Indian Journal of Palliative Care
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June 2020
Volume 26 | Issue 5 (Supplement)
Page Nos. 1-185

Online since Tuesday, June 30, 2020

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EDITORIAL COMMENTARY  

Palliative medicine in the era of COVID-19 pandemic Highly accessed article p. 1
Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_185_20  
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POSITION STATEMENT Top

Palliative care in coronavirus disease 2019 pandemic: Position statement of the Indian association of palliative care Highly accessed article p. 3
Anuja Damani, Arunangshu Ghoshal, Krithika Rao, Pankaj Singhai, Spandana Rayala, Seema Rao, KV Ganpathy, Nisha Krishnadasan, Lt Alice Stella Verginia (Retd. Army), Nandini Vallath, Gayatri Palat, Chitra Venkateshwaran, Jenifer Jeba S, Lulu Matthews, Stanley Macaden, Mary Ann Muckaden, Srinagesh Simha, Naveen Salins, Jeremy Johnson, Savita Butola, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_207_2  
The global pandemic involving severe acute respiratory syndrome–coronavirus-2 has brought new challenges to clinical practice and care in the provision of palliative care. This position statement of the Indian Association of Palliative Care (IAPC) represents the collective opinion of the experts chosen by the society and reports on the current situation based on recent scientific evidence. It purports to guide all health-care professionals caring for coronavirus disease 2019 (COVID-19) patients and recommends palliative care principles into government decisions and policies. The statement provides recommendations for palliative care for both adults and children with severe COVID-19 illness, cancer, and chronic end-stage organ impairment in the hospital, hospice, and home setting. Holistic care incorporating physical, psychological, social, and spiritual support for patients and their families together with recommendations on the rational use of personal protective equipment has been discussed in brief. Detailed information can be accessed freely from the website of the IAPC http://www.palliativecare.in/. We hope that this position statement will serve as a guiding light in these uncertain times.
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ORIGINAL ARTICLES Top

Responding to palliative care training needs in the coronavirus disease 2019 era: The context and process of developing and disseminating training resources and guidance for low- and middle-income countries from Kerala, South India Highly accessed article p. 8
Sunitha Daniel, Chitra Venkateswaran, Poornima Sunder, Shoba Nair, Rajashree K Chittazhathu, Athul Joseph Manuel, Biju Raghavan, Sunil Kumar M M, Vineetha Rijju, Geetha Vijay, Seema Rao, Anupama V Prabhu, Uma Parameswaran, Odette Spruijt, MR Rajagopal, Mhoira Leng
DOI:10.4103/IJPC.IJPC_131_20  
Background: Palliative care has an important role to play in the global coronavirus disease 2019 (COVID-19) pandemic. It is integrated and is a key component in the governmental and community structures and services in Kerala, in India. Palliative care in the state has grown to be a viable model recognized in global palliative care and public health scene. The community network of palliative care, especially the volunteers linking with clinical teams, is a strong force for advocacy, relief support including provision of emergency medications, and clinical care. Objective: To develop a palliative care resource tool kit for holistic care of patients affected with COVID-19 and to support the health-care workers looking after them to enable palliative care integration with COVID-I9 management. Methods: The Kerala State government included senior palliative care advisors in the COVID-19 task force and 22 palliative care professionals formed a virtual task force named Palli COVID Kerala as an immediate response to develop recommendations. Results: Developed a palliative care in COVID-19 resource toolkit which includes an e-book with palliative care recommendations, online training opportunities, short webinars and voice over power point presentations. Conclusion: Integrated Palliative care should be an essential part of any response to a humanitarian crisis. The e resource tool kit can be adapted for use in other low- and middle-income countries.
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How the COVID-19 pandemic experience has affected pediatric palliative care in Mumbai p. 17
Pradnya Talawadekar, Smriti Khanna, Veronique Dinand, Prakash Fernandes, Jayita Deodhar, Mary Ann Muckaden
DOI:10.4103/IJPC.IJPC_189_20  
Introduction: The COVID 19 pandemic has created difficulties for children registered under Children's Palliative Care in Mumbai. 2 hospitals who have started Services last year would like to share their experiences on difficulties faced by Children and their families and unique ways in which solutions were found to help them surmount all odds. Results: Some difficulties faced included transport to visit hospitals for doctor's care and essential medications; for those in native place, unavailability of doctors and medications. Difficulty to return home for those from out of Mumbai and vice versa. Unavailability of rations for those who were not original Mumbai residents. Conclusions: Unique solutions were found for each family. These are presented in this paper.
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Concerns of health care professionals managing non-COVID patients during the COVID-19 pandemic: A descriptive cross-sectional study p. 21
Riniki Sarma, Saurabh Vig, Puneet Rathore, Deepam Pushpam, Seema Mishra, Nishkarsh Gupta, Rakesh Garg, Vinod Kumar, Sachidanand Jee Bharati, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_155_20  
Context: The coronavirus pandemic has put an unprecedented burden on the health-care workers who are the cornerstone of the work system, preparing to mitigate its effects. Due to the lack of protective equipments, guidelines for managing patients, or proper training and education regarding the same, health care professionals (HCPs) working in non-COVID areas may face even greater problems than those working in COVID areas of a hospital. Our aim was to find out the concerns of HCPs working in non-COVID areas. Subjects and Methods: After obtaining institutional ethics approval, a descriptive cross-sectional study was planned. An online Google-based questionnaire was rolled out to all doctors through various social media platforms who were dealing with COVID-negative patients. Results: We received a total of 110 responses. 84.5% of participants were concerned about the risk of infection to self and family, 67.3% were concerned by the disruption of their daily activities. 56.4% of HCPs were disturbed by the lack of any concrete protocol for patient management. Less staff availability, delay in discharging duties toward their patients, and increased workload were other concerns. More than half of the doctors received N-95 masks whenever required and were trained in donning and doffing of Personal protective equipment. Sixty-eight percemt of our respondents labeled their current quality of life as stressful. Conclusion: It is the need of the hour to develop a comprehensive strategy focussing on the above challenges that HCPs working in non-COVID areas are facing. This will go a long way in not only providing holistic care to the patients but also in controlling this pandemic.
