Indian Journal of Palliative Care
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   Table of Contents - Current issue
Coverpage
July-September 2019
Volume 25 | Issue 3
Page Nos. 359-484

Online since Wednesday, July 17, 2019

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EDITORIAL  

Addressing a long-felt need: Introducing palliative care for MBBS Students in the new competency-Based Medical Education Curriculum Highly accessed article p. 359
Pragna Rao
DOI:10.4103/IJPC.IJPC_108_19  
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ORIGINAL ARTICLES Top

Colorful screams of silent emotions: A study with oncological patients Highly accessed article p. 361
Sema Yilmaz Rakici, Elanur Karaman
DOI:10.4103/IJPC.IJPC_79_19  
Background: Art, as a product of human behavior, is the expression of emotions from inner states and may provide catharsis, purification, and release. Several branches of art, most notably music, dance, and painting, can be used for treatment purposes, especially in the case of psychological disorders. Cancer, which is defined as uncontrolled cell growth, has been an important health issue throughout history, but the recent increase in its frequency has made it one of the most significant public health problems. Both the physiological distress the disease subjects the body to and the accompanying emotional distress are important factors to be considered in cancer treatment. Aims: In this study, the role of art in expressing emotions of oncological patients was investigated. Materials and Methods: During the treatment period, patients were interviewed about their experiences, feelings, expectations and perceptions. The picture was used as an expression of emotions. Results: Communication between the patient and doctor is one of the most important elements in the treatment process, and it has come to the fore in branches of medicine, such as oncology, because of its positive contribution to treatment compliance. In general, the study showed a pronounced positivity and expectations on the part of patients from the hope-life-healing process rather than oncological treatment. Conclusion: In this study, we aim to demonstrate how the artistic expression of emotions, in particular, through painting, has a positive effect on healing, hope, and the interactions between cancer patients under oncological treatment and medical professionals.
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“Adjunctive effects of a short session of music on pain, low-mood and anxiety modulation among cancer patients” – A randomized crossover clinical trial Highly accessed article p. 367
Gunasekara Vidana Mestrige Chamath Fernando, Lagath Udara Wanigabadu, Buddhika Vidanagama, Terancy Shyamale Perera Samaranayaka, Jeewandara Mudiyanselage Kamal Chandima Jeewandara
DOI:10.4103/IJPC.IJPC_22_19  
Aims: Pain, a distressing symptom frequently suffered by cancer patients, is inherently associated with anxiety and depression yet often not alleviated with pharmacotherapy alone. This study was aimed at assessing the effect of an instrumental classical music listening session as an adjunct to the ongoing therapies, on pain, anxiety, and mood modulation in cancer patients. Materials and Methods: A randomized crossover open clinical trial was designed involving adult resident patients suffering pain at a tertiary cancer care institution. The same group of patients (n = 24) were monitored for selected outcomes without (day 1) and then with administration of music (day 2). The primary (subjective) outcomes such as pain, anxiety, and mood levels measured on visual analog scale and surrogate (objective) parameters such as pulse rate, systolic blood pressure, diastolic blood pressure, respiratory rate, and pupillary size monitored were compared utilizing paired-sample t-test. Results: Statistically significant improvements were noted in all three subjective parameters; pain and anxiety were significantly diminished until the 4th h (P = 0.007 and P = 0.0022, respectively), while low mood remained alleviated until the 12th h reading point (P = 0.007). Statistically significant reductions were present in surrogate end points such as pupillary size (P = 0.003 up to 12 h) and respiratory rate (P = 0.01 up to 8 h). Declines noted in the heart rate, and blood pressure readings were statistically insignificant. None suffered deterioration of their existing well-being. Conclusions: Hence, we conclude that culturally familiar instrumental classical music demonstrates a significant effect in alleviating pain, anxiety, and low mood as an adjunct to on-going therapies in cancer patients.
