Indian Journal of Palliative Care
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   Table of Contents - Current issue
October-December 2017
Volume 23 | Issue 4
Page Nos. 353-486

Online since Friday, October 6, 2017

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The Indian College of Palliative Medicine: A concept in evolution p. 353
Naveen Salins
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Effect of aerobic exercise on cancer-related fatigue p. 355
Jaivika Govindbhai Patel, Anjali R Bhise
Background: Fatigue is the most common side effect of cancer treatment with chemotherapy and/or radiation therapy, selected biologic response modifiers. The main purpose of this study is to evaluate the effects of aerobic exercise on cancer-related fatigue in patients of the solid tumor after chemotherapy and radiotherapy. Methods: After screening for cancer-related fatigue, 34 patients fulfilled the inclusive criteria and were assigned into two groups (n = 17 recruited in the intervention group and n = 17 in control group). The intervention group received aerobic exercise program which included treadmill walking with low to moderate intensity (50%–70% of maximum heart rate), for 20–40 min/day for 5 days/week. Control group were taught stretching exercises of hamstrings, gastrocnemius, and soleus (to be done at home) and were encouraged to remain active. Outcome measures such as brief fatigue inventory (BFI), 6-min walk test, and functional assessment of cancer therapy-general (FACT-G) were taken at baseline and after 6-weeks. Results: The data were analyzed using the Wilcoxon matched-pairs signed rank test for within group and Mann–Whitney U-test for between group comparisons. The results of this study showed that there was a significant reduction in cancer-related fatigue BFI score (P < 0.0001,), also there was significant improvement in the physical performance as in 6-min walk distance (P < 0.0001) and quality of life, FACT-G score (P = 0.0001). Conclusion: Aerobic exercise for 6 weeks has beneficial effects on cancer-related fatigue in patients with solid tumor after chemotherapy and/or radiotherapy.
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Commentary p. 361
Shrikant Atreya
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Hospital workers' confidence for end-of-life decisions in their family: A multicenter study p. 363
Monica Leon, Luis Omar Chavez, Sharon Einav, Joseph Varon
Aims: To study whether health-care workers feel capable of making resuscitation decisions for their own families, the confidence in their family to represent their own preferences, and if some health-care workers feel greater confidence in their ability to undertake such decisions for their family than others. Methods: An anonymous survey conducted among health-care workers of nine institutions in North and Central America. The self-administered questionnaire included demographic and professional characteristics, attitudes, personal preferences, and value judgments on the topic of resuscitation. Results: Eight hundred and fifty-eight surveys were completed; 21.1% by physicians, 37.2% by nurses, and 41.7% by other health-care. Most of the health-care workers (83.5%) stated that they should be unable to determine their own code status and they would allow their family or spouse/significant other to make this decision for themselves. Physicians felt significantly more capable of making a decision regarding the code status of a close family member than other hospital workers (P = 0.019). Professionals who chose to not undergo cardiopulmonary resuscitation were less likely to feel capable of determining the code status of their family. Conclusions: Most of the health-care workers feel capable of making code status decisions for a close family member and most feel equally comfortable having their family or spouse/significant other represent their code status preference should they be incapacitated. There is considerable reciprocity between the two situations. Physicians feel more confident in their ability to make code status decisions for their loved ones than other health-care workers. Regardless of profession, a personal preference for do not attempt resuscitation status is related to less confidence.
