Free Poster Session
PD 01 (Poster session)
Sublingual ketamine as an analgesic
Pain and Palliative Care Society, Medical, India.
Introduction: Usually we follow the WHO analgesic ladder for pain management but in some cases in addition to this injection ketamine S/L is prescribed
Objective: To analyze efficacy of injection ketamine in pain management
Materials and Methods: Collected data of the number of patients with pain attended the Out patient division of Pain and Palliative Care Society, Kozhikode from 1 st October 2009 to 30 th September 2010. Out of this patients how many required an additional administration of injection ketamine was assessed
Results: The study shows that there was significant pain relief with injection ketamine. It was especially very useful in patients with incidental pain.
PD 02 (Poster session)
Community nursing service: An experience
Pain and Palliative Care Society, Medical, India.
Introduction: Community Nursing Service is a new concept and experiment to provide effective nursing home care to patients. This initiative started in Kozhikode city in May -2010 by palliative care clinic, Kozhikode city. For providing this service the city area was divided into eight specific units. Community Nursing Service was started in one of these areas - Kuttichira of Kozhikode city- to provide effective care to patients. An auxiliary nurse is providing home care to all patients registered under this area. Now 55 patients are under care of this service. The nurse visits the homes of these patients once in a week.
PD 03 (Poster session)
Effective psychiatric intervention in patients with chronic Lllness/bedridden
Pain and Palliative Care Society, Medical, India.
Introduction: Psychiatric disorders are common in patients with chronic or terminal illness. But in many palliative care settings, these disorders are not identified properly. Identification of these problems is essential for offering effective total care to patients
Objective: This study aims to find out the need of effective intervention to identify psychiatric disorders in patients under palliative care treatment
Materials and Methods:
Results: Better delivery of care to patients.
PD 04 (Poster session)
Effective delivery of nursing procedures
Pain and Palliative Care, Society, Medical College, India. E-mail: firstname.lastname@example.org
Introduction: Nursing procedures are being provided to patients at the OPD of Institute of Pain and Palliative Care Society, Medical College Kozhikode. This study tries to analyse effective delivery of nursing procedures.
Objective: Analyse the effective delivery of nursing care to patients at the OPD of Pain and Palliative Care Society, Medical College Kozhikode
Materials and Methods:
Results: Help to build a strong data of the patients and their need. Helps to assess the nursing procedures delivered. Helps to build up more facilities to provide nursing procedure
PD 05 (Poster session)
Study of how do terminally ill patients take their medication at home
Chandorkar Shalaka, MA Muckaden, Mangiri Dighe, Balaji PD
Home Care, Tata Memorial Center, Mumbai, India.
Compliance with prescribed medication was assessed for home care patient using telephonic interview and pill counting. Patients who take less medication than prescribed usually due to anxiety about adverse effect, and fear about drugs, disease. The common drugs involved were analgesic, laxatives. Some took additional medication usually purchased over the counter or from general Practioner in response to adequate symptom control or adverse effect of drug or started alternative therapy. The reason for may be because some unresolved psychological and social, economical issues in spite of providing free medication
PD 06 (Poster session)
First bite syndrome - Medical treatment options for first bite syndrome
Stacy Stabler, Ishita Sharma, Roma Tickoo,
Memorial Sloan - Kettering Cancer, New York.
Background: First bite syndrome is a rare but known complication of parapharyngeal space surgeries. Pain typically fatigues after a few bites.
Materials and Methods: We report management of two patients with first bite syndrome. One is a 60y/o Female who presented with a right jaw pain starting 5 days after a parathyroid tumor resection. The other patient is a 81y/o male with right sided jaw pain after right parapharyngeal space tumor resection. In both patients a trial of Gababpentin titration and BOTOX therapy was performed
Results: Both patients reported significant pain relief with the Gabapentin at 2400mg of Gabapentin a day and the other patient.
Conclusions: Clinicians should be aware of the use of neuropathic agents and Botox injections to help pain of First Bite Syndrome.
PD 07 (Poster session)
The importance of psychosocial stress in the aetiology of cancer
Cansupport, New Delhi, India. E-mail: email@example.com
Introduction: The study involves the comparison of the various risk factors of cancer with psychosocial stress in the aetiology of cancer. The study involved terminal cancer patients giving out their personal and family history. These patients being on the death bed would assume to tell the truth.
Materials and Methods: The study was done in the field during the home visits in the Cansupport organisation. The history is generally taken during the patients first visit. It has to be kept in mind that all the six headings (Smoking, alcohol, betel nut, tobacco chewing, genetic and disease) are under consideration. So a detailed history of the factors were taken. Wherever, a factor was found it was given a point of one. The reason why it was given one is also put in the comment box. The sum total of all the points are added and noted in the right column (Scoring). All the points of the factors are added and put in the bottom row (sum total scoring). This chart was not more than fifty patients. The total percentage of the sum total scoring against the scoring has been calculated and noted on the master sheet. The consecutive totals of the fifty patients have been noted. Then the average of all the totals on the master sheet was done. The averaging was done to bring about a modulation of the figures.
The smoking history of the patient has been taken in details. The relevant history has been noted in the comment box. Generally the life style predicts the patients temperament. Alcohol, betel nut and tobacco leaves were also treated in the same manner. Environment induced factors are where the patient has been in close proximity with any carcinogenic substances. Examples are work in the asbestos industry, high altitude greater than 15,000 ft. In the genetic area the first relation are the parents and the children. The second relations are the siblings and the third relations are the cousins.