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Experience of palliative care services at tertiary comprehensive cancer center during COVID-19 lockdown phase: An analytical original study p. 27
Manisha Singh, Priti Sanghavi, Bhavna Patel, Ravi Umrania, Kikato Chishi, Mayur Ghoghari
DOI:10.4103/IJPC.IJPC_132_20  
Background: Recent pandemic Coronavirus disease 2019 has brought the whole world to a standstill. In India too, phases of the lockdown of the country were declared. This hampered the availability of essential health-care services to needy patients. With full emphasis on the pandemic, patients suffering from other diseases and palliative oncology patients requiring essential palliative care services were affected due to the shutting down of regular health-care services. Aim: In this study, we emphasize that in the middle of a pandemic, we need to continue serving the needs of palliative care patients, and simultaneously, necessary steps should be taken for the prevention of the spread of virus by following guidelines, training, support, and monitoring. Materials and Methods: In this study, we analyzed electronic medical record of 1161 patients who received palliative care from our institute in the first two lockdown periods, regarding their demographics, extent of travel, type of malignancy, and opioid utilization. Results: Of 1161 patients, male outnumbered female and the patient suffering from head-and-neck malignancy were in the maximum number (48.7%). Our essential opioids utilization rate was 34.2%, and patients who traveled from different states were 21.6%. Conclusion: During this pandemic, we cannot overlook the need for essential palliative care services. We can continue regular services with proper precautions as advised and by training the staff. Collaboration with different palliative centers across the country should be done to minimize patient movement.
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Smartphone-based telemedicine service at palliative care unit during nationwide lockdown: Our initial experience at a tertiary care cancer hospital p. 31
Swagata Biswas, Shreya Das Adhikari, Nishkarsh Gupta, Rakesh Garg, Sachidanand Jee Bharti, Vinod Kumar, Seema Mishra, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_161_20  
Background and Aims: With the COVID-19 pandemic, lockdown, and fear from contagion, the advantages of telemedicine are clearly outweighing the setbacks by minimizing the need for individuals to visit health-care facilities. Our study aims to assess how palliative medicine physicians could follow up on cancer patients and barriers they faced, discuss their results, and evaluate their treatment response with the help of telemedicine. Materials and Methods: We conducted a prospective analysis of the smartphone-based telemedicine service at our palliative care (PC) unit from March 25, 2020, to May 13, 2020. We recorded the patient's reason for call, main barriers to a hospital visit, and the assistance given to them by the physician on call. Each caller was asked to measure his/her satisfaction with the service on a 4-point scale. Results: Out of 314 patients, 143 (45.54%) belonged to Delhi and 171 (54.46%) belonged to other states. 157 patients sought help for symptom management; 86 patients needed to restock their opioid medications. Seventy-one patients required information regarding their oncological treatments requiring consultation from other departments. Titration of oral opioids and medication prescription (n = 129), contact details of other PC units at their native state for opioid procurement (n = 55), and attachment to our community-based PC service (n = 22) were main modes of management. Fifty-six patients were very satisfied and 152 patients were satisfied with the service. Conclusion: Telemedicine is the future of health-care delivery systems. In PC, we deal with immunocompromised debilitated cancer patients and telemedicine is immensely helpful for us to provide holistic integrated care to these patients who are unable to visit hospitals regularly.
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An update on initial epidemiological profile, clinical course, and outcome of COVID-19 patients at a tertiary care center in India p. 36
Dimple Pande, Anjali Kochhar, Suman Saini, Usha Ganapathy, Anoop Raj Gogia
DOI:10.4103/IJPC.IJPC_146_20  
Background and Aim: Coronavirus disease 2019 (COVID-19) has become a global pandemic with the spectrum of disease from asymptomatic or mild disease to severe cases requiring intensive care unit (ICU) admission. In India, it started with milder presentation affecting younger population. Later on, an increase in disease severity was observed involving older age group as well. However, there is a paucity of published data regarding patients requiring ICU care in India. This case series describes the initial experience of an ICU in India regarding epidemiological profile, clinical course, and outcome of critically ill COVID-19 patients. Methods: This case series included 27 consecutive laboratory-confirmed COVID-19 patients who were admitted in a tertiary care ICU over 14 days period, followed up till their discharge from ICU. Demographic and clinical data, including laboratory and radiological findings, were compiled with special attention to co-morbidities of the patients. The management of these patients was done as per the institutional protocol for critically ill COVID-19 patients. Results: The median age of the patients was 50 years with no difference in gender. Comorbid conditions were seen in 85% of the patients with diabetes (43.7%) and hypertension (37.5%) as the most common conditions. The median duration of symptoms before admission was 6 days with fever as the most common clinical symptom at presentation. Chest roentogram showed bilateral lung infiltrates in 88.8% of the patients. Mild, moderate, and severe hypoxia were observed in 3, 8, and 16 patients, respectively. Ten patients were managed with oxygen therapy. Seventeen patients (62.9%) required ventilatory support. Mortality rate among patients admitted to our ICU was 59.2%. Conclusions: This case series shows middle-aged patients with comorbid diseases present with severe COVID-19 disease and have poor outcome.
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Patients'/Caregivers' perspectives on telemedicine service for advanced cancer patients during the COVID-19 pandemic: An exploratory survey p. 40
Shrikant Atreya, Gaurav Kumar, Jyotiprakash Samal, Moitri Bhattacharya, Shabnam Banerjee, Pallab Mallick, Debratna Chakraborty, Sunipa Gupta, Saswati Sarkar
DOI:10.4103/IJPC.IJPC_145_20  
Introduction: Novel coronavirus disease 2019 (COVID 19) has usurped human peace and mobility. The confinement of the population and the rising epidemic has disrupted the routine care for non-COVID-19 patients. Telehealth is a growing field, and its application in palliative care is seen as a solution to serve the population in this difficult crisis. Methodology: A exploratory survey was designed to assess the changes in the hospital-based practice of palliative care in the COVID-19 pandemic and patient/caregiver's perception about the provision of telehealth services to palliative care patients of a tertiary care cancer hospital of eastern India. Results: There was a dramatic reduction in the outpatient clinic footfalls by 51% with teleconsultation. Although there was no change in the number of emergency visits, the inpatient admissions reduced by 44%. Nearly 82% of patient/caregivers gave a positive feedback about telemedicine care provided by the department and mentioned that the service provided them with support and connectedness. Almost 64% of the patients and caregivers reported that the service helped allay the fear and reassured them that there was a someone to support them. As high as 76% of the participants felt that they would prefer teleconsultation in future and were ready to pay for teleconsultations if charges were to be applied in the future. Conclusion: Telemedicine is an important tool and an essential service to care for palliative care patients in the community especially when the patient and health-care professionals are separated by a pandemic or natural disaster.
