Indian Journal of Palliative Care
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October-December 2018
Volume 24 | Issue 4
Page Nos. 391-548

Online since Monday, October 15, 2018

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EDITORIAL  

Clear, simple, precise, meaningful: A quick guide to writing for publication Highly accessed article p. 391
Catherine Walshe
DOI:10.4103/IJPC.IJPC_175_18  PMID:30410247
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ORIGINAL ARTICLES Top

Identifying people in need of palliative care services in rural Tamil Nadu: A survey p. 393
Suguna Elayaperumal, Vinayagamoorthy Venugopal, Amol R Dongre
DOI:10.4103/IJPC.IJPC_92_18  PMID:30410248
Background: As a part of initiating community-based palliative care program in the field practice areas of Urban Health Training Centre (UHTC), Villupuram, it was necessary for us to identify people who need palliative care to plan our services. Aim: This study aims to assess the need for palliative care and its determinants in the villages under the UHTC, Villupuram, and to know their sociodemographic characteristics and morbidity profile. Materials and Methods: A community-based cross-sectional survey was conducted in the four villages under UHTC between April and September 2016. A house-to-house survey was conducted by a trained team using a structured questionnaire. The available member of the households was interviewed about the need for palliative care and the morbidity profile among all the members of their household. Written informed consent was obtained before the interview. Data were entered and analyzed using EpiInfo (version 7.2.2.6) software. Prevalence ratio, age- and gender-wise prevalence of people in need of palliative care was calculated. Results: The overall prevalence of people in need of palliative care was found to be 4.5/1000 population (95% confidence interval: 3.2–6.3). Among them, 73.5% were elderly people. The most common condition requiring palliative care was old age-related weakness (41.2%). Conclusion: The need for palliative care services among elderly people was found to be high. This data can be used for planning and implementing community-based palliative care services for the people in our field practice areas.
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Cluster analysis of symptoms of Bangladeshi women with breast cancer p. 397
Farzana Khan, Nezamuddin Ahmad, Fazle Noor Biswas
DOI:10.4103/IJPC.IJPC_77_18  PMID:30410249
Background: Breast cancer (BC) patients may experience multiple symptoms due to the disease itself, cancer treatment or combination of both. Aim: The aim of the present study was to express multiple symptoms experienced by the patients with BC as clusters. Methods: This was a retrospective study. We examined symptom profiles of 120 patients with BC who attended the Centre for Palliative Care, Bangabandhu Sheikh Mujib Medical University in Dhaka, Bangladesh, from January 2009 to December 2013. We included all case sheets of BC patients, which had documentation of needed information. Following symptoms were analyzed: pain, nausea, loss of appetite, constipation, weakness, cough, breathlessness, sleeplessness, lymphedema, sadness, anxiety, and depression. Hierarchical cluster analysis was used to identify the natural groupings within the set. Results: We could identify three clusters, namely (1) “neuropsychiatric,” (2) “gastro-respiratory,” and (3) “miscellaneous” symptom clusters. The symptoms in cluster 2 comprised of cough, breathlessness, nausea, and constipation. Cluster 1 was characterized by pain, depression, anxiety, weakness, sleeplessness, and loss of appetite. Cluster 2 was comprised of cough, breathlessness, nausea, and constipation. Cluster 3 consisted of two symptoms lymphedema and sadness. The results revealed that the multiple symptoms of patients with BC experienced had been clustered together. Neuropsychiatric symptoms and weakness formed a significant strong relationship with each other. Conclusion: Knowledge obtained from this study could be beneficial for better understanding, assessment, and management of symptom clusters in women with BC. It may also help patients to plan ahead for them to seek management of concurrent symptoms to improve their quality of life.
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End-of-life care and social security issues among geriatric people attending a tertiary care hospital of Eastern India p. 402
Subraham Pany, Lipilekha Patnaik, E Venkata Rao, Sumitra Pattanaik, Trilochan Sahu
DOI:10.4103/IJPC.IJPC_26_18  PMID:30410250
Context: The care of sick members is the hallmark of a civilized society. End-of-life care and social security for elderly are emerging issues nowadays. Aims: The aim of this study is to explore the desires of the elderly regarding the end-of-life care decisions along with to find out social security measures among the study population. Settings and Design: The cross-sectional study conducted in the geriatric outpatient department of a tertiary care hospital. Subjects and Methods: The study period was 4 months from August to November 2017. The geriatric patients attending geriatric outpatient department were interviewed using a predesigned and pretested questionnaire. Convenient sampling was used and a total of 138 participants were included in the study. Statistical Analysis Used: Proportions were used in the study. Results: A total of 63.77% participants expected to die at home surrounded by their family members during their time of death followed by hospital (31.88%). Majority (63.77%) stated their opinions to die a senile death. Organ donation after death was the willingness shown by as high as 70.3%, but registered organ donors were 6.5%. 94.2% participants expected to be cremated after their death while others buried in accord to their religious practices. Only 7.24% of participants had a legal will of their financial establishments. It was observed that even half of the population (47.8%) did not have any form of health or life insurance. Conclusion: Home-based care of the elderly is needed so that they can live their last days of life peacefully. Awareness about health and life insurance should be increased by urgent intervention.
