Indian Journal of Palliative Care
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January-March 2018
Volume 24 | Issue 1
Supplement Issue is live here
Page Nos. 1-122

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EDITORIAL  

Reflective practice in palliative care Highly accessed article p. 1
Naveen Salins
DOI:10.4103/IJPC.IJPC_211_17  
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ORIGINAL ARTICLES Top

Rural palliative care in North India: Rapid evaluation of a program using a realist mixed method approach Highly accessed article p. 3
Daniel F Munday, Erna Haraldsdottir, Manju Manak, Ann Thyle, Cathy M Ratcliff
DOI:10.4103/IJPC.IJPC_139_17  
Context: Palliative care has not developed widely in rural North India. Since 2010, the Emmanuel Hospitals Association (EHA) has been developing a model of palliative care appropriate for this setting, based on teams undertaking home visits with the backup of outpatient and inpatient services. A project to further develop the model operated from 2012 to 2015 supported by funding from the UK. Aims: This study aims to evaluate the EHA palliative care project. Settings and Design: Rapid evaluation method using a mixed method realist approach at the five project hospital sites. Methods: An overview of the project was obtained by analyzing project documents and key informant interviews. Questionnaire data from each hospital were collected, followed by interviews with staff, patients, and relatives and observations of home visits and other activities at each site. Analysis: Descriptive analysis of quantitative and thematic analysis of qualitative data was undertaken. Each site was measured against the Indian Minimum Standards Tool for Palliative Care (IMSTPC). Results: Each team followed the EHA model, with local modifications. Services were nurse led with medical support. Eighty percent of patients had cancer. Staff demonstrated good palliative care skills and patients and families appreciated the care. Most essential IMSTPC markers were achieved but morphine licenses were available to only two teams. Remarkable synergy was emerging between palliative care and community health. Hospitals planned to fund palliative care through income from surgical services. Conclusions: Excellent palliative care appropriate for rural north India is delivered through the EHA model. It could be extended to other similar sites.
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Is every life worth saving: Does religion and religious beliefs influence paramedic's end-of-life decision-making? A prospective questionnaire-based investigation p. 9
Alexander Leibold, Christoph L Lassen, Nicole Lindenberg, Bernhard M Graf, Christoph HR Wiese
DOI:10.4103/IJPC.IJPC_128_17  
Background: Paramedics, arriving on emergency cases first, have to make end-of-life decisions almost on a daily basis. Faith shapes attitudes toward the meaning and worth of life itself and therefore influences decision-making. Objective: The objective of this study was to detect whether or not religious and spiritual beliefs influence paramedics in their workday life concerning end-of-life decisions, and whether it is legally possible for them to act according to their conscience. Methods and Design: This is a literature review of prior surveys on the topic using five key words and questionnaire-based investigation using a self-administered online survey instrument. Settings/Participants: Paramedics all over Germany were given the opportunity to participate in this online questionnaire-based study. Measurements: Two databases were searched for prior studies for literature review. Participants were asked about their religiosity, how it affects their work, especially in end-of-life situations, how experienced they are, and whether or not they have any legal latitude to withhold resuscitation. Results: A total of 429 paramedics answered the questionnaire. Religious paramedics would rather hospitalize a patient holding an advance directive than leave him/her at home (P = 0.036) and think death is less a part of life than the nonreligious (P = 0.001). Otherwise, the Spearman's rho correlation was statistically insignificant for all tests regarding resuscitation. Conclusions: The paramedic's religiosity is not the prime factor in his/her decision-making regarding resuscitation.