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Validation of the comprehensive needs assessment tool in patients with advanced cancer p. 374
Grace Meijuan Yang, Grace Su-Yin Pang, Geok Ling Lee, Patricia Soek Hui Neo, Yin Yee Wong, Debra Limin Qu, Yin Bun Cheung
DOI:10.4103/IJPC.IJPC_38_19  
Aims: The 59-item Comprehensive Needs Assessment Tool (CNAT) for cancer patients is an English language survey developed in South Korea. The objective of this study was to validate the English version of CNAT in advanced cancer patients in Singapore. Methods: This was a cross-sectional survey where advanced cancer patients completed the CNAT in English. Confirmatory factor analysis was used to assess construct validity. For known groups validity, independent samples t-test was used to compare CNAT scores based on the Karnofsky performance status and outpatient versus inpatient setting. Cronbach's alpha was used to measure internal consistency. Results: A total of 328 advanced cancer patients were recruited. The mean age was 59.6 years and 49.1% were male. Majority (68.0%) were Chinese, 20.4% were Malay, 7.9% were Indian, and 3.7% were of other ethnicities. The 7-factor model previously established in Korea showed sufficient construct validity with root mean square error of approximation 0.037 and comparative fit index 0.944. All 59 items had a factor loading ≥0.5. Group invariance test showed no difference in the pattern of factor loadings between ethnic Chinese and other ethnic groups (P = 0.155). For known groups validity, there were significant differences in CNAT scores by performance status and outpatient versus inpatient setting. The CNAT total and factor scores showed good internal consistency with Cronbach's alpha of between 0.80 and 0.937. Conclusions: The CNAT showed construct and known-group validity and internal consistency in this study sample and can be used to assess the unmet needs of advanced cancer patients in the Singapore context.
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Availability of informal caregivers for palliative care patients with cancer: Is there a difference between higher- and lower-income settings p. 379
Raafat Abdel-Malek, Dina E Farag, Kyrillus S Shohdy, Sarah Cox
DOI:10.4103/IJPC.IJPC_199_18  
Objective: Family caregivers are the default caring personnel for terminal cancer patients. The characteristics, demographics, distribution, psychological burden, and socioeconomic standards differ between high- and low-income countries. We aimed to assess those factors and their direct reflection on both the patient and the caregiver. Patients and Methods: This is a comparative cross-sectional study for terminal cancer patients in the palliative care unit between the United Kingdom (UK) as a high-income community and Egypt as a low-income community. We assessed the different characteristics, demographics, living place, the degree of relevance, and the availability of caregivers. Results: We have recruited 216 patients from the UK and 117 patients from Egypt. Informal caregivers were available in 74.5% and 92.3% for these patients with a mean age of 71.5 (standard deviation [SD] 16) years and 50.9 (SD 15.18) years, respectively. There has been a statistically significant difference between the two countries' caregivers in being married, family, and living in the same household (P < 0.0001). Conclusion: Low-income countries are more common to have an informal caregiver who is a family member of different degree of relevance. Caregivers in low-income settings tend to be younger, of the female gender, married, and living in the same household than in high-income ones.
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Effect of hypofractionated, palliative radiotherapy on quality of life in late-stage oral cavity cancer: A prospective clinical trial p. 383
Aswin Chandran Veluthattil, Shyama Prem Sudha, Saravanan Kandasamy, Sunitha Vellathussery Chakkalakkoombil
DOI:10.4103/IJPC.IJPC_115_18  
Context: The study was designed to evaluate the effect of a hypofractionated, palliative conformal radiotherapy regimen of 5250 cGy in 15 fractions in inoperable/incurable oral cavity carcinoma. Aims: The primary objective was to assess the change in the quality of life (QOL) with respect to pain and mouth opening pre- and post-radiotherapy using standardized questionnaires. The secondary objective was to assess overall QOL using the same questionnaires and also to assess response rates, survival, compliance, early and late toxicity. Settings and Design: This was a single-arm, prospective trial. Patients with incurable oral cavity cancer referred for palliative intent radiotherapy to the Department of Radiotherapy, RCC, JIPMER were recruited into the study. Subjects and Methods: Forty-eight patients were recruited and twenty-five patients were given conformal radiotherapy to a dose of 52.5 Gy in 15 fractions. QOL was assessed using the European Organization of Research and Treatment of Cancer (EORTC) questionnaires before and 2 months after the completion of radiotherapy. The response assessment was made using the Response Evaluation Criteria in Solid Tumors (RECIST) criteria 2 months after radiotherapy. The early and late toxicities were assessed at 2 months and 6 months after radiotherapy completion, respectively. Statistical Analysis Used: Sample size was calculated to be 53. The Wilcoxon signed-rank test was used to compare QOL scores pre- and post-radiotherapy. Median survival was assessed using the Kaplan–Meier method. Results: There was a significant improvement in the pain, mouth opening, speech, social contact, social eating, felt ill items of the EORTC QLQ-H and N35 questionnaire and role functioning, emotional functioning, social functioning, fatigue, pain, insomnia, appetite loss, financial difficulties, and Global QOL subscales of the QLQ-C30 questionnaire. 72% of the patients had grade 3 acute radiation oral mucositis and 36% had grade 3 acute radiation dermatitis. There were no significant treatment breaks due to toxicity. There were no grade 3 late toxicities observed. Overall median survival was 5.1 months. The overall response rate was 47%. The median time to treatment completion was 24 days. Conclusions: The improvement in QOL parameters suggests that the regimen of 52.5 Gy in 15 fractions is suitable for palliative intent radiotherapy in late-stage oral cavity cancer for effective palliation for short periods.