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Validation of the caregiving knowledge questionnaire-my: Measuring knowledge regarding positioning and feeding among Malaysian informal caregivers of stroke patients p. 406
Chai-Eng Tan, Aznida F Abdul Aziz, May-Yin Hi, Nur Sarah A Azmi, Nur Khairina Ishak, Fathin Alyaa Mohamad Farid, Mohammad Nazri Zulkafli
DOI:10.4103/IJPC.IJPC_99_18  PMID:30410251
Aim: The majority of caregivers for stroke patients in Malaysia are informal caregivers, although there are no valid tools to measure their knowledge regarding caregiving. Therefore, this study validated the Caregiving Knowledge Questionnaire (CKQ-My) as an assessment of Malaysian stroke caregivers' knowledge regarding patient positioning and feeding. Methods: Back-to-back translation was used to produce a bilingual version of the questionnaire. Hand drawings were used to replace photographs from the original questionnaire. Face validity and content validity were assessed, and construct validity was determined by comparing responses from informal caregivers, medical students, and primary care doctors. Finally, the internal consistencies of the subscales were determined. Results: Pretesting showed that the translated version was sufficiently easy to understand. Internal consistency for the positioning subscale (28 items, Cronbach's α = 0.70) and feeding subscale (15 items, Cronbach's α = 0.70) was good. Mean scores for the positioning subscale for caregivers (mean: 17.1 ± 3.9), medical students (mean: 18.9 ± 3.1), and doctors (mean 21.5 ± 2.2) were significantly different (F = 5.28, P ' = 0.011). Mean scores for the feeding subscale for caregivers (mean 13.1 ± 2.5), medical students (mean 16.1 ± 1.9), and doctors (mean 16.1 ± 2.4) also differed significantly (F = 6.217, P = 0.006). Conclusions: CKQ-My has good internal consistency and construct validity for the subscales measuring stroke caregivers' knowledge about positioning and feeding of stroke patients. It has potential as an assessment of effectiveness of caregiver training and for future studies on long-term stroke outcomes in Malaysia.
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Impact of educational training in improving skills, practice, attitude, and knowledge of healthcare workers in pediatric palliative care: Children's palliative care project in the Indian state of Maharashtra p. 411
Arunangshu Ghoshal, Pradnya Talawadekar, Anil Palleri, Joan Marston, MaryAnn Muckaden
DOI:10.4103/IJPC.IJPC_43_18  PMID:30410252
Background: The “Children's Palliative Care Project” was initiated in October 2010 in the Indian state of Maharashtra with a view to improve the quality of life of children with life-limiting conditions. This study evaluates its education and training component through a questionnaire. Materials and Methods: A cross-sectional survey was carried out pre-/post-training among 258 doctors, nurses, social workers, and counselors at three sites in Maharashtra in March 2015. Descriptive statistics were used for data analysis. Results: Sixty-two participants responded. Posttraining, doctors and the nurses had a better level of knowledge, skill set, and attitude; whereas social workers and counselors fared better with prevailing care practices. Participants advocated using morphine only when other analgesics had failed and suggested ways for better service delivery of care. Conclusion: The study gives a rough idea of the prevailing practice of pediatric palliative care among the health-care workers (who participated in the survey) and suggests practical ways to improve it.
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Impact of different sociodemographic factors on mental health status of female cancer patients receiving chemotherapy for recurrent disease p. 426
Anindita Mukherjee, Koustav Mazumder, Sushmita Ghoshal
DOI:10.4103/IJPC.IJPC_64_18  PMID:30410253
Context: Deterioration in mental health and poor quality of life (QOL) among women suffering from breast and ovarian cancer is not a direct result of the illness but mediated by many other psychosocial variables. Aims: The study intended to examine if there was any effect of educational level, residential status, family type, duration of treatment, and income level of family on anxiety, depression, and QOL among the breast and ovarian cancer patients, undergoing second- or subsequent-line chemotherapy. Subjects and Methods: Forty married female cancer patients with breast and ovarian cancer, aging between 40 and 60 years, education level ranges from no formal education to postgraduate degree, income level ranges from Rs. 1000 per month to Rs. 20000 per month, and undergoing second- or subsequent-line chemotherapy for the past 1–10 years were studied. Levels of anxiety and depression were determined by Hospital Anxiety and Depression Scale. The QOL was measured by using WHO QOLBREF scale. Statistical Analysis Used: Mean and standard deviation and Levene's F values were calculated. If Levene's F value was significant, then Mann–Whitney U-test was done or else independent samples t-test was used. Results: Among all the variables, education, residential status, and income affect significantly on anxiety, depression, and QOL. Conclusions: Early detection of psychosocial variables is essential for better screening of the cancer patients undergoing chemotherapy, and therefore, further psychological intervention can be planned accordingly.
