Rolul echipei multidisciplinare în îngrijirea pacientului oncologic imobilizat la pat: studiu de caz clinic complex – o abordare integrată

Introduction

The bedridden oncology patient represents one of the most complex clinical entities in contemporary oncologic practice, characterized by the simultaneous overlap of high symptom burden, accelerated functional decline and marked psychosocial vulnerability. In the context of therapeutic advances, prolonged survival is frequently accompanied by gradual deterioration in functional performance, and for a substantial subset of patients, the loss of mobility becomes the final expression of this trajectory^(1,2). Severe mobility limitation may result from multiple mechanisms, including tumor progression, painful bone metastases, central or peripheral neurological involvement, disease-related complications and/or cumulative effects of systemic or locoregional treatments^(2,4). In practical terms, these mechanisms translate into an abrupt increase in care dependency and a significant deterioration in patient-reported quality of life⁽⁵⁾.

Recent evidence supports the conceptualization of immobility as a multidimensional clinical state with systemic effects on the musculoskeletal system, skin integrity, respiratory and cardiovascular function and, consequently, on tolerance to therapeutic interventions^(3,6). In the absence of proactive measures, immobility accelerates functional decline, amplifies overall suffering, and increases the risk of largely preventable complications^(6,7). Within this framework, a transition is required from a predominantly disease-oriented model of care toward an approach centered on residual functionality, comfort, dignity and the patient’s subjective experience^(1,3,8). The multidisciplinary team represents the mechanism through which care shifts from fragmented interventions to a coherent, patient- and family-adapted plan. The integration of medical, nursing, functional, psychological and social components has been associated with improved symptom control and more predictable care trajectories in advanced stages of disease^(8,9).

Aim of the study

This case study aims to illustrate, in a chronological sequence, how an integrated multidisciplinary intervention can influence the clinical course of a bedridden oncology patient, with particular emphasis on:

1. the prevention of immobility-related complications;

2. the control of dominant symptoms;

3. the maintenance of quality of life.

Case presentation

General data and family context

The patient is a 68-year-old man from an urban area, with no known oncologic history prior to the current episode. He is married and lives with his wife, who progressively assumed the primary caregiver role as his functional capacity deteriorated. Prior to the functional decline, the patient was fully autonomous, with no significant limitations in daily activities.

Oncologic history and course prior to admission

The patient was diagnosed with stage IV non-small cell lung cancer, characterized by bone, hepatic and cerebral metastases, with onset approximately one year before admission to the palliative care unit. In the initial phase, he underwent oncologic treatment with palliative intent (systemic chemotherapy and antalgic radiotherapy), achieving partial symptom control. Subsequently, the disease course was dominated by progression and the installation of progressive functional decline. Several months prior to admission, pain (predominantly of osseous origin) gradually intensified, accompanied by marked fatigue, unintentional weight loss and reduced exercise capacity. The onset of neurological symptomatology, superimposed on worsening pain syndrome, led to progressive reduction in mobility, ultimately resulting in the complete loss of ambulation. In this phase, the patient became totally dependent for mobilization, personal hygiene, feeding and basic activities.

Reasons for admission and initial evaluation

Admission to a palliative care unit was prompted by global clinical imbalance: severe inadequately controlled pain, dyspnea present at rest, profound asthenia, swallowing disturbances and the development of a sacral pressure injury. Significant emotional distress (anxiety, tendency toward social withdrawal) was also present, along with substantial psychological burden at the family level.

The initial assessment revealed severely compromised functional status, complete loss of autonomy and the need for continuous care. The symptom profile included intense chronic pain, dyspnea, extreme fatigue, sleep disturbances, signs of malnutrition and an increased risk of immobility-related complications. The skin examination identified a deep sacral pressure ulcer with unfavorable evolutionary potential in the absence of specific measures.

Rationale for a multidisciplinary approach

The clinical profile of the bedridden oncology patient mandates a multidisciplinary approach as a standard of good practice, through the integration of medical, nursing, functional, psychological and social expertise into a coherent plan centered on the patient’s needs and values. In the absence of structured collaboration, care tends to become fragmented, with insufficiently correlated interventions and limited clinical effectiveness. The integrated model enables comprehensive evaluation and adaptation of strategies to disease dynamics and to realistic goals in metastatic stages.