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Radiation for palliation: Role of palliative radiotherapy in allevieating pain/symptoms in a prospective observational study at two Tertiary Care Centers p. 391
Ashok Kumar, Hari Mukundan, Sharad Bhatnagar, Arti Sarin, Sachin Taneja, Srimukta Sahoo
DOI:10.4103/IJPC.IJPC_35_19  
Purpose: Approximately one-third of patients attending the tertiary care center require palliative management. The purpose of this study was to investigate the role of palliative radiation in alleviating the pain and symptoms and improvement in quality of life (QOL). Methods: This was a prospective study aimed to evaluate patients attending two oncology centers and those who require palliative radiation. During 3 years, 1365 patients attended radiation oncology center for various malignancies. Of these patients, 304 patients were treated with palliative radiation for various indications. These patients were followed up for a period of up to 6 months for symptom relief and improved QOL. Results: About 22% of patients received palliative radiation primarily for carcinoma lung, breast, and prostate malignancy. Analysis revealed elderly patients in the age group of 50–70 being the most commonly affected and most common presentation was pain, swelling, and headache. The most common site of metastases was bone including the spine and brain. Most commonly employed schedule of palliative radiation was 30 Gy in 10 fractions and 20 Gy in 5 fractions. Patients responded well to palliative radiation and had improved pain relief and QOL. Conclusions: Palliative radiation is an important part of the management of cancer care and when given improves QOL, and significant pain relief.
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Self-Expanding Metallic Stents (SEMS) in inoperable esophageal cancer: A prospective analysis of morbidity and survival outcomes p. 398
Brij Sharma, Sujeet Raina, Rajesh Sharma, Vishal Bodh, Sunil K Raina, Neetu Sharma
DOI:10.4103/IJPC.IJPC_185_18  
Background: Palliative treatment for inoperable esophageal cancers by self-expanding metallic stents (SEMS) overcomes disease-related symptoms, preserves the quality of life, and prolongs survival. The aim of this study was to determine dysphagia relief, complications, and patient survival after SEMS in patients with inoperable esophageal cancer. Methods: This is a hospital-based open cohort study conducted over 9 years between January 1, 2009, and December 31, 2017, from the Sub-Himalayan region of the Indian subcontinent. The last patient was recruited on November 16, 2017 and the minimum of follow-up was either death or survival till December 31, 2017. All the patients attending gastroenterology clinic or admitted in medical wards and fulfilling the definition of inoperable esophageal cancer, subsequently treated with SEMS were included. Data were prospectively gathered on demography, dysphagia scores, morbidity, mortality, and survival outcomes. Follow-ups were done during hospital visits or through a telephonic conversation with the patient and/or caregiver. Results: Of 239 patients, 147 (61.5%) were male and 92 (38.5%) were female. Most of the patients (60.7%) are in the age group of 51–70 years. Squamous cell carcinoma (SCC) was diagnosed in 205 (85.7%) and adenocarcinoma (ADC) in 34 (14.2%). Lower one-third was the most common site of tumor and observed in 125 (52.3%) patients. ADC was diagnosed equally in males and females and the mean age of presentation with ADC was equal to SCC. All the patients had dysphagia score 4, which improved to score 1 after SEMS insertion. Females had better survival than that of males. The difference was found to be statistically significant. Conclusion: SEMS effectively reduced dysphagia in inoperable esophageal cancer. Better survival rates were observed in females than males.