The emotional stress has been classified into three fields, work, family and social. These factors have been taken into consideration in a period of five to ten years before the onset of the disease. Work involves dissatisfaction of the individual in the work place. Examples are mental stress, timings, loss of job etc. Family stress involves strained relationships of husband wife, divorce, loss of a dear ones(father, mother, brother, friend etc). Social stress involves the relationships with that of neighbours and relations.
Physical diseases which are chronic have been noted in this column. Diseases such as diabetes, hypertension, disorders of the thyroid etc.
The amount of patients seen would be approximately 150. This is a pilot study. To get a total of 1000 patients we would take about two to three years.
Conclusion: The study involved the various risk factors involved in predisposing to cancer. The factors taken into consideration were smoking, alcohol, betel nut, tobacco leaves, genetic influence, emotional stress and disease involvement.
According to the study the average total for smoking is 13.5%. Smoking has been an age old risk factor for cancer. It is a definitive risk factor where the chances of contracting a cancer increases in smokers. The amount of research done on it has been immense. The amount of chemicals produced by the smoke is approximately 4000 which are known. There are still unknown chemical in the smoke.
Alcohol has been a major factor in the contribution of hepatocellular carcinoma. It has also been a factor for other diseases. So it is a toxic substance for the human body if taken in an uncontrolled manner. Many studies have proved that alcohol is toxic for the body. The average total for alcohol according to the study is 10.5%. The figure is a considerable amount compared to the other figures in risk factors.
The average total of betel nut is about 3%. The surprising finding in this is that a majority of the cancers are of the head and neck region. It may not be ruled out here that other parts of the body may be involved in betel nut cancer. The risk association for betel nut is definitely there but is not as high as that of smoking and alcohol.
Tobacco leaf chewing is also a definite risk factor for cancer. But the percentage is slightly higher than that of betel nut, 4%. Head and neck is also a higher percentage but other parts of the body are also involved.
Environmental induction are aetiological factors at work place or at home. Examples are chronic exposure to carcinogenic materials such as asbestos, dyes etc and high altitude exposures. The average total is 2.5%.
Genetic average total is about 14.5% This group has been divided into three subheadings the first relations which basically involve the parents or the children. The second relation consists of the siblings that are the brothers and sisters. The third relations consists of the cousins. The first relation have an average total of 9.7%, followed by the second relation having an average total of 3%. The third relations have an average total of 1.5%. The picture seems to be appropriate.
Physical has been taken into consideration as it may be an important and an indirect factor for the emotional cause. Here chronic diseases have been taken into consideration for giving the score. The score is the third highest after emotional and smoking. The average total is 13%. This factor is an important indirect cause for emotional stress.
The emotional factor is having an average total of 39.1%. This is the total of all the emotional subheadings. The subheadings have been divided into work, family and social. Work has an average total of 8%, followed by family which has 28% and last but not the least is social which has an average total of 3%. The history taken for the patient in this category ranges from the near past to a decade and a half before the onset of the disease. The emotional stress itself may be a major cause to many of the other aetiological factors. The average total of the emotional stress hitting 38% is much higher than the known aetiological factors(smoking, alcohol, tobacco leaves and betel nut) which is hitting around 10-15%. Persistent emotional stress may lead to higher levels of sympathetic dominance for long periods, which leaves the person in a situation for initiating psychosomatic disorders. Cancer might be one of the diseases under the psychosomatic disorders. At 38% in this pilot study the emotional factor cannot be missed out. Further studies in this area would definitely give us a better understanding to the aetiology of malignancy.
PD 08 (Poster session)
Nursing compliance of patients with the home care teams
Sister Vidya Thakur, Pratik Banerjee
CanSupport, New Delhi, India.
Introduction: The study has been taken with the objective of finding the compliance of patients with nursing advices and care. The patients were terminal cancer patients who were at home with their care taker. The study involved the compliance of the patient and the family to nursing care and advices in their house to a homecare team visit. It has been a pilot study.
Materials and Methods: The amount of cases taken into consideration were 30. These patients were with the home care team till the last or till the patient or the family wanted the home care team. The field of nursing care had been tabulated under eye, ENT, oral artificial feeding, wound, fistula, ostomy, catheter, perineal, lymphoedema, skin, bowel, bleeding, diet and medical advice. Where ever the relevant advice was give the score given was one. The total score of each patient was done in the comprehensive total column. The sum of the comprehensive total column was then added at the bottom. Wherever the home care team faced a problem regarding the advice to the patient a single score was given in the negative total column. This was then totalled up at the bottom of the column. The percentage of the negative total over the comprehensive total was calculated.
Conclusion: The present figure of 14.1% noncompliance in the study is outstanding as it implies that the study showed a 85% compliance of the homecare with that of the nursing advice. This figure turns out to be impressive for the sustenance of home care teams in palliative care. The findings of the pilot study suggest that the government machinery should support such programmes for the palliative patients.
PD 09 (Poster session)
Networking in palliative care
CanSupport, New Delhi, India. E-mail: firstname.lastname@example.org
Introduction: God's most complex creation, the human species, has its own unique basic needs. And one of them is to get connected, be wanted and loved. From time eternal humans are known to have created and lived in communities so that they feel safe and are able to share joys and sorrows of life. These communities were results of networking of people with each other. It is well known that people everywhere and in all times take measures to 'capitalize' on their social relations in order to deal with the challenges of life.
Objectives: Networking for Palliative Care has the primary objective of collecting funds, information and other support from various medical and non-medical groups for rehabilitating the families. Contribution is the heart of any network and free-riders are not likely to be accepted for long in any kind of network.
Materials and Methods: Offer to help others first, and they will return the favor.