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The palliative performance scale predicts survival among emergency department patients, Minia, Egypt p. 368
Amany Edward Seedhom, Nashwa Nabil Kamal
Background: Emergency department (ED) physicians provide care to patients with a wide range of prognoses, and must develop care plans that anticipate patient's survival. However, the tools available to guide care planning had limited data to support their use. There is a new concern to understand if palliative care (PC) should be offered in the ED and the Palliative Performance Scale (PPS), a screening tool used in other settings in PC, has been little used in the ED. Aim: The aim of this study is to assess the prognostic value of the PPS in predicting 1, 3 and 6 months survival in patients admitted through the ED. Design: This was a prospective, cohort study. Subjects and Methods: We evaluated 147 patients at the age of 35 years and more admitted through the ED of Minia University hospital from May 1, 2016 to June 31, 2016. Each patient's PPS score was evaluated initially in the ED, with follow-up assessments of survival at 1, 3, and 6 months. Results: Baseline PPS for the 147 patients was 50. The PPS score was a strong predictor of survival (Log-rank test of Kaplan–Meir P < 0.0001). Patients with an initial PPS score of 40 or less were less likely to survive at 6 months. Conclusion: The PPS score may predict survival in patients admitted to the hospital through the ED. The ease of use holds promise that the use of the PPS in the ED may help ED physicians predict survival and plan for a better decision.
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Effect of expressed breast milk versus swaddling versus oral sucrose administration on pain associated with suctioning in preterm neonates on assisted ventilation: A randomized controlled trial p. 372
Saumil Desai, Ruchi Nimish Nanavati, Rohit Nathani, Nandkishor Kabra
Objective: The objective of our study was to assess the pain associated with suctioning in preterm neonates on assisted ventilation and comparing the use of expressed breast milk (EBM), sucrose, and swaddling to alleviate pain. Methods: Study design: A randomized controlled clinical trial. Inclusion Criteria: Preterm neonates on assisted ventilation. Exclusion Criteria: Major congenital anomalies and severe encephalopathy. Study Duration and Site: 6 months in level III neonatal Intensive Care Unit. In the first phase, we used premature infant pain profile (PIPP) score to assess pain associated with suctioning in preterm neonates on assisted ventilation. In the second phase, the effect of EBM, swaddling, and sucrose on pain relief during suctioning in neonates on assisted ventilation was assessed. Results: There was a significant increase in pain associated with suctioning in preterm neonates on assisted ventilation (preprocedure PIPP score 7.90 ± 2.50; procedural PIPP score 13.63 ± 2.57; P < 0.05). The postintervention mean procedural PIPP score was not significantly different between the EBM, swaddling, and sucrose groups (P = 0.24). Conclusions: Suctioning is painful for preterm neonates on assisted ventilation. There was no difference between EBM, swaddling, and sucrose in relieving pain associated with suctioning.
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Palliative care for children with cancer in the Middle East: A comparative study p. 379
Leila Khanali Mojen, Maryam Rassouli, Peyman Eshghi, Ali Akbari Sari, Majideh Heravi Karimooi
Introduction: High incidence rates of childhood cancer and the consequent deaths in the Middle East is one of the major reasons for the need for palliative care in these countries. Using the experiences and innovations of the other countries can provide a pattern for the countries of the region and lead to the development of palliative care in children. Therefore, the aim of this study is to compare the status of pediatric palliative care in Egypt, Lebanon, Jordan, Turkey, and Iran. Materials and Methods: This is a comparative study in which the information related to pediatric palliative care system in the target countries (from 2000 to 2016) has been collected, summarized, and classified by searching in databases, such as “PubMed, Scopus, Google scholar, Ovid, and science direct.” Results: Palliative care in children in the Middle East is still in its early stages and there are many obstacles to its development, namely, lack of professional knowledge, inadequate support of policy-makers, and lack of access to opioids and financial resources. Despite these challenges, providing services at the community level, support of nongovernmental organizations (NGOs), using trained specialists and multi-disciplinary approach is an opportunity in some countries. Conclusion: Considering the necessity of the development of pediatric palliative care in the region, solutions such as training the human resources, integrating palliative care programs into the curriculum of the related fields, establishing facilitating policies in prescription and accessibility of opioids, providing the necessary support by policy-makers, doing research on assessment of palliative care quality, as well as NGOs' participation and public education are suggested.