Roles of the multidisciplinary team members

1) The medical oncologist and palliative care specialist

The medical oncologist, in collaboration with the palliative care specialist, holds a central role in coordinating overall care. Responsibilities include periodic clinical evaluation, prognostic assessment and recalibration of therapeutic objectives according to disease evolution and functional status. In the context of complete immobility, the focus progressively shifts from disease control to symptom management, including refractory pain, dyspnea, neurocognitive disturbances, insomnia and anxiety. The integration of palliative care supports an anticipatory approach, oriented not only toward symptom relief but also toward the prevention of immobility-related complications. The physician also facilitates communication with the patient and family, supports shared decision-making, clarifies expectations, and establishes proportional limits of interventions within an ethical, patient-centered framework.

2) The nurse

The nurse represents the essential operational component of the care plan, being responsible for implementing daily interventions and continuously monitoring the patient’s clinical condition. Through systematic observation of symptoms, administration of prescribed treatments and provision of basic care, the nurse directly contributes to maintaining comfort and preventing complications. Core activities include skin care, prevention of pressure injuries, appropriate patient positioning and assessment of treatment tolerance. In addition, the nurse fulfills a major educational role by instructing family members on the care of the bedridden patient, recognition of signs of clinical deterioration and symptom management at home. These interventions facilitate continuity of care and reduce the physical and emotional burden placed on caregivers.

3) The physiotherapist

The physiotherapist plays a key role in preventing and limiting the consequences of prolonged immobility, even in the absence of active mobility. Interventions are tailored to the patient’s residual functional capacity and general condition, and aim to preserve joint range of motion, reduce stiffness and prevent muscle atrophy. Passive mobilization techniques, appropriate positioning strategies, respiratory reeducation exercises and facilitation of bronchial secretion clearance contribute to reducing the risk of respiratory complications and improving postural comfort. Through these measures, residual functionality is supported and quality of life is maintained.

4) The psychologist

The psychologist assesses and manages the emotional responses associated with loss of autonomy, poor prognosis and functional dependency, including anxiety, depressive symptoms, demoralization and feelings of uselessness. Psychological support and counseling interventions contribute to maintaining emotional stability and strengthening the therapeutic alliance. Family involvement represents an essential component of the intervention, as supporting caregivers helps prevent emotional exhaustion and ensures continuity of care over the long term.

5) The social worker

The social worker conducts a comprehensive assessment of the patient’s socioeconomic context, identifies available family and community resources, and facilitates access to appropriate support services. This includes counseling regarding social rights, organizing post-discharge care and ensuring connection with home-based or institutional care services. Through these interventions, the social worker contributes to reducing disease-related stress, maintaining family balance and supporting both the patient and caregivers in adapting to the conditions imposed by prolonged immobility.

Stages of the multidisciplinary care plan

The care plan for the bedridden oncology patient is designed as a dynamic process, structured into successive stages that allow adaptation of interventions according to clinical evolution and patient priorities.

1. Comprehensive initial assessment includes the evaluation of oncologic and functional status, the identification of dominant symptoms, the assessment of the risk of immobility-related complications, as well as the analysis of the patient’s psychological and social context.

2. Definition of therapeutic goals and priorities: carried out through a shared decision-making process, with emphasis on symptom control, prevention of complications, maintenance of comfort, respect for patient preferences and proportionality of interventions.

3. Coordinated implementation involves the application of integrated interventions (medical, nursing, physiotherapeutic, psychological and social), with clear delineation of responsibilities and effective interdisciplinary communication.

4. Continuous monitoring and reassessment entails adjustment of the care plan according to clinical response, the emergence of new symptoms or complications, as well as changes in the priorities of the patient and family.

5. Planning of care continuity aims to organize care within the unit, at home or in another supportive setting, through appropriate coordination of available medical and social resources.