Let's say Revathi working for an X NGO meets her friends' (just 5 in the new city) friends in a social gathering of around 150 families. Since she is an honest and helpful person, she is introduced accordingly. She keeps note of the contact details and tells them about her NGO's goals and activities. She would later:
Results: Revathi would have met at least 30 new people and keeping in constant touch with them would be able to slowly expand her circle since she would have at many instances helped many of these new friends and in return would be able to take help from them for her NGO.
Conclusions: Networking is less about meeting new people than having them remember you after the fact. Establish relationships with the contacts you've made. Networking is a reciprocal process and should be done in the spirit of sharing that transcends the information shared. The best net workers reflect that spirit with a genuine joy in their "giving."
PD 10 (Poster session)
Networking in palliative care: A case report
Pain and Palliative Care Society, Thrissur, India.
Introduction: Networking is an integral part of palliative care. The disease experience of a person suffering from long term illness can be addressed only if we can network among various agencies which can make a difference in the life of this particular person. As the complexity of the disease increases, the demands for networking also increase. The result of such networking is quite rewarding.
Objectives: To demonstrate the effectiveness of networking in palliative care through a case study.
Materials and Methods: A community volunteer received an anonymous call to visit a person suffering from AIDS. The volunteer found that the sufferer who is infected by HIV had many additional health problems. The case was complicated by Tuberculosis, Peripheral Vascular Disease and Gangrene leading to amputation of one leg below the knee. In addition, he had a fall while walking on crutches reportedly due to a Cerebrovascular Accident that led to a fall and consequent fracture of femur of the unamputated leg which was also found to have gangrenous toes. The victim was in agonizing pain. The stigma and discrimination associated with HIV/AIDS and lack of neighborhood support added to the stress. Due to the intense suffering and hopelessness the whole family was on the verge of suicide. The pain and palliative care society, through effective networking among the local Primary Health Centre, Orthopedic Department of District hospital, the Skin and Venereal Diseases Department of the Government Medical College Thrissur, the Antiretroviral Therapy Centre of Kerala State AIDS Control Society and Kerala Agricultural University, could provide the needed health care, financial and psychosocial support and thus improve the quality of life of this patient.
Results: The patient's health improved. He, who was on the verge of suicide, came back to life with a smile on his face.
Conclusions: Effective networking can improve the quality of life of patients suffering from long term illness.
PD 11 (Poster session)
Palliative care in campus (Activity in calicut city)
Institute Of Palliative Medicine, Medical College, Kozhikode, Kerala, India. E-mail: email@example.com
Introduction: The young and energetic student community provides powerful human resource if mobilised in proper direction. To mobilise this energy for Palliative Care, specific programmes were envisaged by Institute of Palliative Medicine, Kozhikode for student community within Kozhikode city.
Objective: To empower student community for effective and independent intervention in palliative care
Materials and Methods:
PD 12 (Poster session)
To assess the effectiveness of aloe vera gel in preventing skin reactions associated with radiotherapy
Institute: E-mail: firstname.lastname@example.org nnone
Aims: To assess the effectiveness of aloe vera gel in preventing skin reactions associated with radiotherapy.
Materials and Methods: This prospective, randomized controlled trial included 57 head and neck cancer patients who were scheduled to undergo radiation therapy in the Radiation oncology department of BRAIRCH, AIIMS, and New Delhi. Subjects were randomly assigned to either experimental group (N=27) or control group (N=30).Subjects in the experimental group were advised to apply aloe vera gel to the site of radiotherapy within 2-3 days of start of radiotherapy and continued till one month after completion of radiation therapy. Subjects in the control group received usual standard care. Data were collected at baseline, then fortnightly till completion of RT and at one month after completion of radiation therapy. The collected data were analyzed using STATA.
Results: The two groups were homogenous with regard to all demographic and clinical variables. The incidence of radiation induced skin reaction was almost 100% in the study population during the overall course of RT. There were a significantly delayed onset of skin reaction and low percentage of patients with severe radiotherapy induced skin reactions in the experimental group as compared to control group during the course of radiation therapy. At one month post radiotherapy there was no significant difference between two groups for radiotherapy induced skin reactions. During the later course of radiotherapy (at 6 th /7 th week) significant difference between two groups for pain scores was seen. However there was no significant difference in the two groups in the occurrence of radiation induced skin reaction related complications.
Conclusion: Aloe vera gel was effective in delaying the onset and reducing the severity of radiation induced skin reactions during the course of radiotherapy.
PD 13 (Poster session)
Need and effectiveness of special nursing procedures in lymphoedema and colostomy care
Pain and Palliative Care Society, Medical College, India.
Introduction: It has been noticed that specialized nursing procedures in Lymph oedema and Colostomy Care in palliative care offered to patients provides them comfort. This paper tries to analyze the effectiveness of this specialized care.
Objective: To analyze the need and effective ness of special nursing procedures in Lymph oedema and Colostomy care.
Materials and Methods:
PD 14 (Poster session)
Networking and sharing for maximising patient comfort: A case based report
Madhura Bhatwadekar, Sonali Kulkarni, Geeta Jahagirdar, Priyadarshini Kulkarni
Cipla Palliative Care and Training Centre, Warje, Pune, India. E-mail: email@example.com
Introduction: Palliative care is a patient-centered approach aimed entirely at providing quality care resulting ultimately in improved quality of life for the patient. The pain experienced by the patient is at two distinct levels, viz: Physical and psychological. In order to help the patient in all the aspects of care i.e. physical, psychological, spiritual and social there is a need for an interdisciplinary team with an interface between them so as to maximize care. This in turn advocates for the need of a good network of referral systems at different levels
Materials and Methods:
Results: The patient's concerns were well addressed using the multi-disciplinary team approach
Conclusions: Networking and sharing by a multi-disciplinary team approach help in comforting patient
PD 15 (Poster session)
A study on anxiety manifestations observed in spouses of advanced stage cancer patients
Sonali Kulkarni, Madhura Bhatwadekar, Geeta Jahagirdar, Priyadarshini Kulkarni
Cipla Palliative Care and Training Centre, Pune, Maharashtra, India. E-mail: firstname.lastname@example.org
Introduction: Any disease has 3 dimensions, viz: Physical, Psychological and Social. All the dimensions are taken into consideration for giving better quality of life to the patient. Cancer is a devastating experience not only for the patient but also for close relatives of patient. When detected in advanced stage, reactions may range from shock to numbness and inability to grasp the situation or feel emotions. Literature review shows that anxiety is one of the most observed psychological problems faced by spouses of advanced stage cancer patients.