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Multiple nutritional deficiencies in cerebral palsy compounding physical and functional impairments p. 387
PG Hariprasad, KE Elizabeth, Mathew J Valamparampil, D Kalpana, TS Anish
Introduction: Cerebral palsy (CP) refers to a spectrum of disorders causing physical and intellectual morbidity. Macro and micro nutrient deficiencies often contribute to the subnormal physical and mental capabilities of them. Objectives: To assess the growth, nutritional status, physical and functional ability and quality of life in cerebral palsy children and to determine any relation with their gross motor and functional capabilities. Method: The study was conducted at a Tertiary Care Centre, with the participants in the age group 1-16 years. A pretested evaluation tool was prepared which included Anthropometric measurements, tests for hemoglobin and Vitamin D estimation, evidence of micronutrient deficiencies, Dietary patterns, Epidemiological factors, Functional assessment using GMFM (Gross Motor Function Measure ) and FIM (Functional Independent Measurement) scales and Quality of life (QOL) assessment. The data was statistically analyzed. Results: Out of the 41 children, 30 had quadriplegia, 3 had hemiplegia and 8 had spastic diplegia. 34 (82.9%) were severely underweight, 35 (85.4%) had severe stunting and 38 (92.7%) had severe wasting. Micronutrient deficiencies were noted like vitamin B complex deficiency in 37 (90.2%), vitamin A deficiency in 31 (75.6%), low vitamin D levels in 27 (65.9%) and insufficient levels in 9 (22%), severe anemia in 5 (12.2%) and moderate anemia in 26 (63.4%).The gross motor and functional scores were suboptimum in the majority of patients and the care givers had significant impairment in the quality of life. Conclusion: Majority of children with cerebral palsy had multiple nutritional deficiencies, gross motor and functional disabilities. QOL of the children and their care givers were suboptimum. A comprehensive package that address dietary intake, correction of micronutrient deficiencies especially anemia and vitamin D deficiency, physical and emotional support is recommended for the wellbeing of the affected children.
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Parents' knowledge and attitude regarding their child's cancer and effectiveness of initial disease counseling in pediatric oncology patients p. 393
Manjusha Nair, Lidiya T Paul, PT Latha, Kusumakumary Parukkutty
Objective: To examine parent's knowledge, attitude and psychosocial response regarding their child's cancer and treatment after initial disease counseling by doctor. Materials and Methods: Structured questionnaire based study of 43 mothers of newly diagnosed pediatric cancer patients undergoing treatment in pediatric oncology division. Mothers received initial counseling regarding their child's cancer and treatment from the doctor. Questionnaire was administered 2-6 months after initial counseling and mothers self-reported their responses. Results: 83% mothers had school level education only and 84% belonged to lower and middle socio-economic status. More than 80% mothers knew the name of their child's cancer, type of treatment received by child and approximate duration of treatment. 93% knew regarding painful procedures and 84% mothers reported knowledge about chemotherapy side effects. Hope of cure and satisfaction with treatment were reported by 90% mothers. 81% mothers reported high levels of anxiety and 66% worried regarding painful procedures. As high as 60% of parents were afraid to send their child outside to play and 40% were afraid to send their child to school. 40% mothers wanted more information regarding child's higher education, married life & fertility. On statistical analysis, mother's age, educational status or family background did not influence their knowledge and attitude. Conclusion: Relevant information about child's cancer and treatment can be imparted effectively even to mothers with school level education. This knowledge helps to instill hopeful attitude, confidence and satisfaction in parents. Anxiety and fear related to cancer persists in mothers even after the initial stress period is over. Pain related to injections and procedures is a major concern in parents. Involvement of counselor in the treating team is desirable to overcome these problems.