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Commentary p. 15
Abhijit Dam
DOI:10.4103/IJPC.IJPC_149_17  
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A retrospective study of end-of-life care decisions in the critically Ill in a surgical intensive care unit p. 17
Yi Lin Lee, Yee Yian Ong, Sze Ying Thong, Shin Yi Ng
DOI:10.4103/IJPC.IJPC_81_17  
Aim: Progress in medical care and technology has led to patients with more advanced illnesses being admitted to the Intensive Care Unit (ICU). The practice of approaching end-of-life (EOL) care decisions and limiting care is well documented in Western literature but unknown in Singapore. We performed a retrospective cohort study to describe the practice of EOL care in patients dying in a Singapore surgical ICU (SICU). The surgical critical care population was chosen as it is unique because surgeons are frequently involved in the EOL process. Methods: All consecutive patients aged 21 and above admitted to the SICU from July 2011 to March 2012, and who passed away in the ICU or within 7 days of discharge from the ICU (to account for transferred patients out of the ICU after end-of life care decisions were made and subsequently passed away) were included in the study. Results: There were 473 SICU admissions during this period, out of which 53 were included with a mean age of 67.2 ± 11.1 years. EOL discussions were held in 81.1% of patients with a median time from admission to first discussion at 1 day (IQR 0–2.75) and a median number of ICU discussion of 1 (IQR 1–2). As most patients lacked decision-making capacity (inability to retain and process information secondary to the underlying disease pathology or sedative use), a surrogate was involved: group decision in 27.9%, child in 25.6% and an unclear family nominated member in 20.9%. 28.3% of patients were managed as for full active with resuscitation, 39.6% nonescalation of care, and 32.1% for withdrawal. The main reasons for conservative management (nonescalation and withdrawal of care) were certain death in 52.3%, medical futility with minimal response to maximal care (27.3%), and the presence of underlying malignancy (18.2%). There was no significant difference between race or religion among patients for active or conservative management. Conclusion: 71.7% of patients who passed away in the ICU or within 7 days of discharge from the ICU were managed conservatively. More timely, EOL discussions and better advance care planning may be needed to improve our patient care for patients on conservative management.
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Patients with end-stage oncologic and nononcologic disease in emergency service of an Urban Tertiary Hospital Highly accessed article p. 25
Jose P Amado, Rolando Vasquez, Roberto W Huari, Andrea S Sucari, Teodoro J Oscanoa
DOI:10.4103/IJPC.IJPC_108_17  
Context: In the last decades, patients with chronic terminal diseases have had more frequent visits to emergency services. Aims: This study aims to determine the proportion of terminal illness in patients readmitted to emergency room, to evaluate the use of this service and rate of death. Settings and Design: A cross-sectional study in a tertiary hospital with 120 stretchers which annually reports 160 thousand attentions and 22 thousand admissions. Subjects and Methods: Included 18-year-old patients or older who were readmitted to emergency room. Patient and/or caregiver were interviewed; medical record was reviewed and made 1-year follow-up. Terminal cancer was determined by histologically confirmation in Stage IV and nononcologic terminal disease by total functional dependence (Katz index) or severe cognitive impairment (Pfeiffer questionnaire) in addition of advanced organ failure. Statistical Analysis Used: Fisher's exact and U of Mann–Whitney tests for two independent samples. Results: Ninety-two (26%) of 349 were readmissions; 29 (36.7%) of 79 evaluated patients were identifying with terminal disease. Eleven (38%) of them had cancer (genitourinary in 64%). Nononcologic terminal disease was identified in 18 cases (62%) (Neurodegenerative involvement in 50%). More frequent symptoms were dyspnea 41%, mental confusion 24%, and pain 21%. Terminal patients had 6.2 (standard deviation 8.2) emergency visits at last year, being admitted 48,6% of these visits. Six-month mortality rate was 73 and 61% in oncologic and nononcolgic patients, respectively (P < 0.05). Conclusions: End-stage disease is frequent in readmitted patients to emergency, more of nononcologic kind. These patients use frequently emergency service, with high mortality (more elevated in oncologic).