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Effect of nation-wide lockdown on palliative care services in a tertiary care centre in India: A retrospective observational study p. 45
AR Karthik, Kanika Rustagi, Seema Mishra, Rakesh Garg, Nishkarsh Gupta, Sachidanand Jee Bharati, Vinod Kumar, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_142_20  
Background: The ongoing coronavirus disease 2019 (COVID-19) pandemic has affected all the aspects of life of mankind, posing unique challenges for health-care services. In order to contain the spread of the virus, a countrywide mass lockdown has been imposed in India. Although the lockdown has modified the epidemic trajectory, it has affected the lives of many non-COVID patients. Patients in need of care could not approach hospitals. Methods: This retrospective observational study was conducted in the Department of Onco-Anaesthesia and Palliative Medicine at a tertiary care center in India. The yearly data of patient flow for the year 2019 was compared with that during the lockdown. Results: The single-day average of out-patients, in-patients, and other department consultation requests requiring palliative care decreased drastically during the lockdown in comparison to the previous year. The single-day average of teleconsultations increased more than double during the lockdown. Conclusion: Although lockdown decreases the spread of the epidemic, it increases the suffering of other patients who require medical care. Various steps have to be adopted in the regular working pattern of hospitals to cater to the needs of the patients requiring care, without increasing the risk of contracting COVID-19.
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Running palliative care services at the institute of palliative medicine, kozhikode, amid COVID-19 pandemic: A strengths, weaknesses, opportunities, and threats analysis p. 48
Lulu Mathews, Terrymize Immanuel, Nisha Krishnadas
DOI:10.4103/IJPC.IJPC_137_20  
Context: COVID-19 pandemic and nationwide lockdown has affected the health system. Many health-care facilities are prioritizing their services, and hence, those suffering from life-limiting conditions will have difficulty in accessing health services. Aims: The aim of the study was to perform a Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis of the palliative care (PC) services provided by the Institute of Palliative Medicine (IPM), Kozhikode, amid COVID-19 pandemic. Settings and Design: A SWOT analysis of PC services provided by IPM. Subjects and Methods: The data for SWOT analysis was collected by brainstorming and review of records and registers. Results: Good prioritization and documentation system and routinely adhering to infection control practices are notable strengths. Lack of funding and interrupted supply of personal protective equipment are notable weaknesses. Availability of established communication channels with active community participation are a few opportunities available to improve the services. Working with high-risk groups, return of Non-residential Indians (NRI), lack of transparency and stigma among the general public are the threats that can affect the service delivery. Conclusions: Having good prioritization and documentation system, reinforcing infection control practices, already established emergency homecare system, presence of a well-developed network of community-based PC services, and a vast network of community volunteers and awareness and cooperation of families had helped IPM to quickly reorganize its services and transition smoothly to continue to provide PC for those suffering from life-limiting illnesses in this pandemic situation.
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Challenges encountered while providing holistic care to a cluster of COVID-19 patients p. 53
Sanjeev Kumar, Puneet Rathore, Shweta, V Krishnapriya, Alice Thankachan, Nengneivah Haokip, Balbir Kumar, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_147_20  
COVID-19 emerged as a unique type of health-care crisis. With no established protocols, it became a difficult task to manage this pandemic. Not only individual patients were the point of concern but also multiple clusters were getting reported. Management of these clusters has its own challenges varying from administrative and infrastructural to psychosocial- and stigma-related issues. A well-sought administrative will power along with a dedicated team of health care professionals handled the situation in their best capacity leaving an imprint of peace and harmony.
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Providing palliative home care during COVID-19 pandemic lockdown in India p. 56
Reena Sharma
DOI:10.4103/IJPC.IJPC_148_20  
Introduction: The COVID-19 pandemic and subsequent lockdown in India affected all medical services including palliative care and most consultations were provided remotely through phone or video calls. During this period CanSupport also switched to tele-consultations for the safety of its patients and staff. Materials and Methods: Some patients still needed home visits so CanSupport developed need-based criteria in order to continue providing palliative homecare to those who suffered the most. Results: CanSupport's homecare teams visited 847 patients during the lockdown decided by the criteria developed. Majority of the visits were for supplying morphine and other medications followed by patients with severe pain and those requiring procedures. Conclusion: If guidelines and safety measures are followed, home visits are possible in the present environment.
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Palliative care interventions from a social work perspective and the challenges faced by patients and caregivers during COVID-19 p. 58
Prajakta Dhavale, Akhila Koparkar, Prakash Fernandes
DOI:10.4103/IJPC.IJPC_149_20  
Aim: The aim of this article is to describe the range of challenges faced by both patients and caregivers during the lockdown due to the COVID-19 pandemic. It also seeks to describe the nature of interventions provided by the social work team to address these challenges. In addition, it aims to highlight the lessons that can be learnt in supporting families on palliative care in such unique disaster situations. Methods: This exploratory study uses a qualitative approach and analyses the perceptions of patients, their caregivers, and the staff in providing care. Out of 30 patients worked with during the lockdown period, a total of nine families were selected that had received services during this time. The challenges faced and the interventions provided were analyzed using Framework analysis. We then used this framework to develop the themes that have been presented in the article. Results: The analysis indicates that the range of challenges faced by patients included physical distress due lack of availability of medicines and nursing care; emotional distress due to the interruption of cancer treatment; financial and social distress about loss of incomes, isolation; and spiritual distress due to the uncertainty of last rites as well as fulfilment of last wishes. The concerns outlined by caregivers included: living with guilt due to the inability to ease their relative's distress; the stress of constant care giving; lack of information about available services and confidence to ask for help from others as well as the dealing with the grief of a dying relative. These families were supported through telephone calls and home visits for critical patients with the social work team providing active listening, reassurance, empathy, and networking to assist patients and families at this time. Conclusion: Palliative care is an essential component, especially in a disaster-related situation such as the COVID pandemic as patients and caregivers are left more vulnerable at this time. Telephonic and video calls play an important role in supporting patients and caregivers and in the most critical cases. However, it is also important to find the ways to provide direct home-based support to patients and families at this time so that they feel less alone, cope better, and experience meaningful support to build their resilience.