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End-of-life care: Beliefs, attitudes, and experiences of Iranian physicians p. 431
Hossein Jabbari, Reza Piri, Fariba Bakhshian, Babak Mohit, Mohammad Naghavi-Behzad, Sahar Mohammadi, Nasim Mahmoudzadeh
DOI:10.4103/IJPC.IJPC_74_18  PMID:30410254
Context: Most of the patients suffering from cancer are diagnosed at late stages of cancer, which curative interventions are unable to improve their quality of life. Aim: To survey Iranian physicians' attitudes and practices toward end-of-life (EOL) care. Subjects And Methods: We conducted a cross-sectional survey among physicians participating in a national annually conducted educational seminar. Results: The survey results show that 80% of physicians had between 1 and 3 EOL patients. About 72% of patients received medical care in hospitals. The difference in best setting for care of terminally ill patients was statically significant after controlling for the length of practice and physician belief. The results also showed that that the participants believed that that the level of physicians' knowledge in this field was unacceptable. Conclusion: Physicians of our study were interested to participating in continuing education programs focused on EOL patients.
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The development of the community-based palliative care model in a district health system, Phitsanulok Province, Thailand p. 436
Nithra Kitreerawutiwong, Sunsanee Mekrungrengwong, Orawan Keeratisiroj
DOI:10.4103/IJPC.IJPC_34_18  PMID:30410255
Context: Palliative care (PC) refers to a set of basic health services in Thailand and is in the early stage of implementation. Aim: The aim of this study is to develop a community-based PC model in a district health system (DHS) based on the form of action and evaluation. Methods: A three-step action research: look, think, and act was designed with mixed methods of data collection. Results: A key finding was the confusion on the terminology of the PC, challenge of the referral system of PC patients in DHS, medical equipment and supplies for the PC patients, and insufficient access to opioid analgesics at home. The model of development comprised the training of health professionals, the management of the medical equipment and supplies by people sector, and the development of a referral guideline of the PC patient in DHS. The evaluation showed the higher score of the accessibility to PC than the score of accommodation for patients. It also showed the higher score of the care continuity over the longitudinal continuity for patients. For the carers, the score of guilt is higher than the score of the care burden. Conclusions: A community-based PC model should be monitored by district health managment. The methods of this study are expected to be useful advice on how to solve similar problems in the other regions of similar context.
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Early competing deaths in locally advanced head-and-neck cancer p. 446
Sandeep Muzumder, S Nirmala, HU Avinash, Prashanth Bhat Kainthaje, MG John Sebastian, John Michael Raj
DOI:10.4103/IJPC.IJPC_91_18  PMID:30410256
Introduction: The competing (noncancer) deaths have increased with aggressive treatment approach and better disease control in locally advanced head-and-neck cancer. Aim: The aim of this study is to find incidence, cause and predictors of early competing mortality in locally advanced head-and-neck cancer patients undergoing combined modality therapy. Subjects and Methods: In this retrospective study, a total of 125 locally advanced head-and-neck patients treated from January 2013 to June 2017 were analyzed. The total number of deaths, cause, and the time of death from the start of therapy was recorded. To study the risk factors of competing deaths, univariate and multivariate logistic regression was applied. Data were analyzed using SPSS v. 24 software. Results: A total of 51 deaths (31 cancer deaths and 20 competing deaths) recorded at a median follow-up of 16 months (1–62 months). The incidence of early competing mortality was 12% (n = 15) with a median time of 2.7 months from treatment initiation. Sepsis was major cause of early competing death (n = 13). On univariate and multivariate logistic regression analysis, competing death was significantly associated with pharyngeal (oropharynx, hypopharynx, and larynx) site primary (odds ratio [OR] = 3.562; 95% confidential interval [CI] = 1.207–10.517; P = 0.016), and Stage IVA/IVB disease (OR = 5.104; 95% CI = 1.123–23.202; P = 0.021). Conclusion: Competing deaths is one of the multifaceted problems in locally advanced head-and-neck cancer patients. Sepsis being single most cause of early competing deaths in Stage IVA/IVB pharyngeal and laryngeal cancer.