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Comparison of two intervention strategies on prevention of bedsores among the bedridden patients: A quasi experimental community-based trial p. 28
Sukhpal Kaur, Amarjeet Singh, Manoj K Tewari, Tejinder Kaur
DOI:10.4103/IJPC.IJPC_60_17  
Background: More than 80% of bedridden patients develop bedsores in home care settings. Training of informal caregivers can significantly affect the quality of care to these patients. Objective: The objective of this study is to compare the effectiveness of two caregiver training strategies on prevention of bedsores among bedridden patients. Methods: The study was carried out in Chandigarh. The study center was at PGIMER, Chandigarh. Seventy-eight bedridden patients being taken care in their homes were identified. These were randomly allocated into two groups. Group A received Prevention Package I, i.e., self-instruction Manual (SIM), training, and counseling. Group B received Prevention Package 2, i.e., only SIM. All these patients were followed up periodically for 1 year. During each follow-up, patients were observed for bedsore development. Braden scale was used to assess the risk factors of bedsores. Katz scale was used to evaluate the level of functional dependence of patients. Descriptive statistics was used to analyze the data. Results: The percentage reduction of number of patients at risk of bedsore development as per various domains of Braden Scale was more in Group A as compared to Group B on each successive visit. There was 100% improvement in mobility level in the patients who were totally dependent in both the groups. However, in moderately dependant patients, the improvement in mobility level was more (87%) in Group A as compared to Group B (75%). All the caregivers complied fully with instructions postintervention. Conclusion: Training of caregivers for the prevention of bedsores among the bedridden patients was effective in improving the practices of the caregivers and also in reducing the risk factors of bedsores. One-to-one training with SIM distribution yielded better results than the use of only SIM.
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Prevalence and severity of sleep disturbances among patients with early breast cancer p. 35
Rami Fakih, Mahmoud Rahal, Lara Hilal, Lana Hamieh, Mohammed Dany, Simone Karam, Latifa Shehab, Nagi S El Saghir, Arafat Tfayli, Ziad Salem, Hazem Assi, Sally Temraz, Ali Shamseddine, Deborah Mukherji
DOI:10.4103/IJPC.IJPC_137_17  
Context: Data regarding health-related quality of life in breast cancer patients in the Middle East are limited with fatigue and sleep disturbance being the most distressing symptoms reported by patients treated for early breast cancer. Aims: The aim of this study was to examine the prevalence and incidence of insomnia among patients with early-stage breast cancer patients treated with chemotherapy. Subjects and Methods: This was a prospective cohort study. We enrolled patients with stage I-III breast cancer patients treated with chemotherapy at the American University of Beirut Medical Center. At three different time points (prior to, during, and following chemotherapy), we assessed the severity of sleep disturbances using the Pittsburgh Sleep Quality Index and the Insomnia Severity Index. The Institution Review Board approved the study. Results: Fifty-two patients were recruited. There was a significant increase in sleep disturbances during chemotherapy which improved to below baseline levels on completion of therapy. Prior to chemotherapy, 36% of patients reported poor sleep versus 58% during chemotherapy. The percentage of patients reporting clinical insomnia rose from 11% pretreatment to 36% during chemotherapy reflecting a significant symptomatic burden that is poorly documented and managed in routine clinical practice. Conclusions: Patients with nonmetastatic breast cancer experience an increase in sleep disturbances during the treatment phase. Physicians should be aware of the need to routinely screen for sleep disturbance in breast cancer patients undergoing chemotherapy.
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Hypnotic intervention for unexplained dizziness in patients with advanced cancer: A preliminary retrospective observation study p. 39
Hideaki Hasuo, Kenji Kanbara, Mikihiko Fukunaga, Naoko Yunoki
DOI:10.4103/IJPC.IJPC_165_17  
Context: Patients with advanced cancer rarely complain of unexplained dizziness after excluding identifiable causes. Some patients become anxious because they attribute the dizziness to the progression of their cancer. We hypothesize that unexplained dizziness is associated with neck muscle hypertonicity, a noncancer-related secondary effect. However, most cases are associated with neck muscle hypertonicity, a noncancer-related secondary effect. Aims: We evaluated the usefulness of hypnotic intervention that made patients aware of the relation between dizziness and neck muscle hypertonicity through the experience of muscle relaxation and recognition of muscle tension. Settings and Design: Advanced cancer patients requiring palliative care with unexplained dizziness who received the intervention to induce neck muscle relaxation were retrospectively compared with patients who did not. Subjects and Methods: The severity of dizziness that was evaluated using a numeric rating scale and the intervention efficacy rate were compared between the hypnotic and nonhypnotic groups as the primary endpoints, 7 days after the start of the intervention. Secondary endpoints included the effect size based on dizziness handicap inventory (DHI) scores before and after the intervention, and changes in patients' awareness of the cause of dizziness. Results: The hypnotic intervention had a significantly greater efficacy rate (0.67, 95% confidence interval: 0.46–0.88) than the nonhypnotic intervention (0.26, 95% confidence interval: 0.08–0.44). DHI scores, especially on the emotional subscale, showed significant improvement after the intervention, and 71% of the patients were aware that neck muscle hypertonicity was the cause of dizziness. Conclusions: The rapid improvement in dizziness in the hypnotic group was considered to result from a change in patients' awareness of self-manageable neck muscle hypertonicity as the cause of dizziness.
