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|Year : 2005 | Volume
| Issue : 2 | Page : 108-110
Are our patients getting palliative care too late? An audit
Biju Raghavan, Gayatri Palat, MR Rajagopal
Department of Pain and Palliative Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala, India
Department of Pain and Palliative Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala-682026
Source of Support: None, Conflict of Interest: None
Keywords: palliative care, audit, India, Kerala, developing countries
|How to cite this article:|
Raghavan B, Palat G, Rajagopal M R. Are our patients getting palliative care too late? An audit. Indian J Palliat Care 2005;11:108-10
| » Introduction|| |
Palliative care has historically been synonymous with terminal care. The science of Palliative Medicine espouses the need to provide active total care right from the time of diagnosis of a life-threatening disease (including supportive care during curative interventions) leading on, in the event of a life-limiting disease, to terminal care and thereafter bereavement support. Nevertheless 'almost universally, timing of referral to palliative care is 'late' in the course of the patients' illness'.,  The reasons could be many - ignorance of healthcare professionals and the community at large, regarding palliative care, ignorance of the availability of palliative care, attitudinal problems regarding palliative care etc. To begin to address such issues it is essential to get confirmatory data whether the earlier statement about late referrals is true in the local scenario too.
| » Aim|| |
The primary aim of the audit was to identify whether the patients were being seen in the palliative care unit only at an advanced or terminal stage of their illness. We also intended to find out whether there was any gender difference in accessing palliative care.
The secondary aim of the audit was to identify the common symptoms and types of cancers seen in our palliative care population.
| » Methods|| |
The Department of Pain and Palliative Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala, provides home visit services to patients when they were unable to attend the outpatient clinic. The service covers areas with a radius of 35 kilometres from the institution.
The records of deceased patients who had been registered for the home visit service between July 2001 and June 2004 were audited. The time period between diagnosis to seeking palliative care and the time between seeking palliative care to death were recorded in months. The gender, diagnosis and the reason for seeking palliative home care were also noted.
| » Results|| |
During the three year period from July 2001 to June 2004, the home visit service had seen 369 patients. Of these, 215 (58.27%) were men and 154 were women (41.73%).
The time interval from diagnosis to seeking palliative care was found to be a mean of 19 months. Time between seeking palliative care to death was a mean of three months. The total time from diagnosis to death was a mean of 22 months. [Figure - 1]
The time period between diagnosis to seeking palliative care was found to be 16 months [mean] and 23 months [mean] among men and women respectively, (p value 0.037). The time period between seeking palliative care to death was found to be two months [mean] and three months [mean] among men and women respectively (p value 0.392). The time period between diagnoses to death was 18 months [mean] and 26 months [mean] among men and women respectively (p value 0.093) [Figure - 2].
Head and neck (48, 13.3%) and lung (48, 13.3%) were the two largest groups. [Table - 1] 36 patients (9.76%) had non-malignant diseases. These included geriatric patients with dementia, Parkinson's disease, cerebrovascular diseases, peripheral vascular diseases, coronary artery diseases, osteoporosis with multiple fractures, non-healing wounds due to infected hip prosthesis, bed ridden patients with general debility due to old age and one middle aged person with alcoholic liver disease in hepatic failure.
The commonest reason for seeking palliative care was pain, which accounted for 256 (64.8%) of the cases. [Table - 2]. General debility (36) and breathlessness (16%) were the other common presenting symptoms. [Table - 2]
| » Discussion|| |
Many studies from different parts of the world have consistently shown that patients are referred for palliative care in an advanced or terminal stage of their illness.,, This study corroborates the worldwide trend.
| » Limitations|| |
This was a retrospective audit of patients and record keeping was not always uniform. The recording of the duration in months rather than in days can give rise to fallacies as patients who die within a month of seeking palliative care were recorded as one month. Not all patients had a tissue diagnosis. The sample size was small and possibly not representative of the general population. Patients registered for home care are likely to be more ill than average, and the study was limited to patients within a defined geographical area of 35 km radius. The referral patterns of different clinical units could also have been reflected in the distribution of diagnoses in our population.
| » Conclusions|| |
We found that patients of both sexes were receiving palliative care in an advanced or terminal stage of their illness. On an average patients lived for three months from the time they were seen in palliative care. The timing of referral should be based on the need to address physical or psychological symptoms and not on the estimated duration of survival. We need to find ways to provide supportive care earlier in the course of the disease, by sensitizing health professionals and the general public.
| » Acknowledgement|| |
We thank Dr. T. N. Sugathan, Director, Centre for Survey Research and Management Studies, Kochi, Kerala for the statistical analysis.
| » References|| |
|1.||Good PD, Cavenagh J, Ravenscroft PJ. Survival after enrollment in an Australian palliative care program. J Pain Symptom Manage 2004;27:310-5. [PUBMED] [FULLTEXT]|
|2.||Costantini M, Toscani F, Gallucci M. Terminal cancer patients and timing of referral to palliative care: a multicenter prospective cohort study. Italian Cooperative Research Group on Palliative Medicine. J Pain Symptom Manage 1999;18:243-52. |
|3.||Massarotto A, Carter H, MacLeod R. Hospital referrals to a hospice: timing of referrals, referrers' expectations, and the nature of referral information. J Palliat Care 2000;16:22-9. |
[Figure - 1], [Figure - 2]
[Table - 1], [Table - 2]