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High prevalence of dyspnea in lung cancer: An observational study p. 403
Anuja Damani, Arunangshu Ghoshal, Naveen Salins, MA Muckaden, Jayita Deodhar
DOI:10.4103/IJPC.IJPC_64_19  
Introduction: Dyspnea is a subjective, multidimensional experience of breathing discomfort, commonly seen in patients with advanced cancer. This study is a secondary analysis to seek the clinical prevalence of dyspnea on a subset of patients with lung cancer. Improving the quality of life (QoL) in dyspnea requires aggressive symptom management, which in turn entails a detailed understanding of its symptomatology. Materials and Methods: This was a subset analysis of lung cancer patients of a prospective observational study done over 6 months from April to September 2014 at the Department of Palliative Medicine, Tata Memorial Centre (Mumbai). Results and Conclusions: About 71.43% of the patients with advanced lung cancer experienced dyspnea. Dyspnea increased with worsening fatigue, anxiety, appetite, and well-being. Patients described it as an increased sense of effort for breathing, and it lowered the QoL substantially.
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Characteristics of burden, coping strategies, and quality of life: The effect of age, gender, and social variables in caregivers of renal transplanted patients from Southern Andhra Pradesh, India p. 407
M Nagarathnam, V Sivakumar, S A.A Latheef
DOI:10.4103/IJPC.IJPC_34_19  
Background: Evaluation of burden, coping strategies, and quality of life (QOL) in caregivers may lead to specific interventions to reduce the burden among caregivers. Methods: In this prospective study, characteristics of burden, coping strategies, and QOL in caregivers was investigated and also studied the effect of age, gender, and social variables on these concepts. Results: Mean burden score of the caregivers was 28.66 ± 2.02. Thirty percent of caregivers had mild-to-moderate burden followed by moderate-to-severe burden (20%). Seeking social support was the dominant coping strategy used by the caregivers. Role limitations due to the physical health (RLDPH) and role limitations due to emotional problem (RLDEP) were compromised subscales of QOL. The mean score of RLDPH (P = 0.007) and RLDEP (P = 0.014) were found to be significantly higher in males than that of females. Marital status, education, type of relationship with the patient, religion, occupation, and duration of care giving showed significant effect on burden, coping strategies, and QOL. Lower emotional well-being (P = 0.003) and escape avoidance (P = 0.000) in males and lower physical component (PC) (P = 0.002) in females and lower PC (P = 0.000) and escape avoidance (P = 0.001) were found to be the significant predictors of burden in caregivers of renal transplanted patients. Conclusion: Predictors of burden and QOL subscales varies by gender. Social and clinical variables influence the QOL subscales. Gender- and social group-specific interventions rather than global interventions may reduce the burden of caregivers.
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A comparative study on perceived stress, coping, quality of life, and hopelessness between cancer patients and survivors p. 414
Ottlingam Somasundaram Ravindran, Athira Shankar, Tejus Murthy
DOI:10.4103/IJPC.IJPC_1_19  
Background and Aim: Cancer patients and survivors need to cope with many physical and emotional stressors. This cross-sectional study compared the perceived stress, coping, quality of life (QOL), and hopelessness between cancer patients and cancer survivors and examined the relationship of perceived stress with coping, QOL, and hopelessness in cancer patients and cancer survivors. Materials and Methods: Using a purposive sampling technique, this study was conducted in the Medical Oncology Department of a multi-specialty tertiary care teaching hospital between February and May 2018. Thirty participants (15 cancer patients and 15 cancer survivors) in the age range of 30–60 years took part in the study. Both groups were assessed by the following instruments: Perceived Stress Scale, Coping Checklist, Quality of Life-Cancer, and Beck Hopelessness Scale. Results: Cancer patients are using maladaptive coping strategies and experiencing psychological distress with reduced QOL than cancer survivors. Furthermore, hopelessness was positively correlated with QOL among cancer survivors. Conclusions: Cancer patients are found to be distressed and hopeless with significant reductions in their QOL.