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Prevalence and intensity of dyspnea in advanced cancer and its impact on quality of life p. 44
Anuja Damani, Arunangshu Ghoshal, Naveen Salins, Jayita Deodhar, MaryAnn Muckaden
DOI:10.4103/IJPC.IJPC_114_17  
Context: Dyspnea is a subjective, multidimensional experience of breathing discomfort, commonly seen in patients with advanced cancer. To find the impact of dyspnea on the quality of life in this population, it is important to understand the prevalence and factors influencing dyspnea. Aims: This study aimed to determine the prevalence, intensity, and factors influencing dyspnea in advanced cancer and determine its impact on overall quality of life. Settings and Design: This was a prospective cross-sectional study. The prevalence of dyspnea and its impact on quality of life was determined in 500 patients registered with palliative medicine outpatient department. Subjects and Methods: The patients were asked to fill a set of questionnaires, which included the Cancer Dyspnea Scale (translated and validated Hindi and Marathi versions), visual analog scale for dyspnea and EORTC QLQ C 15 PAL. Details of demographics, symptomatology, and medical data were collected from the case record sheets of the patients. Statistical Analysis Used: Descriptive statistics, univariate, and multiple regression analysis were used to calculate the results. Results: About 44.37% of the patients experienced dyspnea. Dyspnea increased with worsening anxiety, depression, fatigue, appetite, well-being, pain, lung involvement by primary or metastatic cancer, performance status, and deteriorating overall quality of life and emotional wellbeing. Conclusions: The prevalence of dyspnea in advanced cancer patients is as high as 44.37% and has a negative impact on their overall quality of life.
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Palliative care policy analysis in Iran: A conceptual model p. 51
Mojgan Ansari, Maryam Rassouli, Mohhamad Esmaiel Akbari, Abbas Abbaszadeh, Ali Akbarisari
DOI:10.4103/IJPC.IJPC_142_17  
Background: Palliative care programs are rapidly evolving for patients with life-threatening illnesses. Increased and earlier access for facilities is a subject of growing importance in health services, policy, and research. Aim: This study was conducted to explain stakeholders' perceptions of the factors affecting the design of such a palliative care system and its policy analysis. Methodology: Semi-structured in-depth interviews conducted following purposive sampling of the participants. Twenty-two participants were included in the study. The interviews were analyzed using qualitative-directed content analysis based on "policy analysis triangle" framework. Results: The findings showed the impact of four categories, namely context (political, social, and structural feasibility), content (target setting), process (attracting stakeholder participation, the standardization of care, and education management), and actors (the Ministry of Health and Medical Education, health-care providers, and volunteers) in the analysis of the palliative care policies of Iran. Conclusion: In the past 6 years, attention to palliative care has increased significantly as a result of the National Cancer Research Network with the support of the Ministry of Health. The success of health system plan requires great attention to its aspects of social, political, and executive feasibility. Careful management by policymakers of different stakeholders is vital to ensure support for any national plan, but this is challenging to achieve.
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Intranasal ketamine for the management of incidental pain during wound dressing in cancer patients: A pilot study p. 58
Nivedita Page, Vivek Nirabhawane
DOI:10.4103/IJPC.IJPC_143_17  
Introduction: Cancer wounds need regular dressing; else they develop infection, foul odor, and in extreme cases, maggots. Patients resist dressing due to the severe incidental pain during dressing. Intranasal ketamine was tried as an analgesic to reduce this incidental pain. Materials and Methods: Twenty patients with wounds requiring regular dressing were selected; these patients had a basal pain score of 4/10 and incidental pain score of 7/10 during four consecutive dressings. Ketamine 0.5 mg/kg was administered transmucosally 10 min before dressing, and pain scores, hemodynamic parameters, and sedation were recorded for up to 2 h in six consecutive dressings. Results: Ketamine produced a significant reduction in incidental pain without any hemodynamic changes or sedation. Conclusion: Ketamine appears to be a safe and effective analgesic when used intranasally for incidental pain.
