Aim: The aim of this study is to assess stress and coping among caregivers of cancer patients on palliative care and to acquire a deeper understanding of their lived experiences. Materials and Methods: A mixed method study was conducted among caregivers of cancer patients on palliative care using mixed method approach and triangulation design. Data were gathered using self-administered stress rating scale, brief COPE inventory, and structured interview schedule. Nested sampling technique was adopted. The sample size for quantitative approach was eighty and qualitative approach was eight. Results: The results showed that 74% of the participants were females and 30% of them belong to the age group between 51 and 60 years. Fifty-four percent of them belong to Hindu religion and 40% were unemployed. Sixty-two percent of the patients were dependent on caregivers for all activities of daily living. Assessment of stress revealed that 82% of the participants had moderate stress and 18% had severe stress. Participants adopted both negative and positive coping. There was a significant negative correlation (r = −0.722, P = 0.001) between stress and coping. Similar findings were also observed in the phenomenological approach. The theme evolved was “caring companionship to palliative care.” Conclusion: Palliative caregiving is stressfull, challenging and can impact the caregiver's physical, emotional, psychological, and social well-being. Understanding lived experiences of caregivers of cancer patients on palliative care is important for the health professionals to improve the support, guidance, and education given to the caregivers of cancer patients on palliative care.

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Background: Caring for a cancer patient is debilitating for caregivers, especially among Indian population, as culturally people prefer to care at home than at nursing home. Unavailability of palliative care services and professional caregivers adds to the family burden. Objectives: Caregiving difficulties need assessment, but cancer-specific burden instruments are rare in the Indian context. This article presents development and initial validation of Caregiver's Difficulty Rating Scale (CDRS) and highlights the nature of caregiving burden on primary caregivers. Methods: A total of 108 items were prepared in English after case interviews and reviewing the existing scales for face validity. Experts judged the items for content validity, of which 54 items with 100% agreement were retained. Forward-backward policy was used for Hindi translation. Reliability analysis was performed with thirty respondents. The final scale was administered to 100 caregivers of head-and-neck cancer patients for internal consistency and item-scale statistics. For construct validity, know-group comparison was made using EORTCQOL instrument with caregiver-patients dyads. Results: High correlation among the three translated versions (r > 0.76, P < 0.01), Cronbach's alpha (0.948), and spilt-half coefficient (0.965) suggested translation reliability and scale consistency. Caregiver's burden had significant negative correlation with global quality of life of patients (−0.514**). Help for food arrangement, managing work–life, and treatment cost were the highly rated difficulties. Conclusion: CDRS had fifty items under four dimensions – physical, emotional, social, and financial. The scale requires further work on convergent and divergent validity and sensitivity to change which are underway. The study has implications for respite care. Community engagements and caregivers' support group may work as sources of emotional and social support.

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Aim: This study aimed to compare the quality of life (QoL) of cancer patients, with an Eastern Cooperative Oncology Group (ECOG) performance of 3–4, in contact with or without contact, with a specialized palliative care unit (PCU) at a low-resource governmental cancer hospital, as well as studying the impact of this contact on the QoL in their caregivers. Materials and Methods: Hospitalized patients with an ECOG performance of 3 or 4 and their primary caregiver were asked to participate in this observational study. Patients in contact with the specialized PCU and their closest caregivers formed Group A, while patients and families without this contact formed Group B. Contact was mainly one consultation. The patients were asked to complete the Palliative Care Outcome Scale (POS), and the caregivers were asked to complete the Hospital Anxiety and Depression Scale (HADS) and the distress thermometer (DT). Results: There was no statistically significant difference between the median POS values of the patient groups, neither regarding the total sum nor per any item. There were also no statistically significant differences between the median HADS values and median DT values when comparing the caregivers to Group A and B. Conclusion: Consultation with a specialized PCU at this tertiary referral center did not alter the QoL of patients with an ECOG performance of 3–4 nor did it affect the psychological well-being of their caregivers. We argue that monitoring prescribed treatment and follow-up is a necessary component of PC.