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Homecare and the COVID-19 pandemic – Experience at an urban specialist cancer palliative center p. 63
Nivedita Page, Vinay Naik, Priya Singh, Prakash Fernandes, Vivek Nirabhawane, Santosh Chaudhari
DOI:10.4103/IJPC.IJPC_151_20  
Background: With the COVID-19 pandemic wreaking havoc globally, the extremely vulnerable subset of cancer palliative care patients has to go through the worst nightmare. Difficulty in accessing medical care in the event of increased symptom burden, obstacles in reaching hospitals at time of emergencies or end of life, limited access to medication, social distancing causing isolation, leading to psychosocial burden, lack of bereavement support, are few of the issues we identified. Palliative home care is an important tool to allay the anxieties and address the fears of cancer patients and caregivers, by ensuring continuity of care and providing the much needed handholding in these difficult times. This article aims to highlight the home-based care strategy and experience of the Cipla Palliative Care and Training Center during the COVID-19 lockdown. Materials and Methods: We have utilized the data of documentation of the process of designing the protocol, the data entered by the team on unique data management software that is used at the palliative care center to record all palliative care interventions and reflections of the team on their experience of home visits during this period. Results: Continuity of care through home visits will ensure better management of patients in terms of physical symptoms, psychosocial support, allaying fears, and anxieties, as well as the ultimate goal of an improved quality of life. Physical symptoms (24%), morphine drop off (19%), psychosocial support (15%), end of life care (33%), and procedures (9%) were the major indications of visits. Conclusion: The COVID-19 pandemic has increased the need for support, thus reiterating the importance of continuity of care. With abundant precautions and protocols in place, home care through visits is possible. With the lockdown and restrictions now entering their fourth phase, we need to be ready now more than ever to adapt to changing times and evolving definitions of the “New Normal.”
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Opioid dispensing patterns from a tertiary care cancer hospital during the nationwide lockdown in COVID-19 pandemic p. 70
Ruparna Khurana, Mohit Varshney, Seema Mishra, Nishkarsh Gupta, Rakesh Garg, Sachidanandjee Bharti, Vinod Kumar, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_179_20  
Introduction: During the current COVID-19 crisis, striking a balance between adequate pain relief in advanced malignancy patients and avoiding hospitals due to fear of contracting the infection has been the biggest challenge for patients as well as palliative care physicians. This study explored the trends in opioid dispensing for cancer pain before and during the lockdown. Methods: The trends were calculated based on an analysis of quantity of all opioids dispensed. March 24, 2020, was considered as a cutoff for analyzing before and during lockdown period dispensing trends. No information regarding individual patients was retrieved in the current study. Results: There was a decrease in total morphine, tramadol, and fentanyl patch dispensing parallel to decrease in total number of patients visiting the outpatient department. However, there was a statistically significant increase in per capita opioid dispensing during the lockdown period. There was also an increase in the proportion of cancer pain patients that were dispensed morphine during the lockdown. Conclusion: Despite the lockdown, the palliative care team at Institute Rotary Cancer Hospital has continued to provide adequate pain relief to patients that could manage to reach the center. Policy-makers need to be cognizant of the pain relief needs of cancer patients in times when accessing hospitals is becoming increasingly difficult. Cancer-related pain and mortality could well be the next pandemic once the current COVID-19 begins to reduce.
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To Study the barriers in palliative care to nonmalignant cases in COVID-19 crisis in a tertiary health-care center p. 76
Tanya Jain, Roopesh Jain
DOI:10.4103/IJPC.IJPC_164_20  
Introduction: COVID-19, the new pandemic faced by the world, is a novel betacoronavirus causing severe respiratory coronavirus syndrome. Elderly patients, people with underlying chronic illnesses, cancer patients, and those who are immunocompromised are at higher risk and account for higher mortality rate. Unfortunately, there is no approved medication for treatment, till date, thereby supporting triage management and difficult decision-making. Thus, there should be a substantial increase in the palliative care in times of pandemic. There should be an increase in the availability of palliative care services in different care settings. Due to a surge in the number of cases of COVID-19, it has been reported on how palliative care is being delayed, discontinued, or deprioritized. Aim: The aim of this study is to evaluate the barriers occurring in providing the palliative care to the patients with nonmalignant illness. Methodology: A questionnaire was designed after studying previous work over palliative care and pandemic crisis and was distributed among the physicians, surgeons, and the residents; a total of 95 health-care workers were involved. The survey was done through mails. The response then was evaluated and analyzed. Results: As seen by the responses we got from the health-care workers, the main issue is the nonavailability of the personal protective equipment during this pandemic. Keeping the current scenario in mind, regarding COVID-19, the patients are at fear of coming to the hospital at first place, and even if they come then the fear of being alone haunts them. One of the biggest fears of the patient is dying alone, without being in contact with their loved ones. Conclusion: Palliative care should be an essential part of any health-care service in any humanitarian crisis, including the COVID-19 pandemic. Thus, effort should be made to remove the barriers and provide palliative care to the patient.