Objective: To observe benefit of interactions between spouses of advance stage cancer patients in reducing anxiety symptoms.
Materials and Methods: Patients at Cipla Centre come from different socio- economic strata.
These methods are part of the Family-Care model adopted by the Cipla Centre.
Results: After observing anxiety symptoms followed by interactions with spouses, it was found beneficial for reducing anxiety in the spouses who had symptoms.
Conclusion: From above study we conclude that spouses' interactions and sharing experiences help in reducing anxiety symptoms.
PD 16 (Poster session)
Cansupport, New Delhi, India. E-mail: email@example.com
Introduction: Identified the need, that when the main bread winner of the family expires, who will take care of the financial needs of the family.
Objective: To create a socio economic rehabilitation programme to empower the family member to sustain a decent livelihood after the death of a family members.
Materials and Methods: A survey with 50 socio economic backward family and eleven home care was done to assess and create the programme that would support the family both in short term and long term support. We identified and networked with agencies to put the programme in action
Result: We established five activities under the programme
Conclusion: Networking with existing and past beneficiaries. Skill empowering NGO's were able to cater to socioeconomic needs of the families in a significant ways.
PD 17 (Poster session)
Management of vaginal infatuations
Cansupport, New Delhi, India.
Introduction: Managing fistula in cervix cancer patients because of incontinence urine and stool.
Objective: Managing maggots in vaginal fistula patients.
Materials and Methods: Used innovative management techniques in managing maggots.
Result: In three to five days the patients were free from vaginal maggots.
Conclusion: It is an evidence based quick and cost effective method of managing vaginal fistula patients
PD 18 (Poster session)
Management of neuropathic pain in advanced
cancer patients at hospice setting
Minni Arora, FD Patel, Neeru Anand
PGIMER, Chandigarh, India.
Introduction: Neuropathic pain is one of the most difficult pain to be managed. It may arise from any injury in peripheral or central nervous system. Neuropathic pain in advance cancer may be due to wide range of causes like tumour infiltration, compression, post surgical scarring, radiotherapy fibrosis, chemotherapy induced or even paraneoplastic syndromes. Different scales are used to assess this pain. Pharmacotherapy (adjuvants) is the main stay of treatment mostly used in combination with W.H.O. ladder.
Aim: Aim of the study is to diagnose, assess and manage neuropathic pain with pharmacological and non pharmacological measures with limited use of interventional nerve blocks in a hospice setting.
Materials and Methods: Study done on 80 patients admitted at hospice in last one year, with advance cancer and having main complain of pain. All the causes were analyzed, pain identified with all clinical signs and symptoms, assessed and different neuropathic agents were tried.
Results: Effectiveness and side-effects of different neuropathic agents like anti depressants, anticonvulsants, gabapentin, steroids, opoids etc. used for managing such pain and how often nerve is needed will be presented at the
PD 19 (Poster session)
Premature menopausal symptoms: A focus issue in gynecological cancer patients
Netaji Subash Chandra Bose Medical College & Hospital, Jabalpur, MP, India. E-mail: firstname.lastname@example.org
Introduction: Premature menopausal symptoms are a common problem in many female patients of gynecological cancers. Menopausal symptoms can be caused by surgery (e.g. B/L oophorectomy), chemotherapy, pelvic irradiation and hormonal therapy such as tamoxifen or aromatase inhibitors .
Materials and Methods: We included 120 female patients of various gynecological cancers with age ranging from 35-45 years post chemotherapy /radiotherapy/post surgery for the study. They were asked about the symptoms of high concern in their daily living.
Results: 85% women experienced features of hot flushes, 40% women had sexual function issues like vaginal dryness, decrease in libido and negative changes in sexual function. Low levels of self esteem and Life satisfaction was present in more than 70% patients. This was associated with depression in majority of cases. Bone loss leading to pain and disability was present in 95% females either due to aging or due to cancer related treatment. There was 36% increase risk of urinary tract infection in women receiving anticancer therapy.
Conclusion: Menopause related symptoms are prominent in females with gynecological cancers and should be paid attention. Education and guidance for adopting these changes improves their quality of life.
PD 20 (Poster session)
Changes in knowledge, attitudes and values of postgraduate physicians following a palliative care training course
Palliative Care Unit Makerere University / Mulago Hospital, Kampala, Uganda. E-mail: email@example.com
Introduction: Palliative Care (PC) has been part of the medical school curriculum in Uganda since 1993 which has seen an increase in the knowledge about PC amongst junior doctors. There is a need to provide ongoing training for doctors following graduation to ensure that PC is integrated into their practice. We recently began a programme of training for physicians integrated into their postgraduate scheme. With this programme we were aiming not only to give the physicians new knowledge about PC, but by modelling a different way of working and training we were hoping to challenge attitudes and values of the students about PC to achieve a change in practice.
Objectives: We were aiming to assess changes in knowledge, attitudes and values about PC following the training course.