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With unprecedented surge in the incidence and prevalence of cancer in India, it has become imperative to strengthen the workforce for all the domains of cancer care. A large proportion of the activity required for prevention as well as for palliation, lie outside of tertiary institutions, in the community. Palliative care (PC) as a field is expanding exponentially across the country and the service providers often engage and work actively within the local community in their region. This article describes the scope for reducing the cancer burden in the community, through capacity building of community based PC healthcare functionaries in the domains of Prevention, and Early detection of common cancers along with Palliative care – the PEP domains. It suggests aligning and enhancing the workforce already active within the community for PC, for screening, and if feasible, for early detection of common cancers. The article describes possibilities of initiating PEP activities and offers a set of screening questionnaire that may be used when engaged with family/ community setting. The aim is to integrate the activities done, to detect the need for palliative care in a family / community, with that required to detect need for evaluation of most common cancers- oral, breast and cervix. The PEP concept may be adapted to different levels, based on the team presence in the communities, degree of engagement, and availability of trainers and healthcare personnel.

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The patients often present to palliative care with intractable nausea and vomiting. This may reduce the effectiveness of oral drugs and significantly affects the quality of life of these patients. Despite multiple drugs available for treatment, it is often difficult to control the symptoms. Olanzapine is an atypical antipsychotic and acts on multiple receptors and may help in treating vomiting in a patient with advanced malignancy. We report a case of gallbladder carcinoma who presented to us with intractable vomiting which was not relieved with a combination of traditional antiemetics but showed marked improvement with olanzapine.

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Context: Brain metastasis is one of the most feared complications of cancer that poses significant mortality and morbidity in patients with advanced cancer. The incidence is rising because of greater use of magnetic resonance imaging and spectroscopy; and increased survival from recent advances in immunotherapy and modern radiotherapy techniques. Despite all, the prognosis remains poor. Aims: This study aimed to analyze prognostic factors and overall survival in patients with brain metastases. Subjects and Methods: A total of 145 patients were analyzed from July 2014 to June 2015 for various prognostic factors prospectively. Survival analysis was done using Kaplan–Meier curve. Results: The median overall survival was 6 months, while 1- and 2-year survival rates were 8.3% and 1.4%, respectively. Median survival was highest with surgery followed by radiotherapy (11 months). Whole-brain radiotherapy (WBRT) significantly improved the survival (P = 0.006). The most common primary was lung cancer (58%) and the most common histology was adenocarcinoma (36%). Most patients (38%) were diagnosed upfront with brain metastases. Most of the lesions were multiple (80%) and located in cerebrum (58%). Survival was significantly improved with female gender (P = 0.003), Eastern Cooperative Oncology Group performance status (PS) 0–2 (P = 0.006), breast primary (P = 0.004), time lag of >6 months (P < 0.001), solitary lesion (P = 0.002), and controlled primary (P = 0.017). Conclusions: WBRT remains the cornerstone of the management of brain metastases. The present study concludes that the survival of patients with brain metastases is significantly improved with female gender, good PS, primary breast cancer, time lag of >6 months between diagnosis of the primary tumor and development of brain metastases, solitary lesion, and controlled primary tumor.

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Chronic fibrotic interstitial lung disease (ILD) forms a substantial proportion of disabling lung diseases and leads to significant morbidity and mortality. The mortality of these patients when admitted to the Intensive Care Unit with acute respiratory worsening requiring mechanical ventilation can reach up to 90%. Indian law does not allow the physician to make the final decision about mechanical ventilation, we are forced to follow the wishes of the family despite knowing the extremely poor outcome of aggressive intervention and invasive ventilation. Patients more often become ventilator dependent and do not gain much regarding the quality of life with mechanical ventilation. Hence, there is a desperate need for palliative support for these patients with advance care planning to reduce the suffering of these patients toward the end of life. The article describes various methods by which the decision making process of mechanical ventilation could be made simpler and acceptable to the patient and the families of fibrotic Interstitial lung disease patients and also the dilemma faced by chest physician in India with virtually no prior end of life planning and no clear guidelines on ventilation when it comes to palliation of patients with advanced ILD.

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Context: While the survival of cancer patients is prolonged due to the development of new treatment strategies and advancing technologies, the prevalence of symptoms such as neuropathic pain affecting the quality of life is also increasing. Aims: The aim of this study is to determine the relationship between neuropathic pain (NP) and quality of life in hospitalized cancer patients and to compare patients in general wards and those in palliative care wards in terms of NP and quality of life. Subjects and Methods: A total of 156 patients, 53 cancer patients hospitalized in the palliative care unit and 103 cancer patients hospitalized in general wards, were included in the study. The Douleur Neuropathic 4 test was used for NP assessment, and the Edmonton Symptom Assessment System (ESAS), Hospital Anxiety and Depression Scale (HAD), Brief Fatigue Inventory (BFI), and Short Form of Brief Pain Inventory (SF-BPI) were used for assessing pain characteristics and their effects on quality of life. Results: NP was present in 39.7% of cases and nociceptive pain (NP) was present in 32.7% of cases. There were no complaints of pain 27.6% of cases. The patients with no pain complaint were excluded, 54.9% of the patients had NP and 45.1% had NS. The scores of BFI, HAD-depression, ESAS overall, and ESAS tiredness were signifi cantly lower in patients with NP treated general wards compared to patients with NP in the palliative care wards (P < 0.05). Cancer patients with NP in general wards had signifi cantly higher scores of SF-BPI effect, SF-BPI severity, ESAS overall, ESAS pain, ESAS tiredness, ESAS nausea, ESAS appetite, and ESAS well-being as compared to those of general cancer patients with NS (P < 0.05). Conclusions: Since there was a homogeneous distribution among the groups in terms of both cancer treatment and pain management, we directly related the deterioration of the patients' quality of life to NP.