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COVID 19: The New Normal in the Clinic: Overcoming Challenges in Palliative Care p. 81
Deepa Kerketta Khurana, Saveena Gulati Raheja, Madhu Dayal, Dimple Pande, Usha Ganapathy
DOI:10.4103/IJPC.IJPC_173_20  
Background and Aim: In the wave of COVID-19 pandemic, the whole world has come to a standstill. This led to a major setback for cancer patients jeopardizing their treatment plans. This study analyzes the coping mechanisms of running outpatient and inpatient palliative care services in these COVID-19 times – the New Normal. Materials and Methods: An observational study was conducted in the pain and palliative care unit at a tertiary care hospital, India. The data were collected from March 23, 2020, to May 22, 2020, of all patients coming to the clinic and inpatient referrals. Using manual and electronic records, demographic data was collected along with clinical data. Additional data were compiled with special attention to the patient's pain and its management. Results: Despite complete lockdown and initial low patient load, we saw a progressive increase in the number of patients coming to the clinic. A total of 108 patients visited our clinic (65 male and 43 female), of which 78% of the patients were from Delhi. The median age was 43.94 years (range 6 years to 76 years). We had 33 new and 75 old registered cases coming. The main reason was new-onset pain because of noncompliance of drugs; the opioid stock finished with the patient. We saw a very high number of patients requiring strong and weak opioids. Proper personal protection and social distancing helped in preventing crossinfection. None of our staff or patients fell ill during this time. Communication skills were modified to convey feelings and empathize patients. Telemedicine using phone and video calls was used and found to be useful. Conclusion: We share our experience and challenges of providing palliative care in our clinic which can be modified as per the individual requirements in other setups.
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Assessment of the prevalence of symptoms in patients under institutional isolation in COVID-19 pandemic in India p. 86
Sanjeev Kumar, Puneet Rathore, Nandan Choudhary, Neha Singh, Alice Thankachan, Balbir Kumar, Shweta Bhopale, Anant Mohan, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_170_20  
Objective: To understand the trend of prevalence of symptoms of coronavirus disease 2019 (COVID-19) pandemic, some studies have been conducted outside India, but for Indian patients, there is no such study available. Therefore, this study was designed to analyze the trends of symptoms in Indian patients during COVID-19 pandemic. Methods: A retrospective study was conducted on 100 patients (73 males, 24 females, and 3 transgenders) admitted under institutional isolation at a tertiary care center in India using a self-designed survey-based questionnaire. A descriptive analysis of results done based on age and sex. Results: COVID incidence recorded is high in male (73%) as compared to female (24%), yet female patients have a higher prevalence of symptoms as compared to male patients. Conclusion: Male patients are more as far as COVID incidence is concerned, while female patients show high prevalence of symptoms as compared to male patients. Patients presenting with COVID-positive report suffer a significant burden of symptoms, and timely recognition of symptoms and their management can significantly reduce morbidity and mortality due to COVID-19.
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Concerns of health-care professionals managing COVID patients under institutional isolation during COVID-19 Pandemic in India: A descriptive cross-sectional study p. 90
Puneet Rathore, Sanjeev Kumar, Nandan Choudhary, Riniki Sarma, Neha Singh, Nengneivah Haokip, Shweta Bhopale, Anuja Pandit, Brajesh Kumar Ratre, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_172_20  
Objective: Health-care professionals (HCPs) are the frontline warriors in the time of this uncertain and unpredictable crisis of COVID. They face many challenges while caring for these patients, yet they are expected to cope with it and deliver their duties for the betterment of humankind. Our primary aim was to identify and assess the concerns of HCPs working in COVID area in a tertiary institutional isolation center. Methodology: An online Google-based questionnaire survey was distributed through various social media platforms after approval of the institutional review board to a total of 100 HCPs who were treating and managing COVID-positive patients. Results: Of 100 responses, 72% were concerned about the risk of infection to self and family, while 46% reported disruption of their daily activities at a personal level. At the institutional level, 17% were concerned about inadequate personal protective equipment-related challenges. 20% had inadequate knowledge and training about COVID. 16% of participants were anxious all the time, 11% feared all the time, and 12% had stress all the time while treating COVID patients. Connectedness and communication with family and friends, word of appreciation, music, and TV were few strategies to cope up with these challenges. Conclusion: There is a need to identify and address the concerns and challenges faced by HCPs and to develop a comprehensive strategy and guideline to provide a holistic care and to ensure their security in the workplace.
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CARE: A holistic approach toward patients during pandemic: Through the eyes of a palliative physician p. 95
Puneet Rathore, Sanjeev Kumar, Nengneivah Haokip, Brajesh Kumar Ratre, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_175_20  
Words pandemic and panic, if cannot be used synonymously, can definitely be exchanged metaphorically. Pandemics are outcome of an unanticipated crisis, therefore it is always associated with panic and hence it requires a comprehensive approach to get resolved. On the contrary, during the event of an overwhelming pandemic, due to lack of protocols, the entire health-care system faces crisis and it becomes a tedious task to reallocate and reschedule the resource and knowledge for the uninterrupted and smooth delivery of services. Therefore, pandemics need an evidence-based subjective approach toward the patient and family members for addressal and resolution of complex issues arisen due to the disease. A good contingency plan and approach for combating a pandemic is the utmost solution for providing complete holistic care. A comprehensive care approach model is the need of the hour to provide the holistic care during pandemics. In this article, we propose a model of CARE approach that can be useful in providing holistic care during the times of pandemic.
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Concerns and coping strategies of persons under institutional quarantine during SARS-CoV-2 pandemic p. 99
Neha Singh, Sanjeev Kumar, Puneet Rathore, Saurabh Vig, Nandini Vallath, Anant Mohan, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_176_20  
Introduction: The World Health Organization has declared severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as a pandemic. The interventions employed by various health authorities in combating the infection may help in eliminating the threat; however, they have long-term cognitive and mental health effects on the population. Aims: The primary objective was to assess the prevalent concerns and coping strategies and perspectives in persons suspected of SARS-CoV-2 infection under institutional quarantine in India during the period from April 2020 to May 2020. Setting and Design: Its a cross-sectional observational study conducted in the National Cancer Institute, Jhajjar, India. Methodology: After ethical clearance, convenience sampling was done. Relevant demographic details were obtained. Health-care professionally administered questionnaire to assess psychological concerns and coping mechanisms. All statistics are deemed to be descriptive only. Results: The most common physical concern was fever seen in 37% of respondents, followed by cough in 31% and sore throat in 29%. In terms of emotional concerns, 55.3% of respondents were worried and 43% were anxious and 33% were sad. About 80.6% of participants selected support from family and friends helped them cope during the institutional quarantine. 57% maintained a daily routine, 70% selected praying, and 45% used music as a coping strategy. Only 2% felt that they were unable to cope. Conclusion: It highlights that the psychological impact of illness on affected individuals should not be overlooked as it may have the potential to cause major psychiatric morbidity. It also provides a crucial assessment of their coping mechanisms.
