The multidisciplinary team formulated a management plan with the patient, using a holistic, structured and person-centred approach. The team recognised that her chronic pain, reduced physical abilities, cognitive function and wellbeing were likely to worsen over time, without support and appropriate multidisciplinary intervention.
Mrs D acknowledged she felt lonely at times and missed her late husband dearly. She was fearful of falling but did not want to be a burden to her wider family. During the clinic discussion, she felt she probably did need some additional practical support around her home and was open to exploring options. She was also open to looking at additional community-based support for her falls risk and her low mood and grief.
The team explained the next steps, which would include some further sessions with the pain services’ Specialist Occupational Therapist. These sessions initially focused on supporting her to develop some skills to manage her own pain in the long term. She acknowledged she struggled with pacing of activity; she was used to pushing though her pain to achieve a task. She found this particularly difficult to change and she explained she had always fought to maintain high standards, in her work, around the home and in her role as a mother. She acknowledged she felt low at times and missed her husband and the life they led together terribly. She felt lonely and these feelings were more prominent at night when she struggled to sleep.
The occupational therapist visited her in her home to advise on several adaptations that could help maintain her independence and safety around her home. The team signposted her to a local team to support her with her grief and low mood. They booked her in for a series of medication review sessions with the teams’ clinical nurse specialists to review her medication and she also joined the specialist pain service’s Tai Chi group, with regular classes delivered by trained professionals. She was also referred to the local falls prevention service, which included some group based intervention in her local community.