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A comparison of symptom management for children with cancer in Iran and in the selected countries: A comparative study p. 451
Maryam Pakseresht, Shahram Baraz, Maryam Rassouli, Nahid Rejeh, Shahnaz Rostami, Leila Khanali Mojen
DOI:10.4103/IJPC.IJPC_33_18  PMID:30410257
Aim: The aim of this study is to describe the experiences of other countries regarding the status of pediatric palliative care in the field of symptom management and to compare it with the current status in Iran to achieve an appropriate level of symptom management for children with cancer. Materials and Methods: This is a comparative study. The research population includes the palliative care systems of Jordan, England, Australia, and Canada, which were ultimately compared with Iran's palliative care system. Results: The results showed that in the leading countries in the field of palliative care, such as Australia and Canada, much effort has been made to improve palliative care and to expand its service coverage. In the UK, as a pioneer in the introduction of palliative care, a significant portion of clinical performance, education and research, is dedicated to childhood palliative care. Experts in this field and policymakers are also well aware of this fact. In developing countries, including Jordan, palliative care is considered a nascent specialty, facing many challenges. In Iran, there is still no plan for providing these services coherently even for adults. Conclusion: Children with cancer experience irritating symptoms during their lives and while they are hospitalized. Regarding the fact that symptom management in developed countries is carried out based on specific and documented guidelines, using the experiences of these successful countries and applying them as an operational model can be useful for developing countries such as Iran.
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Management of malignant wound myiasis with ivermectin, albendazole, and clindamycin (triple therapy) in advanced head-and-neck cancer patients: A prospective observational study p. 459
Bhavna C Patel, Shrenik Ostwal, Priti R Sanghavi, Geeta Joshi, Richa Singh
DOI:10.4103/IJPC.IJPC_112_18  PMID:30410258
Introduction: Myiasis, tissue infestation by housefly larvae, is commonly found in malignant fungating wounds of cancer patients from climatic condition and lower socio-economic strata. Aim of study: It was aimed to study the effectiveness of systemic Ivermectin, Albendazole& Clindamycin (Triple Therapy) in reducing signs & symptoms associated with maggots in malignant head and neck wounds. Method: 25 adult, advanced head and neck cancer patients presenting with maggots either from wound, oral cavity or nostril, with ECOG score 3 or less were enrolled in this study. Symptoms were assessed using Edmonton Symptom Assessment Scale (ESAS) and wound by Wound Assessment Tool – Hospice, at baseline and then Days 1, 3, 5, and 7. All patients received 3 days course of oral Ivermectin 12 mg per day, Albendazole 400 mg twice per day and Clindamycin 300 mg three times per day for 5 days along with Terpentine oil dressing. All patients received oral Morphine as per their pain score. Results: Mean age (yrs) and weight (Kg) were 42.15 ± 8.23 and 52.31 ± 5.18 respectively. 84% patients were male. Mean oral morphine dose was 100.38 mg. There was significant decrease in number of maggots from day 0 (77.28 ± 13.465) to day 1 (20.60 ± 7.263; 73.34% reduction) to day 3 (1.52 ± 2.104; 92.62% reduction). We found statistically significant improvement (P = <0.05) in scores of wound and all other related symptoms on days 1, 3, 5 & 7, except bleeding, edema, nausea, anxiety, appetite loss and feeling of wellbeing, which remained same on Day 1, but improved afterward. Side effects were self-limiting. Conclusion: Systemic treatment with Ivermectin, Albendazole and Clindamycin (Triple Therapy) enhances the removal of maggots, early recovery and relief from distress and associated symptoms.
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How “elderly staying alone” cope up with their age and deteriorating health: A qualitative exploration from rural Wardha, Central India p. 465
Sourav Goswami, Pradeep R Deshmukh
DOI:10.4103/IJPC.IJPC_51_18  PMID:30410259
Background: This study is done to explore the various changes and problems faced by the “elderly people staying alone” and how they cope up to maintain their life amidst the physical, familial, social, and financial crisis in their lives. Materials and Methods: This qualitative study was carried out in the villages surrounding Bhidi Rural Health and Training Center, located in the Vidarbha region of Maharashtra. A triangulation of free listing and pile sorting exercise was used. Elderly >65 years of age of either sex, living alone in their own houses, for at least 2 years were included in the study. Twenty-four such individuals were selected purposively who could figure out the different words and concepts regarding the three domains of our study for the purpose of line listing, namely, change of life since staying alone, problems faced while staying alone, and how they cope up with the problem of living alone. The data were analyzed using Anthropac software. The study findings were presented to the participants, who later pointed out few recommendations to be made. Results: The “elderly staying alone” face the problems of lack of family, social, and financial support in their day-to-day life. They cope with these problems by a number of ways. Although there are a number of government schemes to protect the elderly, none of these policies are dedicated to this special group of elderlies. Conclusion: There is no social structure that can take care of this vulnerable group of elderlies in rural India. It is high time for the government to step in to bring some societal and familial reforms that will safeguard the elderly staying alone from the ongoing familial, social, and financial hardship.