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PERSPECTIVES Top

Approaches and best practices for managing cancer pain within the constraints of the COVID-19 pandemic in India p. 106
Anuja Damani, Arunangshu Ghoshal, Naveen Salins, Sushma Bhatnagar, Priti R Sanghavi, Vidya Viswanath, Shrenik Ostwal, Gauraiya Chinchalkar, Nandini Vallath
DOI:10.4103/IJPC.IJPC_216_20  
Novel corona virus disease 2019 (COVID-19) is an ongoing pandemic that has impacted the entire world. The Indian government has responded strongly and very stringently to the crisis, through a nationwide lockdown. The health-care (HC) systems in the country are striving hard to maintain equitable care across illness spectra, while responding the emergencies imposed by the COVID-19 crisis. Under these circumstances, guidelines for managing several diseases including that for cancer care have been modified. As modified guidelines for cancer care have their focus on disease management, cancer pain management and maintaining continuity of care for patients with advanced progressive disease have taken a backseat in the available cancer care guidelines. This article describes the challenges, approaches to solutions with evidence-based practices that can be utilized to ensure competent management of cancer pain during the COVID-19 pandemic in India. It provides an overview of adapting to telehealth consultations for identification, evaluation and management of cancer pain, safe and rational use of analgesics and adjuvant drugs, recognizing and responding to holistic care needs and addressing the total pain, ensuring continuity of pain management, and strategies when complying with narcotic drug regulations, while ensuring safety of patients and HC providers.
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Psychosocial aspects of COVID-19 in the context of palliative care – A quick review p. 116
Seema Rajesh Rao, Odette Spruijt, Poornima Sunder, Sunitha Daniel, Rajashree K Chittazhathu, Shoba Nair, Mhoira Leng, Sunil Kumar M M, Biju Raghavan, Athul Joseph Manuel, Vineetha Rijju, Geetha Vijay, Anupama V Prabhu, Uma Parameswaran, Chitra Venkateswaran
DOI:10.4103/IJPC.IJPC_183_20  
In a resource-poor country like India, where the health-care systems are difficult to access, overburdened, and unaffordable to many, the impact of the coronavirus disease 2019 (COVID-19) pandemic can be devastating. The increased burden of serious health-related suffering can impact the well-being of health-care workers, patients, and their families alike. The elderly, the frail, the vulnerable, and those with multiple comorbidities are disproportionately affected. Palliative care, with its comprehensive and inclusive approach, has much to offer in terms of alleviating the suffering, particularly those caused by the distressing physical and psycho-socio-spiritual symptoms, the complex medical decision-making, end-of-life care issues, and grief and bereavement, and needs to be integrated into the pathway of care provision in COVID-19. Psychosocial issues contribute to and amplify suffering and are often underestimated and undertreated and not accessible to many. Empowering frontline professionals in the core concepts of psychosocial support and palliative care thus becomes an absolute necessity. This quick review was done by a group of palliative care physicians and mental health experts from India to develop recommendations for physical and psychosocial care in the context of COVID-19. This review was done as part of that process and highlights the role and challenges of the psychosocial domain of palliative care in the context of COVID-19 situation in India.
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Palliative care challenges and strategies for the management amid COVID-19 pandemic in India: Perspectives of palliative care nurses, cancer patients, and caregivers p. 121
Radhika R Pai, Malathi G Nayak, N Sangeetha
DOI:10.4103/IJPC.IJPC_182_20  
The WHO selected 2020 to recognize the work of nurses and midwives because it is the bicentenary of the birth of the founder of modern nursing, Florence Nightingale. It has been demonstrated amply now as the nurses are the largest sector of health-care workers in every country, playing a pivotal role in response to the novel coronavirus (COVID-19) pandemic worldwide. Every day, nurses are working tirelessly by leaving their homes to assist the sick, allay community fears, and address concerns. This article is written by interviewing the staff nurses working in the wards/outpatient departments of a reputed palliative care center in Karnataka State, reviewing the recent nurses' blogs, editorial commentaries, WHO guidelines, CDC guidelines, and recent short communications on COVID-19 pandemic. The authors in this article attempted to address the palliative care challenges and strategies for the management during the COVID-19 pandemic in India.
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The psychosocial implications on cancer patients: The hidden collateral of the war on coronavirus disease 2019 p. 126
Devesh Sanjeev Ballal, Seema Gulia, Ashish Gulia
DOI:10.4103/IJPC.IJPC_203_20  
The coronavirus disease 2019 pandemic has evolved into a pandemic of unheard proportions. Given the havoc wreaked by this pathogen worldwide, many countries have adopted an extreme, legally enforced method of social distancing, in the form of a lockdown. Unless appropriate preventive steps are taken, the cost of the pandemic and ensuing lockdown may prove to be irreparable. The evident implications of this lockdown, such as the escalating levels of unemployment, impending economic collapse, and severe food shortage faced by the sudden unemployed migrant labor population, have been widely reported. Cancer patients are a particularly vulnerable group even during nonpandemic times, often presenting late in the course of their disease, without the resources needed to avail recommended treatment. The prevalence of psychiatric complications and emotional distress is significantly higher than in the general population, and the trauma of both the pandemic and subsequent lockdown adds significantly to their mental trauma. This review is aimed toward addressing the problems faced by cancer patients in the face of this pandemic and subsequent lockdown, with a glimpse into possible solutions that can be implemented.