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Background: Glioblastoma (GBM) is a terminal illness and associated with poor prognosis. Brain cancer creates significant traumatic effects including death and dying fears not only on patients but also in Asia's tightly knitted families. Very few studies made attempt to elicit the death and dying issues among brain cancer patients. Therefore, the study aimed to explore the patient's perspectives on death and dying among GBM patients during hospitalization. Methodology: The study used qualitative approach. Purposive sampling was used to enroll 31 consented patients for in depth interviews. The in-depth interviews were guided by pre-designed open ended guidelines and took 45 min to 1 h. All interviews were conducted in the private room in the hospital. Interviews were manually documented soon after the interview. Thematic analysis was used to generate themes. R (QOL) software was used for data analysis. Results: Four themes were emerged from the analysis; (i).Understanding about illness (ii).Personal views and feelings on death and dying (iii).Coping with fear of death and dying (iv).Need for early preparation to face death and dying fears. Conclusion: Psychosocial interventions on early death preparation programs are recommended for GBM patients in the in-patient care. Yet, it should be handled carefully and sensitively, otherwise, it creates more psychological and emotional harm than the illness per se.

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The last 15 years has seen clarification of the terminology used to describe prolonged disorders of consciousness within the United Kingdom leading to the emergence of a new diagnosis – minimally conscious state (MCS) in 2002. MCS is distinct from vegetative states, in that a person demonstrates wakefulness with some degree of minimal awareness. The Mental Capacity Act (MCA) 2005 in England and Wales provides a legal framework for assessing an individuals' capacity to make decisions for themselves. The Act also authorizes others to make decisions on behalf of an individual who is assessed as lacking capacity in their best interests. The Act has an accompanying Code of Practice which provides guidance and a best interests “test” to be applied when assessing best interests. Since the advent of the Act, approximately two cases each year go to the Court of Protection for final decisions regarding end-of-life care in people in an MCS. Currently, any decision involving the withdrawal of clinically assisted nutrition and hydration (CANH) for people in an MCS must be referred to the court. In each case, the courts analyze the application of the Act which has become central in the court's decision-making process, particularly when assessing best interests. This article provides an overview of key MCA sections applied in such end-of-life MCS cases and reviews seminal cases elucidating how the Act has been applied. It further describes the evolution of how courts have interpreted the doctrine of best interests when considering withholding or withdrawing CANH and other life-sustaining treatments.

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Anoxic brain injury in children is a rare and devastating occurrence. Families are shocked by the unexpected nature of their child's neurologic injury, which may be the result of a sudden and prolonged cardiac arrest. Organ donation in these children is subject to much discussion and controversy. Recently, we encountered three pediatric patients with anoxic brain damage who progressed to brain death within a few days of admission. Pediatric palliative care was involved from the time of arrival to the hospital in all the patients. The team served as a critical conduit to support families and helped in managing end-of-life decisions including organ donation. All three families consented to organ donation. We discuss here the patients, the palliative care involvement, and the factors responsible for successful donation.

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We report a case of massive upper-limb edema necessitating disarticulation, in a cancer survivor who tended to ignore instructions regarding preventive exercises since 2002 after completion of her treatment for breast cancer. However, she was in a family situation where she was constrained to physically involve in daily chores. Consequently, she presented 14 years later with a lymphedematous arm which weighed over 31 kg, necessitating disarticulation. We highlight the role of preventive exercises in postmastectomy patients and also the efficacy of continuous nerve block techniques in preventing the development of phantom limb pain in cases of disarticulation and amputation. The role of family support for a working female cancer survivor in a country like India needs to be addressed. We salute her commitment to her family as also her grit and determination. Shoulder disarticulation was the last choice for this woman. We also want to highlight the role of the community in monitoring and preventing such disasters.