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The prevalence of chronic pain among adults in India p. 472
Ashok Kumar Saxena, Parmanand N Jain, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_141_18  PMID:30410260
Background: The prevalence of chronic pain (CP) is well described in Europe, America, and Australia. However, little knowledge is available of the prevalence of CP within Asia or Southeast Asia. Given the cultural and genetic variation in pain causation, manifestation, and reporting, the findings of previous western studies cannot be extrapolated to Asian countries. A prevalence study was needed to be carried out to quantify the magnitude and impact of CP in the adult population in India. Methods: Two sets of questionnaires were designed. The first, a screening questionnaire was used telephonically to identify the prevalence of CP, and should there be CP; the second, a detailed questionnaire was administered, to characterize the features and impact of pain. The interviews were carried out face-to-face. Results: A total of 4326 Indian patients were screened, and 836 completed a detailed pain questionnaire during 2006. The prevalence of CP was found to be 19.3% (n = 836). There was a higher prevalence in females (25.2%). Pain prevalence increased steeply beyond the age of 65 years old. There was a significant impact of CP on work and daily function. Conclusion: This Indian adults' population survey about CP found a higher prevalence of CP as compared to other Asian pain prevalence studies; however, the impact of pain was just as significant. In a rapidly aging population, CP is emerging as a significant healthcare problem which may likely to exert an increasing toll on the existing social infrastructure within the next two decades.
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Comparative impact of nonpharmacological interventions on pain of knee osteoarthritis patients reporting at a tertiary care institution: A randomized controlled trial p. 478
Meenakshi Sharma, Amarjeet Singh, Mandeep Singh Dhillon, Sukhpal Kaur
DOI:10.4103/IJPC.IJPC_14_18  PMID:30410261
Context: Nonpharmacological interventions (NPIs) have been advocated for knee osteoarthritis (KOA). There are many gaps in the evidence to their efficacy in India. Aims: The study aims to compare the impact of two packages of NPIs on various outcome variables of KOA patients. Settings and Design: This was a randomized controlled trial in a tertiary care hospital. Subjects and Methods: A study population (n = 123) of KOA patients aged 40–65 years. Stratified block randomization was done for mild or moderate KOA into two groups. Group “A” patients received a package of NPIs including a set of supervised exercise sessions, kinesthesia, balance, and agility (KBA), meditation, weight reduction advice, and weekly telephonic reminders. Group “B” patients received the same package except for KBA & meditation. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) and performance-based measures were measured. Analysis: t-test and repeat measures ANOVA were undertaken. Results: A significant intragroup reduction in WOMAC score was seen from baseline in Group A (P = 0.00, mean difference: −9.7) as well as in Group B (P = 0.00, −12.9). There was also significant reduction inVAS scores at the end of intervention in Group A and Group B as compared from baseline (−3.62, −3.8, P = 0.00). No intergroup difference was observed in either of the scores. VAS score reduction to 0 at different stages of intervention was noticed in 46% (n = 57) cases. There was a significant intergroup difference for 50-Foot Walk Test (P = 0.055, F = 3.28) at 12 months. Conclusion: Both packages of NPIs were effective in providing relief in symptoms. No specific benefit of KBA or meditation was seen except for 50FWT.
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Dedication in caring of hemodialysis patients: Perspectives and experiences of Iranian family caregivers p. 486
Ahmad Ali Eslami, Leili Rabiei, Majid Shirani, Reza Masoudi
DOI:10.4103/IJPC.IJPC_204_17  PMID:30410262
Background: Although dialysis treatment is considered as a life-saving treatment for chronic renal failure patients, the caregivers face challenges in caretaking of these patients. Objectives: This study is aimed to explain the perspectives and experiences among caregivers of the patients undergoing hemodialysis in Iran. Methods: A qualitative design, based on a thematic analysis approach, was used to reach the study aim. In this study, 25 hemodialysis family caregivers were selected by purposeful sampling. The data were gathered through in-depth and unstructured interview and field observation and analyzed by the inductive thematic approach. Results: The three main themes were generated from the analysis of the data indicating that the caregivers face challenges such as heavy burden of care, tension in care, and emotional exhaustion. Conclusion: Caretaking of the hemodialysis patients is constantly accompanied with challenges and concerns regarding the effective care for patients. Health-care providers need to address these concerns based on both patient- and caregiver-focused approaches, rather than only patient focused, to the design and planning for helping the patients and their caregivers.