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Palliative care delivery in cancer patients in the era of Covid-19 outbreak: Unique needs, barriers, and tools for solutions p. 130
Seema Mishra, Swagata Biswas, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_194_20  
World is facing a pandemic recently due to the outbreak of COVID-19 infection. Cancer has been identified as one of the major comorbidities which cause more severe disease due to COVID-19 infection. Moreover, there are several resource limitations and restrictions to avail the standard oncological health facilities due to robust measures taken for infection control. In this situation, palliative care in cancer patients deserves special attention. Their symptom management, psychological, social, cultural needs tremendously increase during the epidemic. Thus, we need to recognize the unique palliative care needs of cancer patients during pandemic and formulate the plan to maintain continuity of services. Triaging systems are essential tools for proper resource allocation during a pandemic. Therefore, we suggest triaging tools for emergency in hospital palliative care services: community-based palliative care and end of life care for cancer patients. Incorporation of newer technologies and identifying the potential resources are the other key components of the preparedness strategy.
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CASE REPORTS Top

Child in institutional quarantine – A unique challenge p. 142
Neha Singh, Nengneivah Haokip, Puneet Rathore, Saurabh Vig, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_162_20  
COVID-19 pandemic has seen thousands of people all over the world placed under mass quarantine. Although quarantine is a successful public health measure, it has been described as an unpleasant experience. This case report presents the process of institutional quarantine of a 5-year-old boy along with his mother and explores the impact of it on their mental health. It provides an insight about the importance of increasing communication, doing collaborative exercises in addressing the concerns of children and alleviating their loneliness. It highlights the role of caregivers in aiding the recovery and providing essential psychosocial comfort to the affected children, making them an indispensable resource for the care team.
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Aplastic anemia: Non-COVID casualties in the COVID-19 era p. 145
Nita Radhakrishnan, Ravi Shankar, Savitri Singh
DOI:10.4103/IJPC.IJPC_152_20  
With the emergence of COVID-19 pandemic, health care for many non-COVID illnesses has inadvertently slid back. For most patients with life-threatening illnesses, the directive from the Ministry of Health and Family Welfare to continue the treatment for essential health services has come as a relief. However, for certain life-threatening illnesses such as aplastic anemia, the situation has been grim. We discuss the poor outcome of 2 children followed up at our center for aplastic anemia and analyze the reasons for the same.
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Concerns of a post-chemotherapy/radiotherapy patient of nasopharyngeal carcinoma presenting with sustained COVID-19 infection p. 148
Shweta, Saurabh Vig, Puneet Rathore, Sanjeev Kumar, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_156_20  
A 47-year-old patient was referred from otorhinolaryngologist with a chief complaint of hearing loss to the medical oncology department where he was diagnosed to have nasopharyngeal carcinoma (NPC). The patient was given six cycles of chemotherapy and 35# of radiotherapy. After a week of therapies, he developed a low-grade fever. He was suspected of COVID-19, but the reverse transcription polymerase chain reaction test came out to be negative. He developed urinary retention, and he was planned for suprapubic catheterization. Before the procedure, he was retested for COVID-19 which came out to be positive. This case report aims to describe the condition of a patient of NPC with COVID-19 infection and to discuss the outcome of disease in this circumstance.
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Why i can't breastfeed my new-born baby? Psychosocial dilemma of a COVID-positive post-LSCS mother p. 150
Sanjeev Kumar, Puneet Rathore, Shweta, V Krishnapriya, Nengneivah Haokip, Alice Thankachan, Sushma Bhatnagar, Balbir Kumar
DOI:10.4103/IJPC.IJPC_157_20  
A 26-year-old postpartum COVID-positive mother admitted in COVID isolation facility at a tertiary care center in India. Her primary physical concern was suture site pain and concerns related to expressed breast milk discarding. Her psychological concerns include distrust on COVID report, belief of unjust isolation, lack of family support, loneliness, feeling of not breast feeding her baby, fear, anxiety, anger, stress, and depression. She was concerned about the stigma anticipated for herself and her baby. Spiritually, she was concerned as she was not able to make harmony between herself and environment.
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Unraveling the role of palliative surgery in the era of COVID-19 pandemic p. 153
Raghav Gupta, AR Karthik, Kanika Rustagi, Nishkarsh Gupta, Sandeep Bhoriwal, Vinod Kumar, Rakesh Garg, Seema Mishra
DOI:10.4103/IJPC.IJPC_158_20  
Palliative surgery forms an important pillar of palliative treatment to provide holistic care to cancer patients in the form of providing relief from pain, local control of disease, hemorrhage, and for the purpose of rehabilitation. During the COVID-19 pandemic, we report the successful management of two cases of colorectal cancer which came under the category of high priority and underwent palliative surgery to provide relief from pain.
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Rendezvous of cancer patients with logistic and socioeconomic challenges during COVID-19 pandemic: A case series p. 156
Raghav Gupta, Riniki Sarma, Seema Mishra, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_159_20  
The coronavirus disease 2019 pandemic has shaken the health-care infrastructure worldwide and has led to enormous challenges for cancer patients. They are suffering on various fronts during this pandemic, especially the often overlooked ones such as logistic and socioeconomic. Through the case series, we have highlighted the various components of these challenges the cancer patients are facing and tried to emphasize that the health-care setups and government along with nongovernmental organizations have to come on the forefront to help the patients mitigate these challenges.
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Anger and Distress of a Curable Gastric Carcinoma Patient Becoming Incurable: A Dilemma of a Pandemic p. 160
Abhity Gulia, Prateek Sharma, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_163_20  
A pandemic is a time of great distress for cancer patients with a heightened risk of infection along with fear of disease progression occurring from postponement of therapy. Our patient who was initially diagnosed early and was awaiting surgery was suddenly terrified when her surgery got postponed due to the pandemic. To add to her distress was the disease progression which left her wondering that what went wrong on her part that she was in such a situation. The dilemma of the present situation is that an already stretched system due to the pandemic cannot accommodate for elective treatments of other diseases more so when there is a risk of complications in cancer patients associated with the infection.