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Benefit or Harm? A study on impact of collusion on the quality of life among palliative care patients p. 61
Anju Victor, Carolin Elizabeth George, Leeberk Raja Inbaraj, Gift Norman
DOI:10.4103/IJPC.IJPC_111_17  
Background: In India, roughly one-half of patients undergoing cancer treatment are unaware of their diagnosis or treatment. The intention of this study is to determine the prevalence of collusion and its influence on quality of life (QOL) among patients in palliative care settings. Methodology: A cross-sectional study was conducted among 100 palliative care patients to assess the extent of knowledge about their diagnosis and prognosis. The caretakers and the treating doctors were interviewed using a semi-structured questionnaire to assess if diagnosis was revealed to a patient. QOL of the patients was assessed using the European Organisation for Research and Treatment of Cancer QOL Questionnaire-C30 questionnaire. Results: The prevalence of collusion was 37%, i.e., in more than one-third of the palliative care patients; caregivers restrained doctors from disclosing the diagnosis. The prevalence of collusion was less among patients with higher educational qualification (P = 0.027) and professionals (P = 0.025). Collusion was not associated with gender, type of family, place of residence, and socioeconomic status (SES). In multivariate regression, collusion (odds ratio = 10.53) was independently associated with poor QOL when adjusted for age, gender, place of residence, religion, educational status, family type, and SES. Conclusion: Collusion is fairly prevalent and it worsens the QOL among cancer patients. Since the main driver for collusion is the strong desire among caregivers to protect the physical and psychological well-being, the findings of the study could motivate the caregiver for a more open and honest communication.
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Validation of malayalam version of national comprehensive cancer network distress thermometer and its feasibility in oncology patients p. 67
MS Biji, Sampada Dessai, N Sindhu, Sithara Aravind, B Satheesan
DOI:10.4103/IJPC.IJPC_160_17  
Context: This study was designed to translate and validate the National Comprehensive Cancer Network (NCCN) distress thermometer (DT) in regional language " Malayalam" and to see the feasibility of using it in our patients. Aims: (1) To translate and validate the NCCN DT. (2) To study the feasibility of using validated Malayalam translated DT in Malabar Cancer center. Settings and Design: This is a single-arm prospective observational study. The study was conducted at author's institution between December 8, 2015, and January 20, 2016 in the Department of Cancer Palliative Medicine. Materials and Methods: This was a prospective observational study carried out in two phases. In Phase 1, the linguistic validation of the NCCN DT was done. In Phase 2, the feasibility, face validity, and utility of the translated of NCCN DT in accordance with QQ-10 too was done. Statistical Analysis Used: SPSS version 16 (SPSS Inc. Released 2007. SPSS for Windows, Version 16.0. Chicago, SPSS Inc.) was used for analysis. Results: Ten patients were enrolled in Phase 2. The median age was 51.5 years and 40% of patients were male. All patients had completed at least basic education up to the primary level. The primary site of cancer was heterogeneous. The NCCN DT completion rate was 100%. The face validity, utility, reliability, and feasibility were 100%, 100%, 100%, and 90%, respectively. Conclusion: It can be concluded that the Malayalam validated DT has high face validity, utility, and it is feasible for its use.