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Effect of supportive psychotherapy on mental health status and quality of life of female cancer patients receiving chemotherapy for recurrent disease p. 399
Anindita Mukherjee, Koustav Mazumder, Vikrant Kaushal, Sushmita Ghoshal
Context: Cancer patients receiving chemotherapy for their recurrent disease often report the presence of anxiety and depression. Aims: In the study, we intended to find out the mental health status and overall quality of life (QOL) of such patients and to identify the effect of supportive psychotherapy. Subjects and Methods: Forty cancer patients undergoing second or subsequent line chemotherapy(CCT) were selected for psychotherapy session. Pre- and post-psychotherapy evaluation of anxiety and depression was determined by hospital anxiety depression scale. The QOL was measured before and after psychotherapy sessions by using WHO QOL-BREF scale. Statistical Analysis Used: Statistical analysis was done by paired t-test, using SPSS V.20. Results: Among 40 patients, 17 patients had breast cancer, and the remaining had ovarian cancer. All breast cancer and 19 ovarian cancer patients were receiving 2nd line CCT. Four ovarian cancer patients were undergoing 3rd line CCT. Results indicated that mean scores (± standard deviation) of anxiety 13.95 (±4) and depression 15.5 (±4.4) both exceeded the cut-off score of 11 and mean score of QOL physical health 29.77 (±10.1), psychological health 31.3 (±10.1), social relationship 35.1 (±9.6), and environmental condition 25.9 (±9.9) was below cut-off score of 60. After psychotherapy, there was significant reduction in anxiety (P < 0.01), depression (P < 0.01) and improvement on QOL physical heath (P = 0.02), psychological health (P < 0.01), environmental condition (P < 0.01), and social relationship (P < 0.01). Conclusions: Supportive psychotherapy helps to reduce the level of anxiety, depression, and increase the QOL. Therefore, psychotherapeutic intervention should be encouraged along with chemotherapy to promote positive mental health and to obtain full benefit of their physical treatment.
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Estimation of need for palliative care among noncancer patients attending a tertiary care hospital p. 403
Parvathy Prasad, Sonali Sarkar, Biswajit Dubashi, S Adinarayanan
Context: Palliative care services, until recently, were mainly restricted to cancer patients with incurable diseases. Hence, evaluative studies of palliative care are sparse in areas other than oncology. Aims: To estimate what proportion of patients attending the Departments of Neurology, Cardiology, and Nephrology of Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, required palliative care and to identify the palliative care needs of those patients. Settings and Design: This was an exploratory descriptive study conducted in the three departments of JIPMER. Materials and Method: There was no predetermined sample size for the study. The participants were all adult inpatients and outpatients who were in need of palliative care in the departments of Cardiology, Nephrology, and Neurology on the day of study. Statistical Analysis: Percentage distribution was used to analyze the categorical variables such as education, gender, age, patients in need of palliative care, and their needs. Results: The study showed that one in ten non-cancer patients in tertiary care hospitals may require palliative care services. Apart from issues in physical domain, a substantial proportion of participants also had issues in the psychological, emotional, and financial domains. Conclusion: This study highlights the need for incorporation and initiation of palliative care services in other non-cancer specialties in tertiary care hospitals to ensure holistic management of such cases. Counseling service has also to be rendered as part of palliative care since a good share of the patients had psychological and emotional issues.
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Referral patterns of gynecological cancer patients to a palliative medicine unit: A 2 years retrospective analysis p. 409
Shrikant Atreya
Introduction: Patients with advanced gynecological malignancies often present with a high burden of symptoms endangering their quality of life. Objective: This study aims at assessing the symptom prevalence in patients with gynecological malignancies referred to palliative care and identify factors that predict high symptom burden. Methodology: This was a retrospective data analysis of gynecological cancer patients referred to palliative medicine department. We reviewed the electronic medical records of patients to obtain data on (1) demography (age, residence); (2) clinical information (diagnosis, stage of cancer, the reason for referral to palliative care service, symptoms, and performance status). The data were reported as frequency and percentages and analysis performed using Chi-square. P < 0.05 was considered to be statistically significant. Results: We analyzed 196 patients with advanced gynecological cancers presenting to palliative medicine department. The pain was the most common symptoms (70.04%) followed by anorexia (34.13%), constipation (28.57%), and fatigue (28.06%). There was a trend toward higher symptom burden in patients younger than 60 years. Among cancer diagnosis, patients with cervical cancer had a higher prevalence of pain (76.66%) followed by ovarian (70.79%) and endometrium (60.97%). Anorexia was the next commonly prevalent symptoms in ovarian (40.45%), endometrium (29.27%), and cervical cancer (28.33%). Conclusion: Considering the high symptom burden among advanced gynecological cancer patients it becomes imperative that patients receive adequate screening for symptoms and appropriate palliative care referral be offered to ensure overall well-being of the patients.