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Understanding the psychosocial impact of oral cancer on the family caregivers and their coping up mechanism: A qualitative study in Rural Wardha, Central India p. 421
Sourav Goswami, Subodh Saran Gupta, Abhishek Raut
DOI:10.4103/IJPC.IJPC_9_19  
Background: A family caregiver is the one who provides care to their near and dear one who is suffering from some debilitating disease like oral cancer. Apart from providing physical care, they also provide emotional and financial support to their close relatives. They can be the patient's spouse, children, and siblings. This study was, hence, designed to understand the psychosocial impact of caregivers of oral cancer patients. Methodology: This was a qualitative study using in-depth interviews of 24 purposively chosen family caregivers irrespective of age, sex, and relationship with patients, who provided deep insight into the psychosocial impact of the disease on themselves during caregiving of their loved ones and how they coped with it. Interviews were taken in Hindi, in the houses of caregivers. Care was taken to maintain utmost privacy while taking the interviews, which were either audio recorded or noted down. Informed written consent was obtained from participants before the start of the study. Themes were evolved from the interviews and content analysis was performed using ATLAS.ti. Results: Six themes emerged after data analysis. Those were the impact on physical health and lifestyle, emotional impact, impact on family and social relationship, impact on financial and work status, improvement of hospital services, spiritual concern, and acceptance of the disease. A concept map was made to provide a vivid explanation of how oral cancer caused these impacts on caregivers and their interrelationship. Conclusion: Caregiving is not an easy job. This study recommends extra care to be taken in preparing them for caregiving to the oral cancer patients with adequate knowledge of the disease process and its consequences along with counseling facilities in the hospital to address the different psychosocial needs of the patients.
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“End-of-life care is more than wound care”: Health-care providers' perceptions of psychological and interpersonal needs of patients with terminal cancer p. 428
Nishal Pinto, Poornima Bhola, Prabha S Chandra
DOI:10.4103/IJPC.IJPC_26_19  
Aim: People diagnosed with cancer and in end-of-life care may have a range of needs. These needs may be inadequately expressed, recognized, or responded to by family members and health-care providers. The present study aimed at exploring health-care providers' perceptions of the interpersonal needs, psychological needs, and unfinished business among terminally ill cancer patients during the end-of-life care. Methods: The sample consisted of 11 health-care providers, including physicians, counselors, social workers, and nurses from the end-of-life care settings in Bengaluru, India. A cross-sectional qualitative design was used and involved semi-structured interviews and focus group discussions. Results: Thematic analysis identified themes related to health-care providers' perceptions of patients' prominent interpersonal needs, psychological needs, and expressions of “unfinished business” and their perspectives and experiences. There were three themes related to psychological needs and concerns: (i) experience and expression of negative emotions, (ii) mental health concerns, and (iii) confronting mortality. Three themes emerged in the domain of interpersonal connections: (i) support and closer connections with family, (ii) disconnection from family relationships, and (iii) building new connections at the hospice. Two themes were identified related to unfinished business: (i) types of unfinished business and (ii) addressing unfinished business. The findings also highlighted health-care providers' perspectives and experiences: (i) need for expanded end-of-life care training and (ii) experiences of emotional labor. Conclusions: The findings have implications for comprehensive training of health-care providers and for assessment, support, and care services in palliative care settings in India.
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Challenges faced by patients undergoing radiotherapy for oral cancer: A qualitative study p. 436
Suvi Kanchan, K Pushpanjali, BD Tejaswini
DOI:10.4103/IJPC.IJPC_40_19  
Background: Oral cancer is one of the most common types of cancers in India. Radiotherapy is one of the treatment options frequently resulting in complications. These complications affect the patient's quality of life, nutritional intake, and consequently undermine the treatment outcomes. Patients' verbal accounts of experiences regarding their overall oral health during radiotherapy have not been described sufficiently. Aim: The aim of the current study was to identify and analyze the issues experienced by patients while undergoing radiotherapy for oral cancer treatment. Materials and Methods: A phenomenology study design was chosen, with in-depth interviews as the selected strategy for data collection. A literature search was conducted based on which an interview guide in English was prepared and modified according to inputs from subject matter experts. The interview guide comprised nine questions, including opening, key, and closing questions, and was also translated into Telugu and Kannada – the two languages predominantly spoken by the patients visiting the hospital. Interviews were conducted with each patient separately, with each interview lasting for 60 min each. The interviews were audio-recorded, transcribed, coded, and categorized, following which themes were derived from the analysis. Results: The key theme that emerged from the study was the “Multifaceted experience of patients undergoing radiotherapy.” Conclusion: Understanding the specific issues faced by oral cancer patients undergoing radiotherapy drew our attention to the dire need for interprofessional collaboration, which could enable health professionals to share their expertise and perspectives toward achieving the common goal of restoring patients' health and improving health outcomes.