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Assessment of psychological distress and its effect on quality of life and social functioning in cancer patients p. 72
Gunaseelan Karunanithi, Rapole Pragna Sagar, Aswin Joy, Parthasarathy Vedasoundaram
DOI:10.4103/IJPC.IJPC_104_17  
Purpose: The diagnosis of cancer and its treatment can make patients psychologically distressed. The purpose of this study is to evaluate the level of psychological distress and social functioning in cancer patients and to assess the association of these parameters with the quality of life (QOL) experienced by the patient. Patients and Methods: All cancer patients attending palliative care clinic who can understand and speak English or Tamil language were taken into the study. An interview technique with a questionnaire is used for data collection after informed consent. The questionnaire consisted of four sections, namely, demographic variables, general health questionnaire, WHO QOL-BREF, and SCARF social functioning index. All questionnaires were translated into the Tamil Language and were evaluated by the experts for content validity. Results: The median scores obtained are psychological distress = 44 (11–98), WHO QOL = 64 (36–117), and social function = 51 (29–79). Out of 251 patients, 30% had severe psychological distress, 25.6% had poor QOL, and 23.2% were with severely affected social function. Skilled laborers had better scores compared to unskilled laborers (P < 0.05). Family size (<2 children) had a positive impact on the QOL (P = 0.008). Patients from urban locales had better social functioning than rural counterpart (P = 0.047), but no difference was observed in distress level or QOL. Increased growth hormone distress score of the patients had a negative impact on both QOL (r = −0.522) and social function (r = −0.244). QOL correlated positively with social function (r = +0.247). Conclusion: Psychosocial stress associated with cancer and its treatment can impact the QOL and social functioning of the patient and needs to be addressed along with the cancer-directed therapy. Decreasing the symptom burden and distress level by palliative care intervention might improve the QOL and social function.
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"Personified as paragon of suffering...... Optimistic being of achieving normalcy:" A conceptual model derived from qualitative research p. 78
Shalini G Nayak, Mamatha Shivananda Pai, Linu Sara George
DOI:10.4103/IJPC.IJPC_140_17  
Background: Conceptual models developed through qualitative research are based on the unique experiences of suffering and individuals' adoptions of each participant. A wide array of problems are faced by head-and-neck cancer (HNC) patients due to disease pathology and treatment modalities which are sufficient to influence the quality of life (QOL). Men possess greater self-acceptance and are better equipped with intrapersonal strength to cope with stress and adequacy compared to women. Methodology: A qualitative phenomenology study was conducted among seven women suffering from HNC, with the objective to understand their experiences of suffering and to describe the phenomenon. Data were collected by face-to-face, in-depth, open-ended interviews. Data were analyzed using Open Code software (OPC 4.0) by following the steps of Colaizzi process. Results: The phenomenon that emerged out of the lived experiences of HNC women was "Personified as paragon of suffering.optimistic being of achieving normalcy," with five major themes and 13 subthemes. Conclusion: The conceptual model developed with the phenomenological approach is very specific to the women suffering from HNC, which will be contributing to develop strategies to improve the QOL of women.
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Anxiety and depression: A cross-sectional survey among parents of children with cancer p. 82
Azad Rahmani, Arman Azadi, Vahid Pakpour, Safieh Faghani, Ebrahim Ali Afsari
DOI:10.4103/IJPC.IJPC_141_17  
Context: Parents of children with cancer are experiencing high levels of psychological distress. Elevated levels of depression and anxiety following the disclosure of diagnosis affect many aspects of parents' health. Aims: The aim of this study was to assess anxiety and depression of parents of Iranian children with cancer. Settings and Design: This descriptive-correlational study was undertaken among 148 parents of children with cancer admitted to a pediatric hospital affiliated to Tabriz University of Medical Sciences, Tabriz/Iran. Subjects and Methods: Participants were selected using convenience sampling method. Hospital Anxiety and Depression Scale was used to evaluate patients' levels of anxiety and depression. Statistical Analysis Used: The data were analyzed using SPSS version 13.0. Results: The study findings showed that the mean anxiety and depression scores were 9.63 ± 3.69 and 8.66 ± 4.59 (range score: 0–21), respectively. Additionally, 41.2% (n = 61) and 32.4% (n = 48) of participants had clinical symptoms of anxiety and depression, respectively. Conclusions: Parents of children with cancer experienced high levels of anxiety and depression. Effective interventions are essential to improve the mental health of parents of children with cancer. These interventions may include mental health screening, psychological counseling, and training programs to cope with the problems caused by the child's disease.