Materials and Methods: This study comprises qualitative interviews with doctors who completed this training. Interviews continued until thematic saturation was achieved.
Results: The study is due to be completed soon but informal feedback following the training suggests the attachment not only increased knowledge about PC but also resulted in changes in values improving the doctors' whole approach to caring for patients, not just those who have life-limiting illnesses. Initial comments from the students taking part in this training include "I will be a better doctor now".
Conclusion: We hope to conclude that a training programme for postgraduate physicians is successful not only in increasing knowledge about PC but also in changing attitudes and values, thus achieving a change in practice.
PD 21 (Poster session)
Audit of a pain and palliative unit in Bangladesh
R Dowla, Akhter PS 1
Bangladesh Palliative and Supportive Care Foundation, 1 National Institute of Cancer Research Hospital.
Introduction: Bangladesh is only beginning to realise the importance of palliative medicine.It was a challenge to start a new service that too in a government set up; Still someone had to take the first step; Eventually when the service is in place -How do we know if a service is effective? When it comes to service and that too involving human subjects, at a vulnerable stage such as life limiting illness; It is indeed important that we ensure good quality of service in place. Health System is one of the most sensitive and probably essential area for evaluation and monitoring. It can be cost effective if a simple and effective health audit is in place.
Background: After completing my training in Singapore in 2006 I had joined Medical Oncology Department at The National Institute of cancer Research Hospital (NICRH) in Dhaka, Bangladesh, as Honorary Pain and Palliative physician and also a trainee in medical oncology. I worked with Prof. and head of the department of medical oncology; together we started probably the first pain and palliative clinic at a government hospital here. I had learnt about scoring pain and WHO guideline at the National Cancer Centre Singapore so I introduced the guideline at the unit and trained the doctors and nurses and volunteer who was posted there. After two years, I felt an audit would be useful to understand the effectiveness of the Pain and Palliative Clinic we started.
Materials and Methods: The hospital is a tertiary care hospital for cancer patients so patients came from all over the country with various malignancy about 72% came with confirmed diagnosis. Day care chemotherapy has 80 beds and those patients came to the pain and palliative unit for management of pain and other symptoms(1)
When a patient was referred to us we would take detailed history and score pain using a combined visual analogue score (VAS) card. then treated the patient using the WHO guideline, and before they left the clinic again we would score pain. So we had the pre and post pain score. We also maintained a register and assigned patient with a pain serial number. We had to do this after half hour to forty-five minutes because most of them stayed far and needed to go soon after their day care chemotherapy or follow up. We maintained a range of time as often one sister would score and by the time she attended was not possible to maintain exact time. I was at NICRH regular till December 2008; now I only go there on call. I was keen to find out how this scoring is being carried out at the clinic.
To understand if a health initiative is working well we do need to introduce a method of quality assurance such as audit. Clinical audit is a quality improvement process(1) And my aim was to do an audit in order to help improve the quality of service and care at the unit.
Audit statement: "90% of patients were scored for pain, before and after 30-45mn of receiving the treatment at the pain and palliative clinic at NICRH"
The following diagram shows the Audit cycle
Audit standards: Standard 1: 90% of the patients arriving at the clinic have their Pain scored before treatment and documented in the register.
Standard 2: 90% of the patients have their follow up Pain Score after the treatment and documented in the register.
First standard is kept at 90% as I assume some of the patients maybe missed due to rush hour especially on the first(Sunday) and last day (Thursday) of the week. This is a trend that I have noticed this while working at the centre.
The second standard is kept to see if we are doing the follow up after 30 to 45 minutes after the treatment. It is not the ideal time but we are forced to keep it within this period as these patients leave the clinic soon after; they usually come for day-care chemotherapy or oncology follow-up, need to leave for home soon as they often live far and outside the city, often in another district (which is minimum three to eight hours journey).
I have assumed approximately 90% of patients will be scored for pain using the visual analogue card. This 10% left out because some patients I have noticed require immediate hospitalisation and they are taken to the wards so its is not possible to score their pain or follow them up always. I also thought staff may just miss scoring some due to time constrain.
After setting standards I needed to go back and observe the practice. Which we did in few stages. Initially spoke to the head of the department; we realised that this was a reason for concern, when I said we will conduct an audit, there was apprehension; the reason for this is that we are not used to doing audit for our service here; so I discussed that this is an exercise to understand and improve our service. Then I sat with our team including the doctors, nurses, volunteer at the clinic. I also discussed that we will again sit and discuss the result.
I was following the audit cycle and stages, so I chose the register as the standard format to collect data [Figure 1]. I decided to look at 100 patients from March 31 st backwards and wanted to see how many of them had pain score done before and after treatment as stated in my standards My assumption was that it will be approximately 90%.Pain score was analysed in 2008 and a 10 month report showed that average pain score was 8.5 which is severe pain. and after 30 -to 45minutes it came down to 3.5 on an average(4) [Figure 2].
So this was an important aspect of justifying existence of dedicated staff at the clinic and looking at pain and scoring pain and of course using WHO guideline as the basic guideline for cancer pain management.(5)
Reaudit: To keep things simple we decided to have two more standards for our reaudit Without a reaudit the audit cycle would not be complete and the purpose if the audit remains unfulfilled. Since we look to improve the service I wanted to also include new standards and conduct a re-audit. I will call these standard 4 and 5
Standard 4 98% patints telephone will be documented
Standard 5 98% patients will be followed up after 24 hours either they will call or nurse will call.
Result: We checked the register where the patient details are documented and pain score is also documented.
Among the 100 patients we noted that there were 52 male and 48 female patients, The average pain score was 6 out of 10 which is two points less than the average estimate before(6.6) with the previous finding in 2008. Probably the WHO pain ladder concept has The patients mostly came with diagnosis of lung cancer. Female patients with cervical and head and neck cancer.