Results: clinical course under integrated care

The patient’s clinical evolution was directly influenced by the ability of the multidisciplinary team to integrate interventions into a unified therapeutic plan, supported by continuous communication and periodic reassessment of objectives. In the context of metastatic oncologic disease, interdisciplinary collaboration enables simultaneous symptom control, reduction of immobility-related complications and orientation of care toward the maintenance of quality of life through management tailored to individual response^(8,9).

Stage 1. Initial clinical stabilization (first days) – intervention of the medical oncologist/palliative care specialist

During the initial phase, the priority objectives focused on reducing overall suffering and stabilizing the clinical condition. The therapeutic regimen was reassessed and progressively optimized, with emphasis on the control of persistent pain and dyspnea present even at rest.

• Pain. Careful titration of a major opioid was performed, tailored to pain intensity and the patient’s tolerance profile, in combination with non-opioid analgesics and adjuvant medication targeting the neuropathic component. This combined strategy resulted in a gradual reduction of pain intensity, without significant adverse effects, and the stabilization of analgesic comfort.
• Dyspnea. The management included administration of low-dose opioids to reduce the subjective perception of breathlessness, oxygen therapy adjusted to clinical need and positioning measures aimed at optimizing respiratory mechanics. The anxiety component associated with dyspnea was addressed through cautious use of anxiolytics.
• Brain metastases/suspected peritumoral edema. Corticosteroid therapy was initiated, with favorable effects on both respiratory symptoms and neurological manifestations.
• Sleep disturbances. The management was sequential; the initial control of triggering factors (pain and anxiety) was followed by the introduction of a hypnotic at the minimum effective dose. This approach led to improved nocturnal sleep continuity and reduced daytime fatigue.
• Associated measures. Interventions were implemented for the prevention and treatment of opioid-induced constipation, control of nausea and therapeutic adjustments in cases of transient psychomotor agitation. The daily reassessment allowed the maintenance of an optimal balance between symptomatic efficacy and therapeutic safety.

The improvement of pain and dyspnea had an indirect favorable effect on anxiety, facilitating patient cooperation and optimizing communication with the multidisciplinary team^(1,3). 

Stage 2. Prevention of immobility-related complications and optimization of somatic comfort (subsequent days) – intervention of the nurse and physiotherapist 

Following the stabilization of dominant symptoms, the therapeutic plan was expanded to focus on preventing complications associated with prolonged immobility and enhancing somatic comfort.

Nursing intervention (skin care, pressure injury prevention, repositioning)

The sacral pressure ulcer identified at admission was evaluated daily and remained stable, without clinical signs of superinfection or progression. Care was provided according to a structured protocol, including systematic assessment of pressure areas, local cleansing with non-irritating solutions, application of dressings appropriate to the stage of the lesion and protection of perilesional skin. Patient repositioning was performed at regular intervals, using appropriate passive mobilization techniques and supportive devices designed to ensure pressure redistribution and reduce friction and shear forces. Measures were implemented to control moisture, prevent maceration and maintain the integrity of intact skin, including in the context of incontinence. Integration of these interventions into daily care routines, together with continuous communication within the multidisciplinary team, contributed to the favorable evolution of the existing lesion and prevention of additional skin injuries, with direct impact on patient comfort (Figure 1).

Physiotherapeutic intervention (passive mobilization, positioning, comfort) 

The physiotherapy program aimed to preserve residual joint mobility, prevent contractures and optimize postural comfort. Passive mobilization was performed systematically, using slow, controlled and painless movements adapted to the patient’s clinical tolerance. Positioning was individualized, employing appropriate supportive devices to ensure proper body alignment, pressure redistribution and reduction of muscular tension. Alternation of positions and analgesic adjustment of posture contributed to limiting the development of contractures and abnormal postures, resulting in reduced postural discomfort and improved perceived daily comfort^(6,7) (Figure 2).