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Symptom prevalence in patients with advanced, incurable illness in Bangladesh p. 413
Megan Doherty, Farzana Khan, Fazle Noor Biswas, Marufa Khanom, Rubayat Rahman, Mohammad Munirul Islam Tanvir, Farhana Akter, Mridul Sarker, Nezamuddin Ahmad
Context: There is a significant need for palliative care for patients living in low- and middle-income countries. The presence and intensity of physical symptoms is a major factor influencing the suffering of patients at the end of life. Objectives: The primary aim of this study was to determine the prevalence and characteristics of common physical symptoms experienced by patients with advanced, incurable illness in a developing country. Method: This study used semi-structured interviews in patients with advanced cancer or HIV/AIDS in Bangladesh. Results: Pain was the most common symptom (70.6%) and was frequently reported to be severe (62.6%). Very few patients received strong opioids to treat their pain (13.7%). Other frequent symptoms included loss of appetite (23.5%) and fever (19.9%). The average number of physical symptoms reported was 3 (range: 0–23). The majority of patients rated their most recent symptom (excluding pain) as severe (64.3%), with 35.8% continuing to have severe symptom intensity despite treatment. Conclusions: This study reveals the significant burden of symptoms, and the associated suffering for patients living with incurable illness, in a developing country. Very few patients received strong opioids, despite frequently having severe pain. Frequently, the treatments that patients received did not alleviate their symptoms. Palliative care is vital for the relief of suffering for patients with advanced and incurable diseases, especially in low- and middle-income countries where access to curative treatments may be limited and patients often present to medical personnel when their illness is in an advanced stage or incurable.
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The psychometric properties and factor structure of persian version of edmonton symptom assessment scale in cancer patients p. 419
Younes Khalili-Parapary, Mehdi Heidarzadeh, Naser Mozaffari, Parisa Naseri
Context: Edmonton Symptom Assessment Scale (ESAS) was developed to assess objective and subjective symptoms in patients with cancer in all stages of their disease. Aim: The aim of the study was to translate and determine the psychometric properties of ESAS in an Iranian population. Materials and Methods: The current study was carried out to determine reliability and validity of ESAS using 246 patients with cancer in Imam Khomeini Hospital, Ardabil, Iran. After translating the instrument to Persian, content and face validity, discriminant validity, internal consistency, and test-retest were done to determine psychometric properties of ESAS. Furthermore, the construct validity was determined using confirmatory factor analysis to evaluate factor structure of the tool in two models: single factor and three factor. Results: With regard to goodness of fit indices including comparative fit index, incremental fit index, and normed fit index, factor structure of ESAS was confirmed with one factor and nine items. Because the values of average variance extracted of each dimension were less than the square of correlation coefficients between the three dimensions of ESAS, three-factor model was not confirmed. Discriminant validity was confirmed by finding significant differences between the two groups, patients with good general and critically ill conditions. Cronbach's alpha for the overall ESAS was 0.88, and correlation between test-retest with 4–6 h interval was 0.86 (r = 0.86 P < 0001). Conclusions: This study showed that Persian version of ESAS with same factor structure mentioned in the original version is an applicable tool for assessing objective and subjective symptoms in Iranian patients with cancer.