Pain score documented was found to be in 98% of cases in both before and after the treatment.
At the follow up, I found that almost 99% of the patients mobile numbers or their caregivers mobile number was documented. Which was encouraging. But the follow up call was not made due to lack of human resource allocated for such job -the nurse who was trained in palliative care (6wks training) was posted at Pain Clinic during the first audit but got transferred to another unit, also the absence of logistic support (no mobiles with connection fee paid),so calls were not made.
Conclusion: It is argued if audit is relevant in developing country like ours? Feel after conducting this simple audit it is absolutely essential and a cost effective way to improve our health service. Measuring outcome of care and evaluation is not new Florence Nightingale is known as one of the pioneers in clinical audit (6) today we have to be more accountable to the population we look after palliative care is growing rapidly all over the world its changed image of evidenced based medicine is supported by setting standards and incorporating good practice such as conducting audit. It was a useful and great learning experience, the simplicity and importance of an audit was never more clear.
National Institute of Cancer Research Hospital: Hospital Cancer Registry; Annual Report 2005.
Available from: http://www.clinicalauditsupport.com [Last accessed on 2009 May 9].
Available from: http://www.evidence-based-medicine.co.uk [Last accessed on 2009 May 9].
Dowla R, Akhter S. "Pain and Palliative Care unit at NICRH -10 month report. published abstract at Kochipallcon Kerala,India. 2008.
Available from: http://www.who.medicines/areas/quality_safety/delphi_study_pain_guidelines.pdf[Last accessed on 2010 May].
Available from: http://www.nice.org.uk/usingguidance/implementationtools/auditadvice [Last accessed on 2009
May 10]. PD 22
PD 22 (Poster session)
Specialised nursing care for chronic oedema management in indian setting
Rosemund, Shakila Murali, Leema Mathew, Somnath Dey
Christian Medical College Vellore, Tamil Nadu, India.
Objective: To investigate the impact of complex decongestive physiotherapy for management of patient with different stages of chronic lymphoedema.
Method: The basic conservative therapy is constituted by manual lymphatic drainage, compression garments and compression bandages using short stretch material, physical exercises (diaphragmatic breathing, range of movement exercise), skin care and personal hygiene. The clinical features, teaching techniques and patient feedback on oedema management will be outlined.
Setting: An outpatient palliative care clinic in a tertiary hospital
Participants: Patient with lympoedema with due to malignancy, vascular causes and chronic illness.
Conclusion: Chronic oedema is a common public problem. It is possible to empower primary care givers in the domiciliary management of oedema.
PD 23 (Poster session)
Screening for depression among elderly in a tertiary care hospital
Barathi B, Betsy Mathew
Department of Pain and Palliative Care, St. John's Medical College Hospital, Bangalore, India. E-mail: firstname.lastname@example.org
Introduction: Depression is a common psychological problem in elderly. Elderly are more prone to depression due to multiple medical and psychosocial problems.
Aim: To screen for depression in elderly patients in acute medical wards at a tertiary level teaching hospital in Bangalore.
Materials and Methods: This was a Descriptive study done in a tertiary level teaching hospital in Bangalore in July - August 2010 among 60 elderly patients aged above 60 years admitted in the acute medical wards. Geriatric depression scale (short form -15) which is a well validated tool in detecting depression in elderly was used to screen for depression among these patients after obtaining an informed consent. Patients who were unable to comprehend were excluded.
Results and Conclusions : Depression was seen 63.3% of the subjects studied; female gender, unemployed and those admitted for more than three days screened positive for depression. There is a need to screen for depression in these patients at various levels of care to detect and treat hidden depression early.
PD 24 (Poster session)
An overview of the palliative care unit at the outset of centenary year of a radiotherapy department
Samrat Dutta, Chatterjee Subrata, Sarkar Shyamal
Palliative Care Unit, Radiotherapy Department, Medical College and Hospital, E-mail: email@example.com
Introduction: Radiotherapy Department of Medical College and Hospital,Kolkata is one of the oldest ones in the country celebrating the centenary year in 2010 and rendering service in cancer care to almost 36,000 patients every year. However among all the cases registered almost 80% cases present in an advanced stage for whom palliative care is essential.
Aims and Objectives: To analyse and review the work done in last 05 years with the aim of improving the care in future to the vast population of end stage cancer patients in West Bengal.
Materials and Methods: The data of last 5 years was analysed using SPSS version 12 and measures of central tendency.
Results: Out of total 184 cases registered, the average number of new cases registered per year was 45, M:F ratio was 1:1.3. Majority of the cases are of head and neck with a trend of increase in this subset of patients by 14%. An alarming rise by 29% of lung cancer cases needing palliative care is also noted. Morphine requirement has also change a trend of increase by 17%. Other services like lymphoedema care,fungating wound care, nutritional support and psychological support is also given to patients.
Conclusion: The study shows an increasing number of palliative care cases in Head and neck and lung cancer and with the incorporation of the certificate course of palliative care training under IAPC the unit looks forward to improve its care more in future.