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Multiple caregiving role with the novel challenge of COVID-19 pandemic: A crisis situation p. 163
Abhity Gulia, Seema Mishra, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_165_20  
Caregivers of cancer patients in the COVID-19 pandemics have been faced with new complexities and challenges related to their patient's care. It has added tremendous stress to the previous multiple caregiving roles. We present the journey of a caregiver of cancer survivor who had played multiple care giving roles for the past 10 years. With the added challenge of the pandemic the caregiver faced severe psychological distress concerning his caregiving role. This was addressed to a large extend with counseling and empathy. Communication is an important measure to relieve the distress and address the complexities faced by caregivers.
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Challenging concerns of transgender community amidst COVID-19 p. 166
Alice Thankachan, Puneet Rathore, Sanjeev Kumar, Shweta, V Krishnapriya, Nengneivah Haokip, Sushma Bhatnagar, Shweta Bhopale
DOI:10.4103/IJPC.IJPC_166_20  
A 30-year-old transgender woman was admitted to the dedicated COVID hospital. She presented with mild symptoms and had various psychosocial insecurities, which remained unattended on reaching our health-care facility. From being left alone by her peers, lack of proper deliverance of information, and the stigma attached to the gender issues made her anxious and fearful. Although there are studies showing the prevalence of psychosocial burden in transgender people, a comprehensive approach led by a palliative care physician is yet to be initiated.
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Psychosocial burdens of a renal transplant recipient with COVID-19 p. 168
Nengneivah Haokip, Puneet Rathore, Sanjeev Kumar, Shweta, V Krishnapriya, Alice Thankachan, Anitha Swamy, Anuja Pandit, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_169_20  
The impact of COVID-19 on transplant recipients is yet to be fully understood. Apart from the physical implications, little has been discussed regarding the psychosocial burden it exerts on the already chronically ill patients. Here, we discuss a case of a 40-year-old male who received kidney transplantation 2 years ago and has tested positive for COVID-19. At the time of admission, he presented with mild symptoms and subsequently developed fever for which he had been managed conservatively. However, a comprehensive approach addressing psychosocial, emotional, and spiritual domains from a palliative care physician's perspective is often overlooked, whether in times of COVID-19 or not and this report aims to identify and assess such gaps.
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A Child with Acute Lymphoblastic Leukemia in Institutional Isolation during the COVID Pandemic: A Multifaceted Responsibility p. 170
Puneet Rathore, Sanjeev Kumar, Shweta, Neha Singh, V Krishnapriya, Alice Thankachan, Nengneivah Haokip, Shweta Bhopale, Brajesh Kumar Ratre, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_167_20  
The occurrence of the COVID-19 pandemic has caused big challenges in medical communities due to its unpredictable and uncertain nature. It leads to a great deal of physical and psychological concerns. It is more prone to patients with comorbidities such as hypertension and diabetes mellitus and also to immune-compromised patients such as cancer patients. Children are no exception. Acute lymphoblastic leukemia (ALL) is the most common malignancy in the pediatric age group. In this case, we discuss the concerns and reflect the issues of a 10-year-old boy of ALL who was tested COVID positive during the evaluation and treatment of his disease and was admitted in a COVID isolation center along with his mother who was COVID negative.
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COVID-19-Positive report posing a delay in treatment course in a middle-aged metastatic neuroendocrine tumor patient p. 173
V Krishnapriya, Puneet Rathore, Sanjeev Kumar, Shweta, Alice Thankachan, Nengneivah Haokip, Saurabh Vig, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_168_20  
The COVID-19 outbreak is an unexpected challenge to all areas of health-care delivery, including cancer centers. The novel coronavirus is known to affect individuals in all age groups, especially patients with multiple comorbidities. A nationwide lockdown has restricted the routine patient care, with health-care services focusing mainly on emergency services and COVID patient management. These restrictions in health services may delay the treatments of non-COVID patients. This conundrum is especially true in cancer patients as they require frequent visits to the hospital, and there is a lack of understanding of the treatment prioritization in cancer patients. In this case, we discuss the concerns faced by a 37-year-old male with neuroendocrine tumor of the anal canal who was tested COVID positive. His surgery was canceled following the report and was shifted to the COVID care facility. Best supportive care was given till further management.
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Integration of telemedicine for home-based end-of-life care in advanced cancer patients during nationwide lockdown: A case series p. 176
Swagata Biswas, Shreya Das Adhikari, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_174_20  
Dignified death is a basic human right that has been widely overlooked in countries like India. During nationwide lockdown, it is extremely challenging to provide quality end-of-life care (EOLC) to all patients with a poor system for dignified death. Telemedicine, whose feasibility for community-based EOLC in rural settings has already been established, was a useful tool for us to overcome these barriers. Adding a widely used smartphone-based application for video calls along with voice calls and text messages made the process more dynamic and convenient. Here, we share our experience with three patients with advanced malignancy in providing EOLC during COVID-19 lockdown. A well-planned study for the utility of this service for a larger cancer patient population from different sociocultural and demographic backgrounds is warranted in the future.
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LETTERS TO EDITOR Top

Telemedicine during the COVID-19 pandemic: Experience at Bahrain oncology centre, Bahrain p. 179
Shiv Pratap Singh Rana, Elias Fadel
DOI:10.4103/IJPC.IJPC_181_20  
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COVID-19 pandemic prompts changes to pain and palliative care at home p. 180
Poonam Kumari, Amarjeet Kumar, Chandni Sinha, Ajeet Kumar
DOI:10.4103/IJPC.IJPC_178_20  
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Palliative care for COVID-19: Let Us be Prepared… p. 181
Megha Pruthi, Gaurav Chanana
DOI:10.4103/IJPC.IJPC_123_20  
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Considerations for palliative intervention procedures in the COVID pandemic p. 183
Sapna Singla, Abhishek Kumar, Rakesh Kumar Sharma, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_171_20  
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True heroes of COVID-19 battle – Our nightingalesPaid article p. 184
Varsha Francis, Ashish Gulia
DOI:10.4103/IJPC.IJPC_204_20  
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