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Evaluation of community-based palliative care services: Perspectives from various stakeholders p. 425
Venugopal Vinayagamoorthy, Elayaperumal Suguna, Amol R Dongre
Background: As a part of Memorandum of Understanding with Tamil Nadu Institute of Palliative Medicine, community-based palliative care services have been initiated 2 years back in our urban field practice areas. Aim: The aim of this study was to evaluate the home care service, a major component of our community-based palliative care, with a view to identify the unmet needs of the services rendered for decision-making about the program. Materials and Methods: It was a descriptive qualitative design carried out by the authors trained in qualitative research methods. In-depth interviews were done among four patients, seven caregivers, two social workers, six nursing staffs, and six medical interns for a minimum of 20 min. Interviews were audiorecorded, transcribed verbatim, and content analysis was done manually. Ethical principles were adhered throughout the study. Results: Descriptive coding of the text information was done; later, similar codes were merged together to form the categories. Five categories under the theme of strengths and five codes under the theme of challenges of the home care services emerged out. Categories under strengths were physical management, psychological care, social support, efficient teamwork, and acceptance by the community. Codes for felt challenges were interdisciplinary collaboration, volunteer involvement, training enhancement, widening the services, and enhancing the community support. Conclusions: This review revealed the concerns of various stakeholders. There is a need for more interprofessional collaborations, where team members understand each other's roles for effective teamwork, as evident from the framework analysis.
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The effect of aromatherapy with the essential oil of orange on pain and vital signs of patients with fractured limbs admitted to the emergency ward: A randomized clinical trial p. 431
Davood Hekmatpou, Yasaman Pourandish, Pouran Varvani Farahani, Ramin Parvizrad
Background and Objective: Pain is an emotional and unpleasant experience associated with actual or potential tissue damage. The literature shows no study on the effect of aromatherapy with the essential oil of orange on unpleasant feelings of patients with fractured limbs. In this regard, this paper aims at studying the effect of aromatherapy with the essential oil of orange on patients with fractured limbs admitted to the emergency ward. Methods: Sixty patients admitted to the emergency ward of Vali-e-Asr Hospital were selected by purposive sampling method and then were divided into two groups of control and experiment by block method. This study was done in one shift work (morning or afternoon). Four drops of the orange oil were poured on a pad and were pinned with a plastic pin to the patient's collar, about 20 cm distant from head. The old pad was replaced by the new one every 1 h. The patients' pain and vital signs were checked every 1 h for at last 6 h. The data were analyzed by SPSS Version 21. Results: Forty (66.7%) patients were male and twenty (33.3%) were female. Their age average was 37.93 ± 18.19 years old. The most fractured cases were in the scapular (11 patients [18.3%]). Friedman test showed that pain in the experiment group (P = 0.0001) decreased significantly rather than the control group (0.339). However, in vital signs, there could be found that no significant change between the two groups was seen. Conclusion: Aromatherapy with orange oil can relieve pain in patients with fractured limbs but has no effect on their vital signs. Therefore, aromatherapy with orange oil can be used as a complementary medicine in these patients.
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Spiritual needs and quality of life of patients with cancer p. 437
Mansooreh Azizzadeh Forouzi, Batool Tirgari, Mohammad Hossein Safarizadeh, Yunes Jahani
Background and Aim: Information about spiritual needs and quality of life (QoL) is limited in Iranian cancer patients. This study was conducted to determine the relationship between spiritual needs and QoL among cancer patients in Iran. Methods: This correlational study included a convenience sample of 150 eligible cancer patients who were hospitalized in the oncology wards and outpatient clinics. Using two questionnaires; the spiritual needs survey and the European Organization for Research and Treatment of Cancer QoL Questionnaire-C30 data were collected. The data were analyzed by SPSS software version 19. Results: Our findings showed that the total mean score of spiritual needs was (64.32 ± 22.22). Among the categories, the lowest score belonged to “morality and ethics” component (2.18 ± 1.64), and the highest score belonged to “positivity/gratitude/hope/peace” component (15.95 ± 5.47). The mean score of QoL was (79.28 ± 19.20). Among the categories, the lowest score belonged to “global health status” component (8.44 ± 3.64), and the highest score belonged to “functional” component (36.57 ± 10.28). Pearson correlation coefficient showed that spiritual needs score positively correlated with QoL (r = 0.22; P = 0.006). Conclusion: The results of the present study suggest that information about the relationship between spiritual needs and QoL in patients with cancer. It should be improve QoL to meet spiritual need of these patients. In addition, the continuous and in-service education of cancer patients and nurses who work with them can be helpful in this area.