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Investigating the attitude of healthcare providers, patients, and their families toward “do not resuscitate” orders in an Iranian Oncology Hospital p. 440
Mohammad Reza Fayyazi Bordbar, Keyvan Tavakkoli, Mahsa Nahidi, Ali Fayyazi Bordbar
DOI:10.4103/IJPC.IJPC_29_19  
Aim: The decision-making process for do-not-resuscitate (DNR) order has always been challenging. Cultural and religious issues have limited the issuance and execution of DNR orders in Iran. The purpose of this study was to assess the attitude of the nurses, physicians, patients, and their families toward the DNR order. Subjects and Methods: In this cross-sectional study, 343 participants (201 patients, 95 family members, and 47 healthcare providers) from Omid Oncology Hospital, Mashhad, Iran, were surveyed during 2017–2018. All the participants were asked to fill in a checklist of demographic information and a validated questionnaire about their attitude toward DNR orders after giving consent. The data were analyzed using SPSS software and values of P < 0.05 were considered statistically significant. Results: Overall, 201 patients and 95 of their family members, as well as 47 healthcare providers (doctors and nurses), were surveyed. The mean age of participants was 48.75 ± 15.62 years. The attitude of the participants regarding the DNR order was significantly different in 10 of the 11 items (P ≤ 0.005). Among the three groups of participants, healthcare providers showed the most positive attitude regarding the DNR order. The attitude of participants regarding the DNR orders was significantly associated with age, occupation status, residential place, educational status, and income level (P < 0.05). Conclusions: Various factors, such as economic status, level of education, place of residence, and gender, can be effective on decision-making regarding the DNR orders. Unified and sustained education regarding moral and cultural issues can be helpful in the reconciliation of the attitudes between caregivers and patients.
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SYSTEMATIC REVIEW Top

A review of biographical work in palliative care p. 445
Michaela Hesse, Simon Forstmeier, Mochamat Mochamat, Lukas Radbruch
DOI:10.4103/IJPC.IJPC_16_19  
Aim: We find several interventions in palliative care to cover psychosocial needs and to relieve distress of patients. There is a growing interest in therapies using biographical approaches, but discussion about interventions is sparse, and there is no concept for comprehensive and sustainable provision. Research on interventions with a single biographical approach is available, but there is no systematic review that tests a range of interventions. Therefore, we look at all studies using biographical approaches for patients and/or caregivers. Methods: In May 2017, the electronic databases of Medline, PubMed, EMBASE, Central, and PsycINFO were searched for qualitative and quantitative empirical reports. Interventions for patients, dyads of patient and caregiver, and bereaved caregivers were included. Data analysis follows the guideline PRISMA. Results: Twenty-seven studies were included – 12 using a quantitative evaluation and 15 using a qualitative evaluation. Interventions using biographical approach are widespread and show broad variations in comprehension and performance. The scope of interest lays on patient and family in trajectory of illness and bereavement. The most common interventions used were life review, short life review, dignity therapy, and bereaved life review. Biographical approaches increase quality of life and spiritual well-being and reduce depression. Interventions show effects independently of the number of sessions or provider. Conclusions: Transferability of concepts seems limited due to the implications of culture on themes emerging in interventions. In some case, there were predicting factors for responders and nonresponders. Further research is needed.
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PERSPECTIVES Top

Understanding the frontiers of human longevity in India: Imperative and palliative care p. 455
Yatish Kumar
DOI:10.4103/IJPC.IJPC_20_19  
This article provides a theoretical and empirical insight on the study of population aging in India, with the special reference to the causes that have made it extremely significant. It evidently looks into the factors that are extensively associated with the process of population aging and have contributed to the Indian society. Demographically speaking, in the Indian context, the process of demographic transition has resulted from a falling birth rate, a slowing death rate, and spike in life expectancy. In the context of developing countries, the concept of population aging has been brought from developed countries. Initially, the outcomes of demographic transition had been experienced by developed regions followed by the rest of the world. Finally, it examines the consequences of complications that arise due to growth in life expectancy at birth, and further suggests the probable remedies to both strategy developers and policy-makers.