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Effectiveness of the certificate course in essentials of palliative care program on the knowledge in palliative care among the participants: A cross-sectional interventional study p. 86
Sushma Bhatnagar, Anuradha Patel
DOI:10.4103/IJPC.IJPC_116_17  
Background: Palliative medicine is an upcoming new specialty aimed at relieving suffering, improving quality of life and comfort care. There are many challenges and barriers in providing palliative care to our patients. The major challenge is lack of knowledge, attitude and skills among health-care providers. Objectives: Evaluate the effectiveness of the certificate course in essentials of palliative care (CCEPC) program on the knowledge in palliative care among the participants. Subjects and Methods: All participants (n = 29) of the CCEPC at All India Institute of Medical Sciences, Delhi, giving consent for pretest and posttest were recruited in the study. This educational lecture of 15 h was presented to all the participants following pretest and participants were given same set of questionnaire to be filled as postintervention test. Results: In pretest, 7/29 (24.1%) had good knowledge which improved to 24/29 (82.8%) after the program. In pretest, 62.1% had average knowledge and only 13.8% had poor knowledge. There was also improvement in communication skills, symptom management, breaking bad news, and pain assessment after completion of the program. Conclusion: The CCEPC is an effective program and improving the knowledge level about palliative care among the participants. The participants should implement this knowledge and the skills in their day-to-day practice to improve the quality of life of patients.
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Aspiring pain practitioners in India: Assessing challenges and building opportunities p. 93
Sushma Bhatnagar, Anuradha Patel, Srinivasa N Raja
DOI:10.4103/IJPC.IJPC_148_17  
Background: Pain medicine is a developing specialty, aimed at relieving pain and suffering, enhancing function, and improving the quality of life of patients. Pain is often ignored, under-reported and mismanaged by health-care providers. Aspiring pain physicians in India face many challenges and barriers in advancing their specialty. Objectives: The objective of this study is to determine the challenges in establishing a pain practice in India and to discuss the opportunities and strategies to overcome these barriers. Subjects and Methods: Face-to-face interactive sessions were held with 60 aspiring pain physicians of India who were chosen as registrants to an International Association for the Study of Pain-Indian Society for Study of Pain multidisciplinary evidence-based pain management program conducted at Delhi and Mumbai. The available opportunities, practical issues and the hurdles in becoming a pain specialist were analyzed and summarized in this commentary. Results: The major barriers identified were: (1) Inadequate knowledge and absence of structured, educational and training courses, (2) bureaucratic hurdles, and (3) concerns of opioid misuse and addiction. The opportunities for personal growth and that of the specialty that could be utilized include the creation of a pain resource team, increasing community awareness, changing attitudes of other physicians toward pain specialty, and research and evidence building of the effectiveness of pain management strategies. Conclusion: India needs a structured teaching and training program in the area of pain medicine that is affiliated by the Medical Council of India or other reputed boards of medical education and certification. There is an urgent need to include pain management in the undergraduate and postgraduate medical curriculum. Enhancing community level awareness by public health education campaigns, developing networks of pain physicians, and appropriate marketing of the specialty is needed to make pain medicine recognized and utilized as a valuable specialty.
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Empowering nurses in providing palliative care to cancer patients: Action research study p. 98
Fariba Taleghani, Mohsen Shahriari, Nasrollah Alimohammadi
DOI:10.4103/IJPC.IJPC_64_17  
Background: Chronic diseases such as cancer would lead to various health needs in patients and their families. To meet needs, developing new educational nursing courses is necessary. Therefore this study was conducted to empower nurses through designing and conducting short-term educational courses for training palliative care nurses. Materials and Methods: This study was a community-based action research which was conducted at Isfahan hospitals that provide services for cancer patients during 2015 at four stages (planning, acting, reflection, and evaluation). Participants (33 samples) included nurses, head nurses, managers of nursing services, nursing professors and professors of oncology department. Data were gathered through individual and group interviews and analyzed using content analysis. Results: Data analysis resulted in 3 categories of "professional development of nursing in palliative care" which included subcategories of: knowledge-based performance and positive change in attitude, "obstacles to provide palliative care" with subcategories of: insufficient professional responsibility, insufficient ability in managing some of patients' symptoms and inappropriate interaction between nurses and physicians and "strategies for improving provision of palliative care" with subcategories of: improving the interactions between physicians and nurses, continuous trainings for palliative care and the necessity of developing palliative care in the country. Conclusions: To facilitate the process of providing palliative care to cancer patients, necessary actions and measures must be conducted including improvement of interaction between the members of health team, organizing continuing educational courses on palliative care and development of providing palliative care all over the country by managers of health centers.