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Quality of life among cancer patients p. 445
Malathi G Nayak, Anice George, MS Vidyasagar, Stanley Mathew, Sudhakar Nayak, Baby S Nayak, YN Shashidhara, Asha Kamath
Introduction: Cancer is a leading cause of death. People living with cancer experience a variety of symptoms. Quality of life (QOL) is a major concern of patients with terminal cancer. Symptoms affect their QOL. Management of symptoms improves distress and QOL. Objective: The objective of the study was to assess the QOL among cancer patients. Materials and Methods: A survey was conducted among 768 cancer patients selected by a convenient sampling technique. Data was collected from cancer patients by interview technique using structured and validated interviewed schedule. Results: Out of 768 cancer patients, 30.2% patients were in the age group of 51–60 years, majority with head–and-neck cancer (40.1%), and 57.7% had stage III disease. QOL of majority of patients was influenced by their symptoms. 82.3% of them had low QOL scores. Conclusion: Cancer patients experienced many symptoms that affected their QOL. There is a need to develop interventions for effective management of symptoms that will empower the patients to have a greater sense of control over their illness and treatment and to improve the QOL.
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Profile of patients opting for palliative care in India p. 451
Prince John, Ravindra B Ghooi
Introduction: Understanding the profile of end users is a key input for designing a service. Centers that provide full-scale palliative care are few and far between in our country, and there is a need to open more centers to extend the services to a larger percentage of patients. Methods: Patient data from the inception of the center till January 2016 have been stored in a database. The data were mined, exported to Excel, and analyzed. Results: The data of 11,258 patients revealed the profile of patients, including their age, gender distribution, marital status, symptomology, and outcome. The present paper describes the profile of patients opting for palliative care in our country. Conclusions: The profile of patients registered at this center validates certain assumptions while debunking others. It is hoped that this profile gives some guidance to those desirous of setting up palliative care services.
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Economics of palliative and end-of-life care in India: A concept paper p. 456
Arunangshu Ghoshal, Anuja Damani, Naveen Salins, Jayita Deodhar, MA Muckaden
Only a few studies have assessed the economic outcomes of palliative care in India. The major areas of interest include hospice care, the process and structure of care, symptom management, and palliative chemotherapy compared to best supportive care. At present, there is no definite health-care system followed in India. Medical bankruptcy is common. In situations where patients bear most of the costs, medical decision-making might have significant implications on economics of health care. Game theory might help in deciphering the underlying complexities of decision-making when considered as a two person nonzero sum game. Overall, interdisciplinary communication and cooperation between health economists and palliative care team seem necessary. This will lead to enhanced understanding of the challenges faced by each other and hopefully help develop ways to create meaningful, accurate, and reliable health economic data. These results can then be used as powerful advocacy tools to convince governments to allocate more funds for the cause of palliative care. Eventually, this will save overall costs and avoid unnecessary health-care spending.
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Translational research in oncology: Implications for palliative care p. 462
Arunangshu Ghoshal
The label “translational research” (TR) has become ever more popular in the biomedical domain in recent years. It is usually presented as an attempt to bridge a supposed gap between knowledge produced at the laboratory bench and its use at the clinical bedside. This is claimed to help society harvest the benefits of its investments in scientific research. The past decade has witnessed a remarkable acceleration in the pace of translational cancer medicine – genome sequencing of various human cancers has been broadly deployed in drug discovery programs, diagnostic tests have been developed to predict molecularly targeted anticancer agents, advent of cancer immunotherapies, an enhanced appreciation of the complex interactions that exist between tumor cells and their microenvironment have revolutionized the management of cancers. Treatment for cancer and palliative care (PC) go hand in hand and the role of TR in PC can no longer be ignored. This paper discusses about the scientific discourse of TR in cancer care and its implications for the practice of PC. It starts with a brief reconstruction of the history of the concept and subsequently unravels how the label is used in clinical/research practice. In conclusion, TR seems to be driven by a changed relationship between science and society. “Translation” has become important because society is thought to deserve a tangible return in terms of health and quality of life on its investment in basic biomedical science.