Stage 3. Psycho-emotional stabilization and optimization of therapeutic cooperation – psychological intervention

Psychological intervention was integrated early into the care plan and conducted repeatedly, with the aim of assessing and managing the emotional impact of immobility and progression of oncologic disease. Clinical evaluation included the assessment of anxiety levels, the identification of depressive symptoms, the exploration of coping strategies and the evaluation of changes in self-image associated with loss of autonomy. The interventions were individualized and adapted to the available psychological resources and the patient’s tolerance for emotional exploration, taking into account his somatic fragility.

• Initial objective: reduction of anxiety and acute distress through structured emotional support, clarification of the interdependence between physical symptoms (pain, dyspnea) and anxiety reactions, and facilitation of expression of fears related to disease progression. Clarifying these mechanisms contributed to reducing the sense of unpredictability and restoring a minimal level of perceived control over the situation.
• Secondary objective: prevention of demoralization and depressive symptomatology by monitoring signs of social withdrawal, diminished hope and emergence of feelings of uselessness. The intervention included validation of emotional experiences without premature pathologization and preservation of personal sources of meaning (significant relationships, family roles, participation in therapeutic decision-making). This approach supported the progressive integration of functional limitations into the patient’s identity, main­tenance of dignity and acceptance of support without internalizing the perception of being a “burden”, while respecting the individual pace and avoiding premature confrontation with existential themes during periods of heightened vulnerability.
• Essential component: support provided to family members, aimed at reducing emotional overload and preventing caregiver burnout. Guidance was offered regarding empathic communication, management of their own emotional responses and preservation of personal resources. Integration of psychological intervention within the multidisciplinary team dynamics facilitated increased patient cooperation, strengthened the therapeutic alliance, and maintained a satisfactory perceived quality of life despite persistent functional limitations.

Stage 4. Socio-community support and ensuring continuity of care – social work intervention

The social worker’s intervention represented an essential component of the integrated therapeutic plan, with the objective of conducting a comprehensive evaluation of the patient’s socioeconomic situation and identifying available family and community resources. This approach enabled adaptation of interventions to the patient’s real-life context and anticipation of difficulties associated with discharge. During hospitalization, access to appropriate support services was facilitated, and relevant administrative aspects were clarified, including social rights and available institutional options. These measures contributed to reducing uncertainty and psychosocial pressure experienced by the family in the context of disease progression. Through ongoing collaboration with family members and the medical team, the support plan was dynamically adjusted according to clinical changes and emerging needs. Structured organization of post-discharge care – either at home or through specialized services – promoted the continuity of therapeutic interventions and increased predictability of care, with a positive impact on the overall experience of both the patient and the family⁽⁸⁾.

Synthesis of the clinical benefits of multidisciplinary care

The implementation of a coordinated therapeutic strategy based on multidisciplinary collaboration generated favorable clinical outcomes in the bedridden oncology patient, through reduction of dominant symptoms and limitation of complications associated with prolonged immobility. The alignment of medical, nursing, physiotherapeutic, psychological and social interventions enabled a unified approach to global suffering, continuously adapted to the dynamics of clinical evolution and the individual characteristics of the patient. Optimization of pain and dyspnea control resulted in rapid stabilization of overall status, with positive effects on sleep quality, reduction of anxiety and improved cooperation within the therapeutic process. Nursing and physiotherapy interventions contributed to maintaining skin integrity, preventing musculoskeletal complications and enhancing daily comfort. Integration of psychological support facilitated emotional adaptation to loss of autonomy and strengthened the therapeutic relationship between the patient and the team, while social work intervention ensured the continuity of care and increased the predictability of the clinical trajectory.

Overall, the multidisciplinary model transformed care from a sequence of isolated measures into a coherent, person-centered therapeutic process, with observable benefits in comfort, preservation of residual functionality, emotional stability and perceived quality of life.

Discussion

This case study supports the central hypothesis of this work, namely that immobility in the oncology patient should be approached as a complex clinical entity with its own systemic implications, rather than solely as a secondary consequence of tumor progression. In advanced or metastatic stages of disease, loss of mobility generates a multidimensional interaction between biological deterioration, functional decline and psychosocial vulnerability, leading to cumulative suffering that extends beyond strictly somatic symptoms. In this context, the integrated palliative care model becomes essential for maintaining an acceptable quality of life for both the patient and the family⁽¹⁾.