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Couple of decades ago, Palliative Mastectomy for locally advanced breast cancers was common, if not frequent surgical procedure in the surgical armamentarium. The advent of better understanding of tumor biology and better multidisciplinary management has certainly narrowed down its role. However there are situations where it is still a potent option. In the subset of patients where palliative mastectomy is to be performed, it is important to aim for clear surgical margins, with good clearance at the third dimension, i.e. the tumor base. Surgeons with adequate experience of breast cancer surgeries should perform the procedure to achieve intended palliation.

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Purpose: Several trials on noncancer population indicate that yoga is associated with meaningful clinical effects. This study evaluated the physical and psychosocial outcomes of yoga in oncologic patients treated with radiotherapy. Methods: We focused on a research through Cochrane Register of Controlled Trials (CENTRAL), BioMed Central, and MEDLINE studies up to May 2017. Results: Yoga was found to have a substantial benefit in cancer patients' distress, anxiety, and depression. It also demonstrated a moderate impact on fatigue and emotional function and a small and insignificant effect on functional well-being and sleep disturbances. As far as the effects on psychological outcomes are concerned, there was insufficient evidence. Conclusions: This systematic review of randomized controlled trials showed that yoga has strong beneficial effects on oncologic patients' quality of life. Results of the current review must be interpreted with caution due to the relative small sample sizes of most of the included studies, while a prospective randomized study stands in need for the confirmation of our results.

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Emergencies in palliative care need to be defined by the potential distress that a clinical issue raises for a person. A 58-year-old male with carcinoma vallecula referred for palliative care presented with recurrent syncopal attacks. On examination, a swelling at the left angle of mandible pressing on the carotid sinus was detected. A clinical diagnosis of carotid sinus syndrome was made, which is an exaggerated response to carotid sinus baroreceptor stimulation and results in dizziness or syncope from transient diminished cerebral perfusion. Rapid identification and judicious interventions in time (cardiac consultation, intravenous atropine 0.5 mg, and temporary pacemaker implantation) were able to manage a potentially correctable cardiovascular emergency in his case.

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A lady walks in with complaints of dysphagia mostly to solids to begin with and gradually progressive to liquids requiring naso-gastric tube feeding ,with history of vomiting after taking food and weight loss of 20kilograms over 2months. Upper gastrointestinal endoscopy showed an ulceroproliferative growth starting at 28cms from the central incisor and extending upto 36 cms with luminal compromise. Biopsy from the lesion was found to be moderately differentiated squamous cell carcinoma. As part of metastatic work-up a PET-CT (Figure 1 shows lesion in the left ventricle) was done which revealed a metabolically active lesion involving the lower third of esophagus and a metabolically active lesion in the wall of the left ventricle which was the only site of metastatic diseae(Figure 2. Maximum intensity projection). Further investigations were done for characterisation of the cardiac lesion. 2-D Echo cardiography was done and was normal with an ejection fraction of 60%. A cardiac MRI was done which showed a soft tissue mass in the wall of the left ventricle which was isointense with normal myocardium and hyperintense on double inversion recovery sequence which measured 3.2 x 3 cms with post contrast enhancement. She was planned for palliative radiotherapy. A total dose of 30Gy in 10 fractions over 2 weeks was delivered.She tolerated the treatment well with Grade I mucositis (as per RTOG grading) and on follow-up after 4 weeks she had 40% relief in dysphagia and could take semi-solid food with little difficulty.

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Suicide risk is very high in the patients suffering from advanced cancer. Around 60% of patients with advanced cancer suffer from cancer related pain and this further accentuates the risk of psychiatric disorders as well as suicide. A fifty year old male who was a known case of carcinoma of floor of mouth, post chemotherapy and post radiotherapy came in the outpatient clinic with complains of throat pain which increased on swallowing. On further probing, it was revealed, that he consumed poison in the recent past while being agitated and upset with the severe throat pain. The recent radiotherapy had only made the pain worse. Cancer pain is an important symptom which should be adequately addressed while reviewing patients in the palliative care / oncologist clinic.

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The aim of this case report is to highlight diagnostic and therapeutic challenges for consultation-liaison psychiatrist in the case of radiation-induced neuropsychiatric syndrome. We report the case of a 61-year-old man presented with neurological and psychiatric manifestations following the radiation therapy for non-small cell lung carcinoma with brain metastasis. We have briefly reviewed and discussed the risk factors, clinical features, diagnostic, therapeutic, and preventive aspect of radiation-induced neuropsychiatric manifestations.

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