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Complementary role of intervention radiology in palliative care in oncology setting p. 462
Ekta Dhamija, Ashwin Deshmukh, Pankaj Meena, Mukesh Kumar, Sushma Bhatnagar, Sanjay Thulkar
DOI:10.4103/IJPC.IJPC_24_19  
Owing to advances in treatment of cancer, there has been increase in life expectancy. Palliative care aims at improving quality of life of patients suffering from malignancy and is now recognized as a separate subspecialty. Management of cancer patients needs a multidisciplinary approach, and radiology has a key role to play at every step of it. Interventional radiology has broadened its scope immensely over the last decade with development of newer and less invasive applications useful in oncology and palliative care. The role of interventional radiologists begins from obtaining tissue for histopathological examination and extends to controlling disease spread with ablation or chemoembolization, to managing the tumor-related complications and relieving stressful symptoms such as dyspnea and pain. This article aims to review the interventional radiologist's arsenal in managing patients with malignancies with a special emphasis on palliative care, providing a more holistic approach in improving the quality of life of cancer patients.
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CASE REPORTS Top

Intramedullary spinal cord metastases of malignant melanoma: A rare case report on paraplegia in palliative care p. 468
Rutula Sonawane, Arunangshu Ghoshal, Anuja Damani, MaryAnn Muckaden, Jayita K Deodhar
DOI:10.4103/IJPC.IJPC_163_18  
Rates of malignant melanoma have been increasing in frequency. Studies have shown that up to 46% of patients with melanoma will experience metastases to the central nervous system. Intramedullary spinal cord metastasis of malignant melanoma is rare. In advanced cancers, surgery might not be possible, and radiotherapy with corticotherapy is a viable option. In the following case, a 54-year-old male presented to the clinic with an intramedullary tumor in the D1 region. He was successfully managed with an integrated palliative care approach with concomitant cancer-directed therapy.
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Endovascular management of radiation-induced hemorrhagic cystitis p. 471
Ganesh G Gowda, R Vijayakumar, Maureen P Tigga
DOI:10.4103/IJPC.IJPC_6_19  
Radiation-induced hemorrhagic cystitis (HC) is an unpleasant and sometimes life-threatening complication confronted while treating pelvic malignancies. A wide array of treatment modalities such as bladder irrigation, fulguration, hyperbaric oxygen therapy, and surgical methods has been proposed to treat hematuria, but there is no consensus on the optimal therapeutic strategy for the same. Reported here is a successful superselective embolization of the bilateral vesical arteries in a patient with refractory radiation-induced HC. This technique proved to be effective in controlling intractable hemorrhage and can be considered an option for the treatment of HC not amenable to conventional techniques.
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Challenges encountered in placement of ostomy bag for palliative care in a patient with colorectal cancer p. 474
Vijay Kumar, Nitesh Kumawat, Jiya Maria Thomas, Ashok Kumar, Ankur Sharma, Manoj Kamal
DOI:10.4103/IJPC.IJPC_23_19  
Fecal fistula develop in patients with cancer associated with difficult management situation, which is often complicated by prior treatment including surgery, radiation therapy, and chemotherapy. Affecting factors such as timing of additional adjuvant therapy or palliative care, technical considerations for operating on irradiated bowel, poor wound healing, increased risk of additional fecal fistula, and decreased likelihood of spontaneous fecal fistula closure all need to be considered in this scenario. Here, the authors focus specifically on the management of fecal fistula associated with cancer and/or radiation- induced injury to the bowel.
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Palliative chemotherapy in elderly patient with comorbidities: Is it a paradox? p. 477
Sumit Goyal, Manish Sharma, Manoj Gupta, Ankush Jajodia, Venkata Pradeep Babu Koyyala
DOI:10.4103/IJPC.IJPC_2_19  
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Narrative overview of translation of a community palliative care intervention at Nadia district, West Bengal p. 478
Tulika Bhattacharyya
DOI:10.4103/IJPC.IJPC_180_18  
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Are we really providing quality care to patients? A physician's perspective p. 481
Shrenik P Ostwal
DOI:10.4103/IJPC.IJPC_153_18  
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Nefopam: Another Pragmatic Analgesic in Managing Chronic Neuropathic Pain p. 482
Abhijit S Nair
DOI:10.4103/IJPC.IJPC_215_18  
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Levorphanol: Rewinding an old, bygone multimodal opioid analgesic! p. 483
Abhijit S Nair, Omkar Upputuri, Srinivasa Shyam Prasad Mantha, Basanth Kumar Rayani
DOI:10.4103/IJPC.IJPC_11_19  
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