The clinical course of the analyzed patient demonstrates that stabilization of dominant symptoms represents the foundation upon which the entire multidisciplinary intervention is built. Control of pain and dyspnea not only had an immediate palliative effect, but also created the necessary conditions for effective implementation of subsequent interventions. This therapeutic sequence is consistent with current recommendations regarding early integration of palliative care in oncology, which emphasize the importance of timely symptom management, structured communication and proactive care planning in advanced stages of disease⁽²⁾.

In the present case, alleviation of physical suffering enabled tolerance and optimization of nursing, physiotherapy and psychological interventions, confirming findings from the literature on the benefits of integrated palliative care in advanced lung cancer⁽³⁾. The role of the medical oncologist and the palliative care specialist extended beyond pharmacological intervention to include coordination of therapeutic objectives and facilitation of the decision-making process. Establishing priorities, assessing proportionality of interventions and integrating patient values into the therapeutic plan contributed to a genuinely person-centered approach. The literature on interdisciplinary palliative care highlights decision-making support and coherence of interventions as defining elements of high-quality care in complex clinical situations⁽⁴⁾. In this case, effective symptom control allowed the recovery of a minimal relational autonomy, indispensable for preserving patient dignity.

Nursing interventions constituted the operational core of care through continuous symptom monitoring, prevention of complications and maintenance of skin integrity. Stability of the pressure injury and absence of superinfection reflect the effectiveness of a structured strategy based on systematic interventions adapted to individual tolerance. These findings are consistent with evidence supporting individualized repositioning plans, use of support surfaces and reduction of friction and shear forces as central elements in pressure ulcer prevention^(5,6). The analyzed case confirms that effective prevention depends on continuity and coordination rather than isolated technical measures.

Prolonged immobility induces additional functional decline independent of oncologic progression, manifes­ted by joint stiffness, painful contractures and postural discomfort. In this context, physiotherapeutic intervention primarily aimed at maintaining comfort and limiting functional complications, rather than achieving true rehabilitation. This approach is supported by recent literature and European position documents promoting integration of palliative care with principles of geriatrics and rehabilitation to address the multidimensional needs of advanced oncology patients^(7,8).

The psychological dimension of care proved to be closely interconnected with clinical evolution. Emotional distress resulting from loss of autonomy and functional dependence initially influenced patient cooperation and adaptability to care. The introduction of psychological support following stabilization of physical symptoms facilitated expression of fears, reduction of anxiety and preservation of a sense of control and dignity, even in the context of irreversible functional decline. The literature indicates that distress frequently remains underdiagnosed in the absence of structured screening tools and clearly defined therapeutic pathways^(9,10). Family involvement in the therapeutic process contributed to reducing emotional burden and strengthening the caregiving framework.

The social worker’s intervention played a key role in ensuring continuity and coherence of care. Facilitating access to resources, organizing post-discharge care and supporting caregivers directly influenced care stability and reduced the risk of acute decompensations. The literature recognizes the central role of social workers within interdisciplinary palliative teams in connecting patients and families with available support networks and maintaining socio-familial balance⁽¹¹⁾. In the present case, these interventions increased predictability of the therapeutic trajectory and alleviated pressure experienced by the family.

A transversal element supporting the effectiveness of the applied model was structured communication within the multidisciplinary team. Clarity of responsibilities, periodic reassessment of objectives and transparent dialogue with the patient and family enabled the continuous adjustment of interventions and alignment with clinical evolution. The literature identifies these factors as determinants of palliative team performance⁽⁴⁾.

Although the patient’s functional status remained severely compromised, multidisciplinary care delivered within a specialized center ensured clinical stability and prevention of major acute complications. This outcome reinforces the objective of the study: to demonstrate that success in managing the bedridden oncology patient should not be measured by functional recovery, but rather by the reduction of global suffering, prevention of avoidable events and preservation of quality of life in the context of advanced disease.