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Coping styles and life satisfaction in palliative care p. 491
Rajat Garg, Vinay Chauhan, B Sabreen
DOI:10.4103/IJPC.IJPC_63_18  PMID:30410263
Background: Patients in palliative care suffer variously due to underassessment of needs and suboptimal intervention, coupled with lack of access to palliative care. This study attempts to identify effective coping strategies which lead to life satisfaction, among those afflicted with terminal cancer. Materials and Methods: This observational, cross-sectional study was carried out among terminally-ill cancer patients undergoing palliative care. Cancer patients receiving palliative care who give consent and were aged 18 years or older were included in the study. Those with cognitive deficits, delirium, or psychosis were excluded from the study. COPE scale, Temporal Satisfaction with Life Scale, and sociodemographic Performa were administered and analyzed. Pearson's r correlation coefficient test and multiple linear regression analyses were used to evaluate correlation and effect of coping strategies on life satisfaction. Results: Religious coping was the most frequently used coping strategy by patients, followed by acceptance. Females showed higher problem-focused coping, whereas males had higher emotion-focused and avoidant coping strategies. Females manifested more religious coping. Males showed more acceptance of their illness. Those without a partner had significantly higher emotion-focused coping strategies and higher religious coping. Income, social support, and problem-oriented coping were positively related to quality of life. Life satisfaction showed significant negative correlation with denial, substance use, and venting utilized as coping methods. Conclusion: Problem-focused coping (religious coping and acceptance) was found to be more effective than other methods. Patients in palliative care could be instructed for the use of problem-focused coping. Such training might enhance their life satisfaction, helping them experience greater control over the course of illness.
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An observational study to assess the socioeconomic status and demographic profile of advanced cancer patients receiving palliative care in a tertiary-level cancer hospital of Eastern India p. 496
Gaurav Kumar, Nibedita Panda, Rakesh Roy, Gautam Bhattacharjee
DOI:10.4103/IJPC.IJPC_72_18  PMID:30410264
Introduction: Socioeconomic status (SES) comprises of not just gross income but also educational qualification, financial security and individual perceptions of social status and class. It has been observed that people with low SES have less access and utilization of palliative care services. With this background, this observational study was carried out at SGCCRI to assess and evaluate the SES of patients attending the palliative care department and analyse the major social concerns of patients in the last days of life. Objectives: Assessment of socio- economic status and demographic profile of patients with advanced cancer receiving palliative care. Materials and Methods: From May 2017 to October 2017 we assessed the demographic features and socio-economic status of 80 advanced cancer patients receiving palliative care by interviewing them face to face with the help of a self designed social assessment sheet. Results: A total of 80 patients consented to be interviewed with regards to assessment of their socio-economic conditions. Majority were male patients (64%) with the highest percentage in the age group of 60-70years (33%). 38% of the patients interviewed were from rural surroundings. Only 38% of the patients had completed their basic education. Approximately 30% of the patients interviewed had income less than 1lakh/month while majority (>60%) had income in the bracket of 1lakh- 2lakh. In 30% of cases, the patient was the sole earner in the family. Conclusion: It was observed that majority of patients and their family were constrained with regards to financial resources and large percentage of patients had social insecurity with respect to future of family members.
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A comparative study of transdermal buprenorphine and oral morphine in the treatment of chronic pain of malignant origin p. 500
Kakali Choudhury, Partha Dasgupta, Nishana Paul, Krishnangshu Bhajna Choudhury, Bodhisatta Roy, Shampa Maity
DOI:10.4103/IJPC.IJPC_83_18  PMID:30410265
Background and Objective: The study was designed to compare the efficacy and adverse effects of buprenorphine transdermal (TD) against oral morphine in pain management of cancer patient. Methods: A randomized open-labeled prospective study was done in palliative cancer pain clinic in a tertiary care medical college between August 2017 and January 2018, to compare the efficacy (pain assessed by VAS) and adverse events (CTCAEv4) between arm A, buprenorphine TD, (20 μg/h, extended 7 days formulation) and arm B, oral morphine (10mg immediate releasing formulation). Patients with solid tumour malignancies with VAS score >40 (moderate to severe pain) were included in study. Results: 63 patients were analyzed. Commonest primary cancers were breast in females and head and neck in male individuals in both arms. Initial VAS score of arm A and arm B were 81.25 and 82.26 respectively. By 1st week, 11 arm A patients were relieved from pain. Another 17 patients of arm A became pain free by 2nd week, total dose of 40 μg/h. Only 4 patients needed 60 μg/h for pain relief. In arm B, 2 patients were relieved by 1 week with total 30mg/day morphine, 11patients were relieved with 60 mg/day by 2nd week and 12 patients with 90 mg/day. 6 patients were relieved with 120 mg/day dose at the end of 4th week. Nausea and constipation were stastically higher in Arm B compared to that of Arm-A. Conclusions: TD Buprenorphine had similar efficacy with oral morphine, with better toxicity profile and better compliance.