PD 25 (Poster session)
Pal-onc clinic - Bangalore Baptist hospital
Macaden Stanley C, Livingstone Ravi, Benjamin Santosh, Chandy Abraham, Naveen Thomas, Jacob Saro, Sashikala Prasad, Ruby Ruth Evangeline, Vinayshree Palekar, Nirmala S 1 , Subramanium Murali 1 , Vinoda Dinakaran 2
Department of Physician and Head of Palliative Care, Bangalore Baptist Hospital, Bangalore, 1 Consultant Radiation Oncologist, M.S. Ramaiah Memorial Hospital, Bangalore, 2 Church of South India (CSI) Hospital, Bangalore, India. E-mail: firstname.lastname@example.org
According to WHO, Palliative care is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life.(1) However patients are often referred late and are unable to benefit much due to the short period of support through palliative care. Though an ideal period of palliative care service could be 3 - 6 months, according to the National Hospice and Palliative Care Organization, USA, only half of hospice patients in the USA today get palliative care for less than 3 weeks.(2) Early referral and involvement are necessary to make palliative care available to improve quality of life. To achieve this objective a unique combined clinic called the
Pal-Onc clinic was initiated at the Bangalore Baptist Hospital from 2001 through its palliative care programme.
Through this poster presentation we share our experience of organizing and conducting this service over the past nine years.
A combined clinic helps to bring in palliative care and support early in the time frame available. It is very convenient and reassuring for the patient and family. It helps to achieve patient care goals quickly by better coordination of care through various professionals involved. It helps to provide balance between over treating and not treating and encourages care which is appropriate for the individual and family. It improves team work and serves as a good educator for all involved. It is a good model of networking among health professionals to provide effective palliative care.
1. Available from: http://www.who.int/cancer/palliative/definition/en/ [Last accessed on 2010].
2. Available from: http://www.nhpco.org/files/public/Statistics_Research/Hospice_Facts_Figures_Oct-2010.pdf [Last accessed on 2010].
PD 26 (Poster session)
Palliative care networking in a teaching tertiary care hospital
Shoba Nair, B Barathi, Thiophin Regina Mary, Lovely Mathew
St. John's Medical College Hospital, Bangalore, India.
Introduction: Palliative Care is a nascent specialty, even after two decades of its introduction in India. Our institution, St. John's Medical College Hospital Bangalore is a teaching institution. It is all the more important that Palliative Medicine finds it's place as a specialty in a teaching institution. Networking between different specialties in the hospital is very essential for the growth of the specialty.
Materials and Methods: Retrospective analysis of the patient records since the inception of Palliative care in our institution. Correlating the patient data with networking initiatives like introductory lectures in various departments in the institution and outside the institution, training programmes for doctors, nurses and volunteers, public awareness programmes in the hospital and initiation of new services like palliative Care in HIV and Geriatrics. Descriptive statistics is used to analyze the data.
Results: A year wise analysis of patient data for both malignant and non-malignant diseases clearly indicate that the number of patients that avail the service increased over the years. Over the past few years the number of patients has increased at a faster rate when compared to previous years. This can be co-related to the various lectures that we have given in other departments and also the initiation of various courses like the IAPC course - Essentials in Palliative Care, Palliative Care in HIV, Volunteer training programmes and initiation of new services like Palliative Care in HIV and Geriatrics.
Conclusions: Networking with different departments in our institution and outside has helped Palliative Care to grow as a specialty in our institution. More doctors and nurses in our institution look at Palliative care as a specialized area and are keen to have our team's in-puts in the management of patients. Networking should not be looked at as a one off procedure. It should be continuous and sustained. Lot more needs to be done to establish Palliative Care as a recognized specialty in our country.
PD 27 (Poster session)
Pattern of referral of patients to palliative care unit in Dr B Borooah Cancer Institute (Rcc), Guwahati
Bhagabati Kabindra, Arun Deka, Dwipen Kalita
B Borooah Cancer Institute
Aims and Objectives: WHO emphasizes on Palliative Care should begin at the time of cancer diagnosis and should cover all four cardinal aspects of care. But, in actual practice, it is seen that most of the patients are referred to a palliative care unit at the terminal stage only. This study is to ascertain when and why the patients are being referred to palliative care unit in Dr. B. Borooah Cancer Institute.
Materials and Methods: A retrospective study of patients referred to Palliative Care Unit for a period of six months. All patients included irrespective of referring departments, diagnosis and stage. Patients were investigated for the time of referral - 1 st visit, 2 nd visit, subsequent visits or in terminal stage and for reasons of referral - pain, other symptoms, psychological & social care and comprehensive palliative care.
Results: A total number of 1517 patients referred for palliative care from 1 st July to 31 st December, 2010. Number of patients referred from various departments - Surgical Oncology - 455 (30%), Head and Neck Oncology - 364 (24%), Gynaecological Oncology - 136 (9%), Med Oncology - 334 (22%), Radiation Oncology - 228 (15%). On average, 48% of patients were referred to palliative care unit on diagnosis, 29% referred during definitive treatment phase and 23% at terminal stage. Reasons for referral - pain 41%, associated symptoms 7%, psychological and social support 10% and comprehensive palliative care 42%.
Conclusion: Findings show that patients in BBCI (RCC) are referred mostly at the time of diagnosis and during definitive treatment phase rather than at the terminal phase.
PD 28 (Poster session)
Alternative therapy to improve quality of life after chemotherapy
Babita Mohanty, Mani Jena, T Nayak, Rekha Das,
S Nayak, M B Nayak, P K Nayak
Reg. Cancer Center, Cuttack Orissa, India.
Background: chemotherapy produces nausea, vomiting, Severe pain in the abdomen, Weakness, Loss of weight, Xerostomia, loss of appetite and taste, Loss of hair, Anxiety and depression, Emotional and spiritual distress, Psychological distress causing a significant impact on QOL. Use of complementary therapies has increased in recent years.(1)
Objectives: Our double blind study compared control arm and study arm patients receiving yoga pre/post chemotherapy and identified factors including prior belief in treatment effectiveness. Anulom Bilom (AB) or alternate nostril breathing is an ancient practice of aerating and energizing the tissues by deep inhalation, visualizing energy flowing throughout the body. It is for the purpose of inhaling prana, or life energy, and exhaling negative energies.(2)
Done correctly, AB is safe and beneficial. A steady, slow, cleansing inhalation removes the old energy, "toxins," etc. The process is slowly repeated over and over, with rhythmic, steady, and full inhalation and exhalation(3) as with much of yogic practice, the concept of energy medicine does not always translate to Western medicine.
