Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0973-1075.150199
Source of Support: None, Conflict of Interest: None
Smartphone applications in healthcare delivery are a novel concept and is rapidly gaining ground in all fields of medicine. The modes of e-communications such as e-mail, short message service (SMS), multimedia messaging service (MMS) and WhatsApp in palliative care provides a means for quick tele-consultation, information sharing, cuts the waiting time and facilitates initiation of the treatment at the earliest. It also forms a means of communication with local general practitioner and local health care provider such that continuity of the care is maintained. It also minimizes needless transport of the patient to hospital, prevents needless hospitalization and investigations and minimizes cost and logistics involved in the care process. The two case studies provided highlights the use of smartphone application like WhatsApp in palliative care practice and demonstrates its utility.
Keywords: Continuity of care, Palliative homecare, Smartphone applications
Over the last few years use of short message services (SMS) and smartphone-based communication applications in health care has shown its wide application and potential to improve access to health care; enhance efficiency of service delivery; improve diagnosis, facilitate timely treatment and support public health programmes. ,,, This effective means of communication is providing timely and accurate results to the correct recipient, safeguarding their privacy and confidentiality and avoids misunderstanding and misinterpretation of the results. There are various uses of mobile phone message services and smartphone-based communication applications such as: Appointment remainders;  to monitor chronic medical conditions; ,,, to improve treatment compliance; , to provide psychological support; , managing communicable diseases via contact tracing and partner notification for sexually transmitted illnesses , and to promote health promotion programs like smoking cessation. ,
Tata Memorial Hospital uses many modes of health related e-communications such as web based electronic medical records (EMR) where patients and families can access their medical records, blood investigations, scans and all patient-related information using an individual patient login key and password. This information can be accessed at home or any other remote setting using a computer or smartphone. The other modes of e-communications used are e-mail, short message service (SMS), multimedia messaging service (MMS) and WhatsApp (text, pictures, and video). Although these applications are not substitute for face-to-face interview and clinical examination, in most of the situations especially in palliative care setting it minimizes needless transport of the patient, cost and logistics involved. It also provides a means for quick information sharing, cuts the waiting time and facilitates initiation of the treatment at the earliest. It also forms a means of communication with local general practitioner and local health care provider such that continuity of the care is maintained. 
A 60-year-old pleasant lady, widow, high school educated, who is known to have Type 2 Diabetes Mellitus, Ischemic Heart Disease, and Metastatic Carcinoma Breast with nodal and skeletal metastasis was referred to Palliative Medicine for symptom control and supportive care.
During her initial outpatient visit to Palliative Medicine department she had 8/10 somatic nociceptive pain over spine and ribs, extreme fatigue, anorexia and had an Eastern Cooperative Oncology Group (ECOG) of 4. Her mobility was impaired due to severe pain and spine metastasis, which had a great impact on her activity of daily living. Initial symptom control and supportive care measures were instituted and she was referred to palliative home care services where she was triaged as priority 1 (scheduled home visit within 3 days). The homecare services are coded as High (01), Medium (02) and Low (03) priority. In High priority, patients received home visit in 0-3 working days, Medium priority, in 0-10 working days and Low priority, in 0-15 working days. She was on Step 1 Non-steroidal Anti-inflammatory Drugs (NSAIDs) + Step 3 (Transdermal Fentanyl) + Adjuvant (Pregabalin) analgesics for pain.
She had two daughters both married and settled overseas. The immediate caregivers were distant relatives staying close to her house and visiting her daily. Her niece, who is a practicing dermatologist, was facilitating her ongoing medical care. Patient was fully aware of the diagnosis and prognosis, and maintained a positive outlook toward illness and life.
She was on a regular follow-up with palliative home care and over next few weeks on a weekend she developed diplopia and painful weakness of the right upper limb. Information of her illness was shared with the palliative home care doctors by her niece via text messages, patient pictures and a video through WhatsApp. The doctor reviewing these e-communications requested for an urgent MR Brain and Plain X-ray of right shoulder. The photos of the reports were sent to palliative home care doctor via WhatsApp. MR brain was suggestive of base of brain disease with leptomeningeal and skull base involvement. Plain X-ray of right shoulder was suggestive of pathological fracture. Scanned copy of the MR and X-ray reports were sent to the local general practitioner and management plan for raised intracranial tension and pathological fracture was communicated. Priority 1 home visit was rescheduled. In the interim patient had developed deranged renal functions, hyponatremia and fluctuating blood sugars. Patient's daughters who returned to see her mother was in constant touch with the palliative home care doctors through call and text. They frequently use to send patient's pictures and reports and occasionally patient videos via WhatsApp and on call palliative homecare doctor was able to provide after-hours consultation. The timely symptom management improved the quality of life of the patient and caregivers were very satisfied by the support they received. Her analgesic doses and complications (seizures, aspiration pneumonitis) were managed at home with the help of local general practitioner support with continued input from palliative home care. With this process needless hospitalization was deferred and patient received quality home-based palliative care. She died peacefully at home with symptoms well controlled. The total duration of home based palliative care contact was 54 days. We felt smartphone applications played a crucial role in providing timely and continued palliative care input.