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Decubitus ulcer development: An investigation on its effect and evidence in home care patients p. 505
Sevgi Seyhan
DOI:10.4103/IJPC.IJPC_85_18  PMID:30410266
Background and Aims: Decubitus ulcer (DU) is one of the commonly observed health problems among home care patients. As well as deteriorating social, physical, and psychological conditions of the patients, it is a cause of severe economic loss due to long-term bed occupancy and high care costs. This study aimed to examine the factors which affect the development of decubitus ulcer among home care patients and provide extensive data to the literature. Patients and Methods: This study was conducted with on home care patients aged over 40 years old who were registered at Etimesgut Ankara Sehit Sait Erturk State Hospital. Following the face-to-face interviews with the patients at home, the scores of Subjective Global Assessment (SGA), Mini Nutritional Assessment (MNA), Daily Life Activities (DLA), and Geriatric Depression Scale (GDS) were recorded. Development of DU was monitored through routine examinations in the home care patients. It was encountered how SGA, MNA, DLA and GDS functioned in predicting the development of DU using logistic regression during effort and also how status of equipment and presence of comorbid diseases affected its development. Results: It was determined that malnutrition affected development of DU by decreasing mobility while the presence of psychological problems increased the risk for development. Furthermore, number of comorbid diseases and status of health equipment used by the patients were found effective in the development of DU. Conclusion: It is obvious that decreased inability of independent mobility in DLA increase the risk for malnutrition and consequently two assessments show a negative impact on psychology of the patient.
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Initial perceptions about palliative care in patients with advanced cancer: A prospective cross-sectional audit p. 512
Nishkarsh Gupta, Vinod Kumar, Rakesh Garg, Sachidanand Jee Bharati, Seema Mishra, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_94_18  PMID:30410267
Introduction: There is enough evidence to suggest that early introduction to palliative care (PC) for patients with advanced cancer is beneficial. However, despite this, the patients often come late to PC physicians. There are a number of studies examining the preferences and practices of the physicians with respect to PC. However, there is limited literature exploring the patients' preferences and awareness regarding the PC services. This audit was done to identify the understanding and perceptions of PC in patients visiting PC outpatient department (OPD) and identify strategies to enhance their understanding. Materials and Methods: This prospective cross-sectional study was conducted in 200 advanced cancer patients visiting PC OPD in a tertiary care hospital. The patients were asked to fill a questionnaire to assess their knowledge and expectations form PC on their first visit. Results: Majority of the patients were from nearby areas and around 20% of them had to travel more than 300 km to receive palliative consultation. Unfortunately, majority of the patients had not heard the term PC before and were not aware of its meaning. Most of them (90%) were send to control pain which was too severe to be managed by the oncologists. We think that the major reason for the lack of awareness about PC services is limited availability across the country and lack of coordinated approach. Conclusions: The main problem identified in the audit was the inadequate information, lack of PC setups, and late referral of the patients to PC. Hence, we should make a model where PC services are integrated with the curative services and offered throughout the illness after cancer diagnosis.
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Who can provide spiritual counseling? A qualitative study from Iran p. 517
Elahe Farshadnia, Nadereh Memaryan, Ali Asghar Asgharnejad Farid, Jafar Bolhari
DOI:10.4103/IJPC.IJPC_104_18  PMID:30410268
Background and Aim: Given the increased prevalence of mental illnesses in recent years, many therapists and researchers use spiritual counseling (SC), which is one of the spiritual interventions. However, unfortunately, the use of this intervention by the therapists is nonscientific because the ambiguities of this issue are high in the mental health field of Iran. The aim of this study is to survey the following most important challenges: what groups are qualified to provide SC, what kind of knowledge should be known by suitable individuals, who can train spiritual counselors, what they should teach, and what teaching methods should be used. Methods: The present conventional qualitative content analysis used deep semi-structured interview to collect data from the view of stakeholders. A total of 15 people were selected through purposive sampling. After transcription of the interviews, the data were analyzed based on the Graneheim and Lundman model. Results: Results obtained from data analysis covered five main themes including SC candidates, general conditions, sciences required, SC curriculum, and spiritual counselors' training method. Conclusions: The present study has answered to the most basic questions in SC scope. Since spiritual services are rooted in our culture and religion, native guidelines should be created for them as soon as possible through conducting similar qualitative researches. Furthermore, it is worth considering teaching and training case in this scope to make spiritual service providers concern about solutions to promote these services.
