Subacute Rehabilitation Does Have Benefits for Patients With Advanced Cancer

© 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. This manuscript version is made available under the CC-BY-NC-ND 4.0 license: http://creativecommons.org/licenses/by-nc-nd/4.0/ This author accepted manuscript is made available following 12 month embargo from date of publication (Oct 2017) in accordance with the publisher’s archiving policyTo the Editor: It is with concern that we read a recent Letter to the Editor by Desai et al.,1 that stated “people with gastrointestinal cancer did not benefit from the admission to subacute rehabilitation,” concluding that inpatient rehabilitation could do more harm than good. People with advanced cancer may not always achieve physical gains after rehabilitation but to state there is no benefit is an oversimplification. This was a very small sample size (n = 22), one-third of whom had metastatic pancreas cancer where rapid functional decline is seen in the last weeks of life. Is this a sufficient sample on which to base the letter's conclusions? Careful individualized screening of people with advanced cancer to determine who may benefit from rehabilitation is essential when planning care. The outcomes used in this study to measure rehabilitation success (survival, further chemotherapy) do not capture rehabilitation gains. Limiting outcomes to these measures ignores functional outcomes of importance to patients and caregivers such as maintaining independence for as long as possible.2,3 Patient-driven palliative rehabilitation goals focus on maintenance of function and participation,4 not whether they can have further chemotherapy. Rehabilitation, which includes caregiver education and training, optimizes patient function, reduces caregiver burden, and facilitates supported discharge home.2,3,5 A growing body of evidence demonstrates that palliative rehabilitation can maintain and optimize functional ability.5–8 Rehabilitation is highly valued by patients with advanced disease4,9–11 and serves to improve patient confidence to actively participate in everyday activities.4,12,13 It enables patients to regain hope through exerting control over valued activities, even in the face of progressive physical deterioration.5,11,12 Psychosocial support during rehabilitation can be invaluable to facilitate adjustment to functional decline and enhance quality of life.10–13 It is dangerous to flag potential harms of rehabilitation without discussing the potential benefits. Inadequate communication about goals of care can be harmful, but discussing the scope including potential and limitations of rehabilitation is considered clinical care. Effective communication is essential in all clinical practices, and potential harms caused by unrealistic hope may be mitigated by clear, truthful communication delivered in a sensitive manner. When prognosis is openly discussed with patients, rehabilitation clinicians working with palliative care patients can agree on realistic goals of care. Of note, rehabilitation physicians have been found to be less likely to consider prognosis as a barrier to rehabilitation than oncologists14 while palliative care physicians' understanding of the potential benefits of rehabilitation varies.15 The specialties of oncology, palliative care, and rehabilitation bring different skill sets and perspectives that all contribute to optimizing patient function over the disease trajectory.16 Functional decline is inevitable for people with advanced cancer, and not all patients will benefit from palliative rehabilitation. However, a narrative that highlights potential harms of rehabilitation without exploring potential benefits is misleading. Importantly, the potential of palliative rehabilitation to optimize function warrants further investigation, irrespective of prognosis