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Complementary therapies for symptom management in cancer patients p. 468
Aanchal Satija, Sushma Bhatnagar
Cancer patients are often poly-symptomatic which distressingly affects their quality of lives (QOLs). Alhough, conventional management provides adequate symptom control, yet is coupled with some limitations. Complementary therapies (CTs) have shown beneficial effects in cancer patients for symptomatic relief. The aim of this article is to provide evidence-based review of commonly used CTs for symptom management in cancer care. Hypnosis has promising evidence to be used for managing symptoms such as pain, chemotherapy-induced nausea/vomiting, distress, fatigue, and hot flashes. Guided imagery increases comfort and can be used as a psycho-supportive therapy. Meditation substantially improves psychological function, mental health, and QOL. Cognitive behavioral therapies effectively reduce pain, distress, fatigue, anxiety, and depression; and improve subjective sleep outcomes along with mood and QOL. Yoga has short term beneficial effects for anxiety, depression, fatigue, perceived stress, QOL, and well-being. T'ai Chi and qigong are beneficial adjunctive therapies for supportive cancer care, but their role in reducing cancer pain is not well proven. Acupuncture is effective for reducing treatment related side-effects, pain and fatigue. Other therapies such as massage techniques, energy therapies, and spiritual interventions have also demonstrated positive role in managing cancer-related symptoms and improve overall well-being. However, the clinical effectiveness of these therapies for symptom management in cancer patients cannot be concluded due to poor strength of evidence. Nonetheless, these are relatively free from risks and hence can be given along with conventional treatments. Only by tailoring these therapies as per patient's beliefs and preferences, optimal patient-centered holistic care can be provided.
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Chronic cancer pain: Diagnostic dilemma and management challenges p. 480
Deepti Ahuja, Sachidanand Jee Bharati, Seema Mishra, Sushma Bhatnagar
A 32-year-old female, diagnosed case of neuroendocrine tumor of pancreas, was admitted to the pain and palliative care unit with complaints of diffuse abdominal pain which was severe in intensity with score on numerical rating scale-9/10. Pain was not relieved even after taking tablet morphine immediate release 360 mg every 4 hourly, paracetamol 500 mg 6 hourly, and gabapentin 300 mg 8 hourly. She had undergone distal pancreatectomy with splenectomy and also received multiple lines of chemotherapy. After making a diagnosis of opioid-induced hyperalgesia, opioid rotation from morphine to fentanyl was done. This case report reflects various conditions where strong opioids fail to relieve cancer pain, and a multimodal approach is needed for its management.
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Reversal of opioid-induced toxicity p. 484
Shrenik P Ostwal, Naveen Salins, Jayita Deodhar
Opioids are commonly used for pain control in palliative care setting. Accumulation of active metabolites of opioids can cause a well-recognized toxidrome including respiratory depression (RD), decreased conscious level, pinpoint pupils, and drop in blood pressure. Opioid toxicity is often associated with amount ingested and its speed of absorption in the body. This can have life-threatening effects on various body systems. Naloxone is an opioid antagonist that competitively binds to opioid receptors and reverses all their effects. The indication for use is RD because of known or suspected opioid overdose. This article presents a case report of 61-year-old female, a case of advanced pancreatic cancer, progressed on disease-modifying treatments and referred to palliative care for best supportive care. She developed features of morphine toxicity that was promptly identified and managed with use of naloxone and other supportive measures.
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Online since 1st October '05
Published by Wolters Kluwer - Medknow