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Effectiveness of the MELD/Na score and the Child–Pugh score for the identification of palliative care needs in patients with cirrhosis of the liver p. 526
Juan Carlos Perdomo Puentes, Hirondina Rocha, Sara Nicolau, Gonçalo Ferrão
DOI:10.4103/IJPC.IJPC_97_18  PMID:30410269
Objective: Identification of palliative care needs in patients with liver cirrhosis using the MELD/Na score and the Child–Pugh score. Materials and Methods: A retrospective study of hospitalized patients with hepatic cirrhosis between January 2015 and December 2016 using the Child–Pugh score and the MELD/Na score in January 2018. Results: Recognizing end-of-life patients (the past 12 months of life) is a challenge for health professionals, especially in diseases with poorly defined criteria, such as cirrhosis of the liver. The verification of rapid functional decline and health indicators can be verified using already defined scales such as the Child–Pugh score and the MELD/Na score. Patients were classified according to the Child–Pugh score in Class A (17%), Class B (48.9%), and Class C (34%). The corresponding survival rate was as follows: class A (87.5%), Class B (30.4%), and Class C (31.25%). The MELD/Na score intervals were >9 (2.15%), score 10–19 (46.8%), score 20–29 (27.7%), score 30–40 (19.1%), and score >40 (4.3%). Nearly 51.1% had a MELD/Na score >20 and 48.9% <20. The study revealed that 59.6% of patients died before 12 months. They were end-of-life patients who needed palliative care to reduce the impact of the disease. Conclusions: The Child–Pugh score and the MELD/Na score represent a viable and easy-to-use tool to identify patients in need of palliative care, among those with liver cirrhosis. Early identification, timely evaluation, and effective treatment of physical, spiritual, family, and social problems improve the quality of life of people with incurable diseases and their families.
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PERSPECTIVES Top

Telerehabilitation for chronic obstructive pulmonary disease patients: An underrecognized management in tertiary care p. 529
Kalyana Chakravarthy Bairapareddy, Baskaran Chandrasekaran, Umang Agarwal
DOI:10.4103/IJPC.IJPC_89_18  PMID:30410270
Pulmonary rehabilitation (PR) is proved to be best supportive management in chronic obstructive pulmonary disease (COPD) individuals. The literature claims the reduction of dyspnea, fatigue, exacerbations, and improved functional capacity and quality of life. Home-based PR is being prescribed widely than hospital-based rehab due to be less cost and ease of caregiver burden, but efficacy is usually questioned. The poor efficacy may be probably due to recurrent exacerbation and poor quality of life even after years of home rehabilitation. Telerehabilitation is an excellent rehab measure where the COPD patients exercise at his home, while expertise from the tertiary care centers monitors the rehab sessions remotely. In India, the tele-PR is at its budding state. This review shall enable the readers with the basics of telerehabilitation in comparison with the other available rehab measures and evidence in the management of COPD.
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CASE REPORTS Top

Purple urine bag syndrome: A scary but easily manageable condition in a patient with prolonged indwelling urinary catheter p. 534
Dinesh Kumar, Namrata Donga, Rekha Macwan
DOI:10.4103/IJPC.IJPC_88_18  PMID:30410271
“Purple urine bag syndrome” (PUBS) is a rare but distressing presentation of urinary tract infection (UTI) among moribund patients on indwelling urinary catheter. A 56-year-old woman with carcinoma of the left breast and metastasis in vertebrae and liver was bed ridden. She was on Foley's catheter for 9 months, with the last catheter changed 3 weeks back. A 75-year-old woman presented with non-Hodgkin's lymphoma for 2 years and moderately differentiated squamous cell carcinoma of the right parotid region (8 months). She experienced fall and fracture of femur, bed ridden, and on Foley's catheter for 7 years. She had facial wound with maggots for 3 days. Both the women developed purple-colored urine with no other symptoms of UTI. No investigations were carried out and they were empirically treated with nitrofurantoin, catheter change reassurance, and increased fluid intake. Urine color was normal by a week. PUBS can be managed easily at home with simple antibiotics, adequate hydration, and family/patient counseling in palliative care settings.
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Does palliative sedation produce an ethical resolution to avoid the demand for euthanasia in a Muslim Country? p. 537
Ercan Avci
DOI:10.4103/IJPC.IJPC_105_18  PMID:30410272
One of the major purposes of palliative sedation is to reduce demand for euthanasia. The present paper analyzes a grievous case which demonstrates the killing of a 23-year-old son by his father due to the son's unbearable pain resulting from metastatic colorectal cancer. The article aimed to elaborate the case to figure out whether palliative sedation can be an alternative to euthanasia in a Muslim country. Nevertheless, the analysis of these two end-of-life issues revealed that the limitation of palliative sedation to an expected lifespan of less than 2 weeks as well as the Islamic view on the importance of protecting consciousness preclude reaching a conclusion that palliative sedation can be an alternative to euthanasia in this particular case. Furthermore, in such cases, the primary problem may be the lack of adequate and appropriate palliative care services, rather than the need for euthanasia or palliative sedation.
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LETTERS TO EDITOR Top

Magic word “palliative:” an end to cure but no end to care p. 545
Mranalini Verma
DOI:10.4103/IJPC.IJPC_86_18  PMID:30410273
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Lofexidine for treating opioid withdrawal syndrome in palliative care patients p. 546
Abhijit S Nair
DOI:10.4103/IJPC.IJPC_103_18  PMID:30410274
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Feasibility of chronotherapy for preventing delirium in patients with cancer: An idea for future clinical trials p. 547
Leila Radrazm
DOI:10.4103/IJPC.IJPC_124_18  PMID:30410275
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