A 64-year-old gentleman, known hypertensive, having advanced stage of adenocarcinoma of stomach with peritoneal metastasis, bilateral pleural effusion, and ascites was referred to Department of Palliative Medicine for symptom control and ongoing supportive care. Ascites needed paracentesis to relieve dyspnea and patient was maintained on oral Frusemide/Spironolactone combination for both ascites and edema. He was initiated on oral Tramadol 50 mg every 8 th hourly for pain. The daughter was counseled and poor prognosis of the patient was discussed.
As per patient's wishes, patient was cared at home. The patient's wife and daughter was the primary caregiver. The wife was elderly, not literate and had poor perspective of illness or care process. The son was a young adult who studied and worked simultaneously and had little involvement in the care process. The daughter was married and has an 18-month-old child and resided in a different place. She was the major support and was main portal for communication between palliative home care team and family. She used WhatsApp to send text messages, patient images and patient videos to the team. The team worked in close liaison with the family physician, which helped in maintaining the continuity of care.
Patient had a sudden worsening of clinical condition due to malignant bowel obstruction and also developed acute renal failure secondary to obstructive uropathy. In accordance to patient's wishes and preferences, patient was managed at home with IV hydration, nasogastric tube, anti-secretory drugs, transdermal Fentanyl and IV steroids. Progress of management was monitored through continuous exchange of images and videos through WhatsApp and symptom control was assessed through direct patient interview via video chat. This process complemented the homecare provided and enabled the daughter to balance her time both at work and home.
Patient died peacefully at home and the total duration of home-based palliative care contact was 39 days. Bereavement follow-up showed patient's family was coping well and were pleased with the care provided.
Moribund patients with advanced life-limiting illness can receive continued care at home with the help of collaborative and ongoing support from the palliative home care team and local family physician. Audio-visual communications aided through smart phone applications can improve this facilitation. Using applications like WhatsApp messenger, which allows the user to share clinical images, clinical video, photograph of reports, photograph of medications and text messages can bring palliative home care management to a new level by enhancing the channels of communication between patient, palliative care doctor, caregiver and local family physician. This technology is useful in palliative care for the patients lacking access to medical services due to both debilitating medical condition and geographic isolation. A study done by Coyle et al. demonstrated certain benefits such as limited need for daily physical examination and assessment, screening for a need for a clinical visit or admission, communication assistance to patients who cannot speak or hear and increased satisfaction by the patient and the caregivers.  In a palliative care setting it also decreases monetary burden on caregiver as it saves the cost of travel and consultations and prevents unnecessary hospital admission and investigations.
The current smartphone applications like WhatsApp messenger is much cheaper and easily available when compared to the teleconferencing systems. The most teleconferencing solutions pertain to the transfer of electronic medical data from one institution to another, only a small percentage of such programs can be applied to home health care. It is a worldwide phenomenon to incorporate the newer technologies into the field of health and social care, even though there is lack of evidence to support this. 
The rapid development, adoption and use of various smartphone applications also present with crucial challenges for clinicians and users. The important challenges are to ensure patient confidentiality, safety, establish cost-effectiveness and engage patients and clinicians to optimize their use in health decision-making. Although healthcare and academic institutions should support the improvements offered by technological advances, they must do it within a supervised framework, after thoroughly evaluating clinical outcomes and unintended consequences. Challenges in using mobile phone applications in health care also include incomplete coverage of mobile networks across regions, lack of standards, and possible information overload. 
At present we have a mobile user society and the worldwide deployment of mobile and wireless networks and the wireless infrastructure in health care is able to provide healthcare to anyone, anytime, and anywhere without constraints of location or time. It's application in palliative home care has demonstrated significant improvement in control of physical symptoms, address non-physical issues and improves patient satisfaction. Special attention needs to be given to its potential benefits and challenges in palliative care and certainly its open a new area of research in palliative care.