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SYSTEMATIC REVIEW Top

Quality of Life of patients with chronic kidney disease in Iran: Systematic Review and Meta-analysis p. 104
Bahareh Ghiasi, Diana Sarokhani, Ali Hasanpour Dehkordi, Kourosh Sayehmiri, Mohammad Hossein Heidari
DOI:10.4103/IJPC.IJPC_146_17  
Introduction: Renal diseases are among the major health problems around the world that cause major changes in patients' lifestyle and affect their quality of lives. The aim of this study was to evaluate the quality of life of patients with chronic kidney disease (CKD) in Iran through a meta-analysis. Materials and Methods: This study was conducted using authentic Persian and English keywords in the national and international databases including IranMedex, SID, Magiran, IranDoc, Medlib, Science Direct, Pubmed, Scopus, Cochrane, Embase, Web of Science, and Medline. The data were analyzed using meta-analysis (random effects model). Heterogeneity of studies was assessed using I2 index. In this study, SF-36: 36-Item Short Form health-related quality of life (HRQOL), kidney disease quality of life-SF (KDQOL-SF), KDQOL and KDQOL-SFTM questionnaires were used. Data were analyzed using STATA Version 11 software. Results: A total of 17200 individuals participated in 45 reviewed studies, and the mean score of CKD patients' quality of life was estimated by SF-36 (60.31), HRQOL (60.51), and KDQOL-SF (50.37) questionnaires. In addition, meta-regression showed that the mean score of CKD patients' quality of life did not significantly decrease during the past years. Conclusion: The mean score of quality of life of patients with CKD was lower in different dimensions in comparison with that of normal people. Therefore, interventional measures should be taken to improve the quality of life of these patients in all dimensions.
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CASE REPORTS Top

Ultrasound-Guided real-time pterygopalatine block for analgesia in an oral cancer patient p. 112
Nishkarsh Gupta, Rohini Dattatri, Sachidanand Jee Bharati, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_150_17  
Oral cancers are one of the most common cancers in India. These patients have pain during the course of the disease. Various drugs including opioid and nonsteroidal anti-inflammatory drug have been used to manage pain. However, these are associated with side effects such as constipation and vomiting. An early interventional block may decrease the requirement for analgesics and improve the overall quality of life. We describe a case of oral carcinoma successfully managed with ultrasound-guided pterygopalatine block.
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Intravenous lignocaine infusion for intractable pain in Ewing's sarcoma p. 115
Nivedita Page
DOI:10.4103/IJPC.IJPC_125_17  
A 23-year-old female presented to our palliative care center with Ewing's sarcoma of the humerus with lung metastases. Pain in her arm was unrelieved by nonsteroidal anti-inflammatory drugs, neuropathic medication as well as morphine. She could not tolerate any further increase in opioid dose but was so distraught due to the pain that she wanted to die. An intravenous lignocaine infusion in a dose of 2 mg/kg was given over an hour for three successive days. This successfully relieved her pain after which she was settled with her original medication. We feel that in palliative care settings, where intractable pain and tolerance to morphine are so common, intravenous lignocaine infusions could provide a safe and effective tool for pain relief.
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LETTERS TO EDITOR Top

Beware! reduced functional capacity and quality of life with increased fatigue level among the breast cancer survivors undergoing chemotherapy in India p. 117
S Ramachandran, Selvaraj Sudhakar, Fousiya Thaslim, S Veena Kirthika, K Padmanabhan, Asir John Samuel
DOI:10.4103/IJPC.IJPC_170_17  
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Ziconotide: Indications, adverse effects, and limitations in managing refractory chronic pain p. 118
Abhijit S Nair, Anne Poornachand, Praveen Kumar Kodisharapu
DOI:10.4103/IJPC.IJPC_113_17  
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Volunteers in palliative care: An experience in South Australia p. 119
Chandragupta Pavaskar
DOI:10.4103/IJPC.IJPC_192_17  
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IAPCON 2017 CONFERENCE ABSTRACT Top

Use of analgesics in palliative care patients in Trivandrum rural areas p. 122

DOI:10.4103/0973-1075.223226  
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