Prior research has suggested that nurses, regardless of workplace or culture, are confronted with a variety of stressors. As the worldwide nursing shortage increases, the aged population becomes larger, there is an increase in the incidence of chronic illnesses and technology continues to advance, nurses continually will be faced with numerous workplace stressors. Thus, nurses, especially palliative care nurses, need to learn how to identify their workplace stressors and to cope effectively with these stressors to attain and maintain both their physical and mental health. This article describes workplace stressors and coping strategies, compares and contrasts cross-cultural literature on nurses' workplace stressors and coping strategies, and delineates a variety of stress management activities that could prove helpful for contending with stressors in the workplace.

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Cancer of the cervix uteri is a common cause of pain among women. On the physical realm, the cancer may cause somatic [soft tissue and bone], visceral and neuropathic pain [lumbosacral plexopathy]. Radiotherapy and chemotherapy may cause neuropathy too. Psychological, social and cultural factors modify the pain. Evaluation of the individual type of pain and a patient-centred approach are fundamental requirements for rational management. Disease modifying treatment like radiotherapy and chemotherapy must be considered when applicable. Pain control is usually achieved by the use of WHO three-step ladder, remembering that possible association of renal dysfunction would necessitate caution in the use of NSAIDs and opioids. Side effects must be anticipated, prevented when possible, and aggressively treated; nausea and vomiting may already be present, and constipation can worsen pain when there is a pelvic mass. Pain emergencies can be treated by quick titration with intravenous morphine bolus doses. Neuropathic pain may warrant the use of usual adjuvants, with particular reference to cortico-steroids and the NMDA antagonist, ketamine. In intractable pain, many neurolytic procedures are tried, but a solid evidence base to justify their use is lacking. Continuous epidural analgesia with local anaesthetic and opioid may be needed when drug therapy fails, and desperate situations may warrant interventions such as neurolysis. Such physical measures for pain relief must be combined with psychosocial support and adequate explanations to the patient and the family.

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Pain in carcinoma cervix is a multidimensional experience with sensory, affective and cognitive-evaluative components. Many patients do not receive adequate pain management because of a lack of proper assessment, misconceptions regarding the pharmacologic and non pharmacologic methods of pain management and failure to distinguish between different types of pain. In our audit pelvic and nodal recurrence were the commonest cause of pain presenting as as pelvic pain, [42%], lumbosacral plexopathy [40%] and abdominal pain [34%] [n = 30]. Pain on defaecation caused by rectal obstruction, and suprapubic pain due to pyometra can be relieved by colostomy and drainage. Very little literature is available on the pain syndromes associated with carcinoma cervix. The present article is a review of cancer and treatment related pains in carcinoma cervix.

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The work environment significantly affects the physical, psychological, emotional and/or spiritual wellbeing of individuals is unquestionable. Adverse effects have been noted among healthcare professionals working with clients experiencing pain and suffering often associated with cancer, palliative or end-of-life care; however, little is known about how or in which manner the nurse-patient-family relationship may affect the psychosocial health and wellbeing of nurses working in these areas. Three concepts have been highlighted as most frequently associated with the adverse consequences of caring work: these are compassion fatigue (secondary traumatic stress), burnout and vicarious traumatization. The following discussion investigates these concepts and their implications on palliative and hematological cancer nursing practice.

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Squamous cell carcinoma of head and neck (SCCHN) is one of the commonest cancers seen in India, constituting up to 25% of their overall cancer burden. Advanced SCCHN is a bad disease with a poor prognosis and patients usually die of uncontrolled loco-regional disease. Curative intent management of loco-regionally advanced SCCHN has become more evidence-based with active clinical research in the form of large prospective randomized controlled trials and meta-analyses. However, little has been written about palliative radiotherapy (PRT) in head and neck cancers. It is widely recognized that PRT provides effective palliation and improved quality-of-life in advanced incurable malignancies. It is in this context that this study proposes to review the existing literature on palliative radiotherapy in advanced incurable SCCHN to help formulate consensus guidelines and recommendations.

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The term demoralization has been used to describe existential distress and despair of patients with advanced disease. Aim: This study sought to determine whether a cluster of symptoms interpreted as demoralization could be identified and distinguished from a cluster of depressive symptoms. Materials and Methods: As part of the Coping with Cancer Study, a federally funded multi-site study of advanced cancer patients, 242 patients were interviewed on a broad range of mental health parameters related to depression, grief, quality of life, self-efficacy, coping and religiousness/spirituality. Results: A principal components analysis revealed separate depression and demoralization/despair factors. Seven symptoms constituted the demoralization/despair factor: loss of control, loss of hope, anger/bitterness, sense of failure, feeling life was a burden, loss of meaning and a belief that life's meaning is dependent on health and were found to be internally consistent (Cronbach's a = 0.78). Only 14.8% of subjects with "syndromal demoralization" met DSM-IV criteria for Major Depression (MDD); 7.4% for Minor Depression. Of those with MDD only 28.6% had syndromal level demoralization. Prior history of MDD predicted current MDD, but not syndromal demoralization. Demoralization, not MDD, was significantly associated with the patient's reported level of inner peacefulness. When compared with MDD, syndromal demoralization was more strongly associated with wish to live and wish to die and equally predictive of mental health service use. Conclusion: The symptoms of demoralization are distinct from depressive symptoms and appear to be associated with the patient's degree of inner peacefulness.

