According to Rutgers (2016), serous tumours are the most common BOTs at 53.3% while mucinous tumours represent 42.5%. Other less common histotypes take the remaining share of 4.2%. Most BOTs are diagnosed in their early stages as compared to ovarian cancer. For example, a study by Jinawath and Shih (2015) points out that 78.9% of patients with BOTs a diagnosed at FIGO stage I while only 21.1% are diagnosed at FIGO stage 1-IV. When diagnosed early, the prognosis of the borderline ovarian tumours is excellent.
Most stage 1 patient has a 5-year survival rate of 95-97%, which can be considered a highly successful rate (Rutgers, 2016). However, due to late recurrence, 10-year survival reduces to only 70-95% (Anglesio et al., 2013). The stage of the BOT is a major factor of survival whereby those diagnosed at stage II-III have an endurance rate of 65%-87%. Despite the high survival rate, some patients have a more aggressive form of BOTs that may lead to their later (Rutgers, 2016). The management of BOTs involves conservative or radical surgery and consequently chemotherapy. Since most of those diagnosed with BOTs are of the reproductive age, conservative surgical options that seek to preserve parts of the uterus or the ovaries are highly preferable for the patients.
The radical surgery involves the entire removal of the uterus and the ovaries (Kurman & Shih, 2016; Black et al., 2016). However, conservative surgery is associated with a higher degree of recurrence compared to radical surgery. Those diagnosed late with terminal BOTs have a short time to live. Besides, their ability to function is highly inhibited. This study will present the following case of a 46-year-old female patient diagnosed with a terminal high-grade borderline mucinous tumour. It will analyse and discuss the occupational therapy interventions undertaken following the determination of a short life span of three (3) to four (4) months before the patient can be discharged home.
The patient is a 46-year-old female who was recently admitted to the oncology unit with shortness of breath, constant pain, and increased left pleural effusion. The medical history of the patient shows that she was previously diagnosed with a terminal illness high-grade borderline mucinous tumour, which presents a case of the recurrence of the condition. Other medical records of the client show a history of lower back pain, anaemia, CPAP, obesity, OSAS, PESA, right leg deep thrombosis, and anxiety.
The operation report for the borderline mucinous tumour shows that the client has a large amount of pleural effusion, adhesion, and unusual cystic lesion. Additionally, the client previously had a right ovarian cystectomy after which she also received chemotherapy. In the current diagnosis, the available medical report shows a widespread presence of tumours and ovarian necrosis. Further, the tumours are also spread out to the intestine, with others extending to the bones, liver, and lymphangitic pulmonary lesion. Following the diagnosis, the patient is terminally ill. She has a shortened lifespan of three (3) to four (4) months. The client requires occupational therapy support to ensure that end-of-life care can enhance her quality of life, including her ability to perform different activities that support easier and fruitful living.
Occupational Therapy Assessment
The occupational therapy assessment for the client followed the Canadian Model for Occupational Performance and Engagement (CMOP-E framework). The CMOP-E model provides an important approach to assessing a patient’s physical and cognitive capabilities while at the same exploring the performance and engagement social and environment factors (Chi, Demiris, Lewis, Walker, & Langer, 2016). Additionally, the assessment further involved the determination of the client’s current level of occupational performance in her personal activities of daily life (PADL).
The assessment found that the client’s vision, hearing, and communication capabilities were not inhibited. At best, they could be described as excellent. On the other hand, the patient’s cognition in relation to time, place, date, and recognition of people as well and very alert. Additionally, the patient was affective and corporative, engaged, and pleasant. She did not demonstrate any problems when interacting with other individuals. However, the current diagnosis has taken a toll on the patient. She reports being fatigued and tired. Further, she has oxygen at a reach to be used when the need is due to the shortness of breathing that is part of the diagnosis.
Occupational Therapy Intervention
The occupational therapy intervention seeks to provide a shower chair to ensure that the patient experiences easy bathing. Another important intervention is to provide a frame for the toilet, which can increase its height and hence make it easier for the patient to get off the toilet. The frame can also make it trouble-free for the patient to support herself when getting off the toilet, hence consequently reducing the chances of a fall.
To make sure that the client receives the best occupational support, follow-up at home by the occupational therapist is done to assess her progress. Following the visit, the client reports that the hospital bed with the monkey bars is very helpful since it increases her mobility in and out of the bed. The bed’s ability to be lifted on the upper part provides an important capability for the patient to sleep in a suspended position, thus reducing fatigue and distress from shortness of breath when sleeping.