Practical criteria for referral of the bedridden oncology patient to palliative care

Based on the analysis of the presented case and in accordance with data from the literature, referral to a specialized palliative care center should be considered in the presence of one or more of the following:

• complete or near-complete immobility, with loss of functional autonomy;
• severe or multiple physical symptoms that are difficult to control in the outpatient setting;
• occurrence of immobility-related complications (pres­sure injuries, painful contractures, recurrent infections);
• significant emotional distress in the patient and/or family;
• caregiver burden or overload;
• the need for coordination of complex interventions and frequent reassessment of therapeutic objectives.

Aim of the case presentation

The objective of this case presentation is to demonstrate, through the analysis of a complex clinical case, that the bedridden oncology patient requires early integration into a specialized palliative care framework in order to benefit from care that is genuinely oriented toward maintaining quality of life. The case illustrates that immobility in the oncologic context is not merely a consequence of disease progression, but a clinical state with systemic implications that requires coordinated, continuous and interdisciplinary interventions.

The analysis of the patient’s clinical course highlights that only within a setting that enables authentic collaboration among the medical oncologist, palliative care specialist, nurse, physiotherapist, psychologist and social worker can the following be achieved:

• stabilization of dominant symptoms;
• prevention of immobility-related complications;
• preservation of comfort, dignity, and psycho-emotional balance;
• assurance of continuity of care.

Thus, the study supports the premise that the care of the bedridden oncology patient cannot be reduced to a sequence of isolated symptomatic interventions, but must be conceptualized as an integrated therapeutic process dynamically adapted to clinical evolution and individual needs.

Impact of the case presentation on palliative practice/clinical implications

Immobility in the context of advanced oncologic disease should be interpreted as a marker of major clinical vulnerability, resulting from the interaction between biological progression, functional decline and psychosocial fragility. This condition requires early palliative assessment and integration into a specialized framework before the onset of irreversible complications. Rigorous control of pain and dyspnea constitutes the operational premise of multidisciplinary intervention, as symptomatic stabilization enables effective implementation of nursing measures, physiotherapy and psychological support, as well as patient participation in the decision-making process.

Coordination of interventions by the medical oncologist and the palliative care specialist ensures therapeutic proportionality and coherence of objectives, preventing fragmentation of care. Prevention of immobility-related complications – through continuous, individualized and integrated interventions – limits secondary functional deterioration and reduces the associated morbidity. The integration of psychological and social support optimizes therapeutic cooperation, preserves dignity and sustains continuity of care at both family and community levels. Early referral to specialized palliative services enhances resource efficiency and stabilizes the clinical trajectory, defining a model of care centered on reducing global suffering and maintaining quality of life in advanced or metastatic oncologic disease.

Key message 

Immobility in the oncology patient represents a multidimensional clinical condition requiring early integration into a coordinated palliative care model. Rigorous control of major symptoms, prevention of immobility-related complications and integration of psychosocial support must be implemented within a coherent multidisciplinary framework, oriented not toward functional recovery, but toward the reduction of global suffering and the preservation of dignity and quality of life.

Conclusions

The present case demonstrates that immobility in advanced oncologic disease is not merely a late consequence of tumor progression, but a complex clinical condition that amplifies biological, functional and psychosocial vulnerability. The effective management of this profile requires early integration into a specialized palliative care framework in which symptom control, complication prevention and psychosocial support are coordinated within a coherent therapeutic model.

Stabilization of pain and dyspnea constitutes the operational foundation of multidisciplinary intervention, facilitating the implementation of nursing measures, physiotherapy and psychological support. Continuity and individualization of interventions reduce immobility-associated morbidity and prevent further functional deterioration. In this context, the success of palliative care is not defined by recovery of autonomy, but by the capacity to limit global suffering, prevent avoidable complications and preserve dignity and quality of life in advanced oncologic disease.   

Corresponding author: Anda-Elena Crișan E-mail: anda_crisan2005@yahoo.com

Conflict of interest: none declared.

Financial support: none declared.

This work is permanently accessible online free of charge and published under the CC-BY licence.