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Terminal illness often throws up challenges that conventional treatments fail to address satisfactorily. Complimentary therapies such as foot massages are being rediscovered for their particular benefits in palliative care. This article includes a brief description of the process and discusses the author's experience with it's use.

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Critical junctures in patients' lives such as chronic illnesses and advanced diseases may leave the persons in a state of imbalance or disharmony of body, mind and spirit. With regard to spirituality and healing, there is a consensus in literature about the influence of spirituality on recovery and the ability to cope with and adjust to the varying and demanding states of health and illness. Empirical evidence suggests that spiritual support may act as an adjunct to the palliative care of those facing advanced diseases and end of life. In this article, the author draws from his empirical work on spirituality and culture to develop a discourse on palliative care and spirituality in both secular and non-secular settings. In doing so, this paper offers some understanding into the concept of spirituality, spiritual needs and spiritual care interventions in palliative care in terms of empirical evidence. Responding to spiritual needs could be challenging, but at the same time it could be rewarding to both healthcare practitioner (HCP) and patient in that they may experience spiritual growth and development. Patients may derive great health benefits with improvements in their quality of life, resolutions and meaning and purpose in life. It is hoped that the strategies for spiritual support outlined in this paper serve as practical guidelines to HCPs for development of palliative care in South Asia.

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Delirium is a distressing and disturbing clinical event. Palliation of the symptoms by multi-component interventions can be effective. The goal of interventions is to raise the deliriant threshold by combined symptom relief, environmental, psychological and pharmacological interventions. Haloperidol remains the drug of choice for delirium. For intractable delirious symptoms at the end of life terminal sedation may be indicated.

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This article explores the issues of hospice palliative care volunteer attrition and retention (i.e., why volunteers leave and how to keep them interested). In addition, common sources of stress for volunteers will be identified and suggestions for alleviating stress will be offered. Volunteers are special people; patients and families greatly appreciate the care and support they provide and the other staff members' (e.g., nurses) jobs are often made easier because of them. Thus, maintaining a committed group of volunteers is an extremely important task for volunteer coordinators. The literature reviewed in this article focused mostly on North American studies and was limited to research that specifically involved hospice palliative care volunteers as participants.

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Palliative care professionals promote well-being and ease suffering at the end-of-life through holistic care that addresses physical, emotional, social and spiritual needs. The ways that individuals cope with serious illness and prepare for death are often done so within a religious context. Therefore, it is essential that palliative care practitioners are sensitive to and have an appreciation of different religious perspectives and rituals to meet the unique needs of their patients and families. This paper provides a brief overview of the five major world religions - Buddhism, Christianity, Hinduism, Islam and Judaism - with particular emphasis of the respective perspectives on suffering, death and afterlife. Despite wide variation in these traditions, an understanding of common rituals surrounding death, funerals and bereavement can improve care for patients, families and communities facing the end-of-life.

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World Health Organization defines palliative care as the active total care of patients whose disease is not responding to curative treatment. Palliative care for the terminally ill is based on a multidimensional approach to provide whole-person comfort care while maintaining optimal function; dental care plays an important role in this multidisciplinary approach. The aim of the present study is to review significance of dentist's role to determine whether mouth care was effectively assessed and implemented in the palliative care setting. The oral problems experienced by the hospice head and neck patient clearly affect the quality of his or her remaining life. Dentist plays an essential role in palliative care by the maintenance of oral hygiene; dental examination may identify and cure opportunistic infections and dental disease like caries, periodontal disease, oral mucosal problems or prosthetic requirement. Oral care may reduce not only the microbial load of the mouth but the risk for pain and oral infection as well. This multidisciplinary approach to palliative care, including a dentist, may reduce the oral debilities that influence the patient's ability to speak, eat or swallow. This review highlighted that without effective assessment of the mouth, the appropriate implementation of care will not be delivered. Palliative dental care has been fundamental in management of patients with active, progressive, far-advanced disease in which the oral cavity has been compromised either by the disease directly or by its treatment; the focus of care is quality of life.