The raising of the toilet using the frames is also found to be very helpful since it allows the client to sit and rise easily, thus reducing fatigue. However, the family’s report shows that they are experiencing difficulties in cleaning the patient following the lack of enough space to move. Additionally, the shower chair is not helpful in cleaning the lateral side and the back of the patient.
The therapy process faces various challenges. For instance, only one visit to the home is made, a situation that limits the ability to measure a client’s progress and the outcomes of the intervention effectively. The client is also admitted again to the hospital due to seizure. This case also hinders the ability to determine where there is a reduction in the burden to the family. The nature of the illness also makes it difficult to determine whether any improvement or not can be detected in the patient.
The outcomes of the occupational therapy intercession were partially desirable since the patient reported more independence and satisfaction with some of the interventions that were availed to her. In terms of social and environmental factors, the patient has a supportive family with one sister, sister-in-law, and brother. After the discharge, the patient and the family plan to move her to the sister’s house. Regarding the physical environment, the patient will move to her sister’s place since her condition is deteriorating.
Her independence is also decreasing to the extent of requiring support and aid from others to undertake normal and basic daily and living activities. However, the client requires support for various occupational performance issues. Firstly, she has reported fatigue. Additionally, she has difficulties in performing personal care bathing, dressing, and showering. On the other hand, the client requires assistance for the upper and the lower body. The patient also has difficulties in functional mobility. In fact, she has to use a monkey bar to assist in getting on and off the bed. Hence, the client requires a 4-wheel walker for short distances around the house or room where she will be staying.
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However, it was difficult to have a good assessment of the outcomes of the intervention since the client was readmitted in the hospital, thus interrupting the progress of the interventions (Schell, Gillen, Scaffa, & Cohn, 2013). On the other hand, the nature of the illness required the engagement of a multi-disciplinary team of medical professionals and occupational therapists. Due to the short span of life, it was difficult to measure progress.
Despite the above challenges in appraising the outcomes of the intervention, the end-of-life occupational therapy is highly recommended. The intervention followed the best practices that are supported by research. According to Pergolotti, Cutchin, Weinberger, and Meyer (2014), in all instances, the aim of occupational therapy intervention is to improve the quality of life of all patients, regardless of the seriousness of their conditions.
The ability of a patient to retain independence in basic personal and familial tasks greatly improves his or her quality of the life. Independence forms part of the major areas of focus of the occupational therapy (Badger, Macleod, & Honey, 2016). It is for these reasons that the intervention of providing a hospital bed and monkey bars was viewed as an important approach to ensuring that the patient can easily get off the bed. Additionally, raising the toilet and the putting in place frames for the patient to support herself was a valuable step in ensuring that the patient could go to the toilet and easily get off.
On the other hand, family support is very crucial in any occupational interventions for the end-of-life care (Morrison, 2016). According to Pergolotti, Williams, Campbell, Munoz, and Muss (2016), terminally ill patients prefer to stay at home rather than the hospital where family members surround them. In this case, the decision of the occupational therapists to have the patient supported from home was in line with the best and recommended practices for handling such clients.
However, the occupational therapy invention process failed in terms of not providing adequate time for follow-up with the client. According to Ekström, Abernethy, and Currow (2015), follow-up is very important since it allows the occupational therapists to not only determine the progress of the patient but also to provide an assessment of the areas that need readjustment (Pergolotti et al., 2016). For terminally ill patients, their fast health deterioration means that some of the interventions may become ineffective expressly, thus requiring new ones.
Concisely, the case of the terminally ill patient and the interventions that were put in place represent the best practices for occupational therapy. However, as identified in the case, the nature of the illness and the readmission of the patient to the hospital made it difficult to have a critical appraisal of the impact of the interventions that were put in place. The client’s assessment involved a determination of the functional mobility and a comparison of the premorbid levels. On the other hand, other assessment options included the exploration levels and abilities to engage in domestic and community activities of daily life (DADL and CADL).
The main goal of the occupational therapy intervention for the current client is to provide an end-of-life support. Further, the goal that is identified by the client and the carer revolves around the desire to return home and to increase independence in self-care, mobility, and to minimise the current burden on the family. In other words, the occupational therapy seeks to maximise independence in PADL and further increase functional mobility.
To achieve the above goal, some of the strategies that are viewed as important include the provision of energy conversation education, the provision of equipment to support mobility such as a bed with monkey bars to maximise bed mobility. Overall, the occupational therapy interventions presented a reprieve for the patient since they improved the quality of her life based on the feedback that she reported. However, some of the shortcomings of the intervention such as only one visit at home lie in the area that requires improvement in the future to ensure that occupational therapists can measure the progress of the patient. Despite the shortcomings, the intervention can be termed as successful since it adhered to the best practices for addressing such a case.
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