Materials and Methods: stratified random sample of 400 inpatients with Cancer Stomach receiving chemotherapy in our regional cancer hospital were divided into two groups. Group A received AB for 30 minutes b.i.d. in empty stomach for at least 5 hours. The patients were instructed to take deep inspiration for 15 secs, breath holding for 5 secs, followed by slow and full expiration for 15 secs. Those who could not do it with 15sec inspiratory cycles were told to start with 5 sec inspiratory cycle and gradually increase it to 15 sec inspiratory cycle in a phased manner. Group B did not receive any alternative therapy. They practiced AB for 2 weeks before the scheduled chemotherapy. Standard CT was given to all cases.
Observation: Pulse, BP, Oxygen saturation was recorded during AB. Incidences of nausea, vomiting, alopecia was recorded in both groups 1 week, 2 week and 4 weeks after CT.
Results: Statistically significant (P value <0.001) decrease (52%) in nausea, 24% in vomiting 56% decrease in alopecia was recorded in Group A. The corresponding value in Group B was 78%, 82% and 80%.
Conclusions: AB has a promising role to improve QOL in chemotherapy, but needs further study.
1. Barrie Cassileth; Marjet Heitzer; Jyothirmai Gubili, Integrative Oncology: Complementary Therapies in Cancer Care,; Cancer Chemother Rev.2008;3(4):204-211.
2. PermanyerRamacharaka Y. Science of Breath.Chicago,Illinois: Yogi Publication Society;1904:12-38
3. Silva M, Mehta S. Yoga, the Iyengar Way. New York: Alfred A. Knopf;1992:155-163.
PD 29 (Poster session)
The role of iapc0 certificate course in improving nurses' communication outcome in a cancer patients' interview
Mani Jena, Basanti Panda, Babita Mohanty, Sumita Mohanty, Sukdev Nayak
Reg. Cancer Center, Cuttack Orissa, India.
Background : Previously there was lack of proper palliative care education for nurses. Many problems also arise because of lack of communication between the patient and the Nurses. This communication gap leads to many misunderstandings and comes in the way of proper nursing care. IAPC course is a basic certificate course for the nurses/doctors. This is a course of for two months. It only gives the basic working knowledge regarding advanced cancer patients who needs palliative care.
Materials and Methods: Before taking the course our nurses' team (group A) took an interview with the patients and counseled them. The same nurses took the IAPC certificate course and exam. During the certificate course they were required to write a Case reflection(of a particular cancer patient). They also did Literature Reading to substantiate their findings. They also conducted guided patient counseling in presence of IAPC faculty. Besides they attended educational programme in our hospital and outside cancer hospital. 5 nurses of the same group empowered by the certificate course again conducted the patient interview and counseled the same patients during their follow up visits
Observation: Patients' satisfaction was evaluated by a third party of counselors by asking the patients a set of structured questionnaire.
Results: Patient satisfaction was less than 30% due to the poor communication and lack of proper education of nurses' team.
But after completion of the IAPC certificate exam the same nurses performed well as judged by the same patients in their subsequent hospital visit.
patient satisfaction was definitely higher in the group B 65% who were empowered by the training programme and all other positive activities mentioned in the "Methods ".
Conclusion: IAPC course is definitely helpful to empower the nurses. The patients' satisfaction in advanced cancer case is increased. The feeling of empowerment, value and recognition of the nurses also improved after the IAPC exam.
PD 30 (Poster session)
Softening the pain of fungating wounds
Basanti Panda, Babita Mohanty, Mani Jena, Manjula Nayak, Sukdev Nayak
Reg. Cancer Center, Cuttack Orissa, India.
Introduction: There are different varieties of wounds in cancer of which fungating wounds are a common problems. It requires comprehensive nursing care with complex management & choosing consider a wound care regimen like pain, exudates, necrotic tissue, bleeding, odour infection, comfort, patient lifestyle & Psychological support.
Objectives: Relieving physical pain of fungating wounds by simple homemade principles was the primary objectives.
Secondary objectives were Promotion of comfort and Enhancement of quality of life
Materials and Methods: Warm saline irrigation, Application of honey, Packing with newspaper flakes, Avoid frequent changes of dressing. However pressure dressing was used in case of bleeding. Metronidazole (250mg) crushed tabs were applied to the Lesion to reduce odour and nonsporing anaerobes. The pain and bleeding during dressing changes is minimized using autoclaved alum. The lesion is covered with cotton cloth sterilized by hot ironing.
All the above procedures were demonstrated by our team. The family members were encouraged to practice in our presence. Once they were confident of doing it confidently, they were discharged to do it at their home.
Observation: Another team evaluated the pain, swelling, exudates, bleeding, infection and fungation during their second visit to our hospital. Patient's satisfaction was recorded in percentage for educated patient and rupees scale in uneducated patients.
Results: Pain relieved - 70%, Swelling-20%, Exudate -80%, Bleeding-70%, Fungation-80%
Conclusion: Homemade wound care with warm saline, honey, newspaper flakes helped to control relieving physical pain, smell, exudates, bleeding, infection and fungation. In most of cancer patient satisfaction was 60% in educated patients and 90% in uneducated patients. The concept was accepted without any inhibition in patients from poorer strata of the society. But our team explain resistance from some of the educated patients from relatively higher socio economic back ground.