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Metastatic bone pain is acommonly encountered clinical condition seen in oncology clinical practice. About 50% of all cancer patients develop metastases in their lifetime and half of them develop skeletal metastases. Despite its importance, no specific therapeutic strategy, to prevent or treat this complication of cancer has been demonstrated. This study comparing two radiotherapy regimens was conducted at a cancer center in New Delhi, India. Patients with confirmed bone metastases were randomized into two treatment arms, Group A (single fraction) and Group B (multiple fractions). Patients were followed up for 12 weeks. Pain relief was the primary endpoint of the treatment. Other parameters were improvement in analgesic score, performance status, and acute side effects like nausea, vomiting, tiredness, and lassitude. Fifty patients were evaluated at the end of the study. Overall response rate was seen in 86% of cases, whereas complete response was seen in 36% of cases. The two treatment regimens were found to be comparable with respect to other endpoints. Hence, a single fraction treatment, which is more convenient and cost effective, is a more logical approach in the Indian scenario in selected cases.

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Handling collusion among patients and family members is one of the biggest challenges that palliative care professionals face across cultures. Communication with patients and relatives can be complex particularly in filial cultures where families play an important role in illness management and treatment decision-making. Collusion comes in different forms and intensity and is often not absolute. Some illness-related issues may be discussed with the patient, whereas others are left unspoken. Particularly in palliative care, the transition from curative to palliative treatment and discussion of death and dying are often topics involving collusion. Communication patterns may also be influenced by age, gender, age, and family role. This paper outlines different types of collusion and how collusion manifests in Indian and Western cultures. In addition, promising avenues for future research are presented.

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Mr. P was a 57-year-old man who presented with symptoms of bowel obstruction in the setting of a known metastatic pancreatic cancer. Diagnosis of malignant bowel obstruction was made clinically and radiologically and he was treated conservatively (non-operatively)with octreotide, metoclopromide and dexamethasone, which provided good control over symptoms and allowed him to have quality time with family until he died few weeks later with liver failure. Bowel obstruction in patients with abdominal malignancy requires careful assessment. The patient and family should always be involved in decision making. The ultimate goals of palliative care (symptom management, quality of life and dignity of death) should never be forgotten during decision making for any patient.

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AIM: To introduce palliative care into undergraduate medical and nursing education, and to ascertain if such training improved students' knowledge of palliative care. MATERIALS AND METHODS: Third year nursing students and fourth year medical students at the St John's National Academy of Medical Sciences, Bangalore had five weekly lectures in palliative care. A 20 item questionnaire was administered to 4th year medical students before and after the educational intervention, and again after one year. The same questionnaire was administered to the control group of final year medical students. The questionnaire for 3rd and 4th year nursing students had 15 questions. RESULTS: The mean scores for medical students was 9.08 (S.D 2.5) in the pretest, 10.43 (S.D 1.63) in post-test I, and 8.43 (SD 1.36) in post test 2. The control group scored 8.36 (SD 2.52). The mean scores for nursing students was 8.7 (S.D 1.8) in the pretest, 10.73 (SD 2.63) in post test 1 and 8.23 (SD 4.1) in post test 2. The control group scored 8.13 (SD 2.39). CONCLUSION: There was no lasting improvement in knowledge scores in both groups of students. Inclusion of palliative care in the undergraduate teaching of medical and nursing students in India is feasible, but thought needs to be given to the curriculum content, teaching methods and evaluation techniques.

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Head and neck cancer recurrences after definitive radiotherapy present a difficult therapeutic problem, as only a small proportion of patients have resectable disease. When surgery is not possible, reirradiation might be a feasible option for selected patients, particularly those with favourable prognostic factors such as second primaries, nasopharyngeal or laryngeal tumours or delayed recurrences. Current evidence indicates that in this group of patients reirradiation offers better control rates than palliative chemotherapy. The loco regional control rates of reirradiation without surgery is 20% at five years and 27% at two years. The overall survival rate with reirradiation ranges from 10% to 35% at two years and 0% to 14.6% at five years. The first randomized trial directly comparing chemotherapy with reirradiation is in progress. This article outlines the indications for and results of reirradiation and chemotherapy in post radiotherapy recurrences of head and neck cancer.

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Spirituality is multifaceted. The various beliefs regarding the concept of spirituality, spiritual needs of terminally ill patients and the methods of spiritual assessment are discussed here. There is a close association between demoralization, distress, spiritual pain and spiritual distress. Standardised clinical methods to assess spiritual distress and provide spiritual care and healing are available. Spiritual well-being is a significant dimension of overall health-related quality of life. Although there seems to be traditional and natural spiritual care in our society and especially in palliative care settings, hardly any formal training or interventions are available. This paper aims to encourage soul searching in the end-of-life care.

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