Free Paper Session
OD 01 (Free paper session)
Characteristics and pattern of mortality in cancer patients at a Tertiary care oncology center: Report of 259 cases
Gaurav Prakash, Sameer Bakhshi, Vinod Raina, Sushma Bhatnagar, Atul Sharma, Lalit Kumar, NK Shukla, PK Julka, GK Rath
Dr. B. R. A. Institute Rotary cancer Hospital, All India Institute of Medical Sciences, New Delhi, India.
E-mail: [email protected]
Introduction: Deaths in cancer-patients are a common occurrence and there are multiple possible causes of terminal event in a cancer patient's life. While progressive malignancy is assigned as a cause in most cases; actual peri-mortem conditions are less clearly addressed. Deficiencies in addressing palliative care issues by care-giver leads to discrepancies in understanding and reporting cancer deaths.
Objectives: To study characteristics of death, nature and intent of ante-mortem therapies and complications in patients with advanced malignancy.
Materials and Methods: In calendar year-2008 data of all deaths were analysed for immediate cause of death, type of palliative therapy administered in hospitalized cancer-patients. Cause of death mentioned on death certificate and as interpreted from review of hospital records/investigations was compared separately.
Results: Total of 259 deaths were recorded in a calendar year. 57% were cases of solid tumors and 41% cases of hematological malignancies. Median duration of hospital stay prior to death was 7 (1-106) days. Sepsis was the commonest immediate cause of death in 117/259 [45%] cases followed by progressive malignancy in 64/259 [25%] cases. 38% patients were given palliative anticancer therapy and 18% were given best supportive care alone. Only 13/267 [5%] patients who died had controlled cancer. There were discrepancies in information derived from death certificate and case records in 84/259 [32%] cases.
Conclusion: It is important to audit mortality data of cancer patients on regular basis as this can provide valuable insight in palliative-care practice. Mortality pattern and palliative-care need are different in resource limited settings as compared to developed world.
OD 02 (Free paper session)
Evaluating "Good geath" concept from iranian bereaved family members' perspective
Kerman Medical University, Razi Faculty of Nursing and Midwifery, Kerman, Iran. E-mail: [email protected]
Despite an increase in the attention given to improving end-of-life care, our understanding of what constitutes a good death is surprisingly lacking. This study thus was conducted to evaluate good death concept from Iranian bereaved family members' perspective. A descriptive, cross-sectional study designed. Using Good Death Inventory (GDI), concept of good death was evaluated. 150 bereaved family members fulfilled this questionnaire. Data were analyzed by SPSS. Based on the results, the highest scores belonged to the domains "Being respected as an individual", "natural death", "religious and spiritual comfort" and "control over the future". The domain perceived by family members as less important was "unawareness of death". Providing good death requires professional caregivers to be sensitive and pay attention to the preferences of each unique person's perceptions through her or his senses. In order to implement holistic care, caregivers must pay attention to patients' spiritual needs. Establishing a specific unit in a hospital and meeting each patient as unique being and a part of a family could be the best way to improve quality of end of life care that is missing in Iran.
OD 03 (Free paper session)
Detection of psychological distress in caregivers of terminally ill cancer patients
Savita Goswami, Jayita Deodhar
Tata Memorial Hospital, Mumbai, India.
E-mail: [email protected]
Introduction: Family caregivers of the terminally ill have a significantly elevated incidence of depression, anxiety, anger, psychosomatic symptoms, restriction of roles and activities, strain in relationships, and poor physical health. 2003 SAGE Journal, Palliative vol-17, No 7, 567-575, Respite in palliative care- A review and discussion of the literature, indicated that there are no studies assessing the effects of respite provided by specialist palliative care services on caregivers' outcomes.
• To study a prevalence of psychological distress in caregivers of terminally ill cancer patients.
• To study responses of caregivers of terminally ill cancer patients.
Materials and Methods: Participants included caregivers of adult and pediatric terminally ill cancer patients who are registered with palliative care clinic (n= 50). During their clinic visits after one month consecutively for three months caregivers completed psychological measures of general health, impact of event, irritability, anger and depression. Caregivers were also provided psychotherapeutic interventions and support during visits.
Results: Out of total participants (n=50) half were females. 66% caregivers at the first visit, 64% caregivers at the second visit and 70% caregivers at the third visit scored high on GHQ - 28. Majority of caregivers had shown higher level of anxiety and internalized anger. Moderate to sever hyperarosal and stress reactions seen as an impact of stressful life event. Constant psychological support and psychoeducation is well appreciated by majority of caregivers.
Conclusion: Caregivers of terminally ill cancer patients experience sever psychological distress. Strategies are needed for supportive psychotherapeutic intervention to minimize the impact and improve coping.
OD 04 (Free paper session)
Studies for sleep disorders are imperative in symptomatic patients on opioid therapy for chronic non-cancer and cancer pain: Two cases
Memorial Sloan-Kettering Cancer Center, New York.
E-mail: [email protected]
Introduction: Abnormal sleep architecture can occur during the process of opioid induction, maintenance and withdrawal. Central sleep apnea (CSA) has been reported with chronic opioid use and approximately 30% of stable methadone maintenance treatment patients have CSA.
Materials and Methods: Mr. A is a 58 year old male prostate cancer survivor with multi-site chronic pain secondary to severe degenerative joint disease. Mr. B is a 68 year old male with metastatic prostate cancer and compression fracture of the T12 vertebra causing severe back pain. He has a known history of idiopathic pulmonary fibrosis on home oxygen. Their pain was well managed on opioids, but both reported poor night-time sleep and snoring, gasping, choking, excessive daytime napping and fatigue. Both were referred for polysomnography/sleep studies.
Results: Mr. A was diagnosed with complex sleep apnea and Mr. B with moderate obstructive sleep apnea, disturbed sleep architecture and moderate oxyhemoglobin desaturations. They were recommended Continuous Positive Airway Pressure (CPAP) and Adaptive Sero Ventilation (ASV) support with improvement in their symptoms.
Conclusions: Sleep studies must be considered in symptomatic patients on chronic opioid therapy. Patients must also be advised avoidance of critical tasks requiring high vigilance until their symptoms are treated.
OD 05 (Free paper session)
Journey of cancer patient- A systematic evaluation
Aanchal Sharma, Alka Bhatnagar, Vikas Gogia, Deepa Khurana, Seema Mishra, Sushma Bhatnagar
Dr. B.R.A.I.R.C.H., All India Institute of Medical Sciences,
New Delhi, India. E-mail: [email protected]
Introduction: Ensuring the timely availability of adequate health care is important in proper treatment of disease. This becomes even more important when the management of disease depends on the stage in which it presents i.e malignancies. We by an interview technique evaluated this patient journey from when symptoms started till he received appropriate treatment.
Materials and Methods: Patients visiting Pain and Palliative Care Clinic and admitted in Palliative Care ward at Dr. BRAIRCH, AIIMS were asked questionnaire from a Performa and was filled in patients own language over a period of 3 months. The format of the proforma explains the disease's first presentation to physician, evaluation at its initial phase and the causes of delay in getting right treatment.
Results: We studied 50 patients over a period of three months. The average duration of the patients having the symptom and correct diagnosis is 62 months. From this average duration till receiving the actual required treatment is further is 3010 days. The most common causes of the delays are improper guidance at initial evaluation phase of disease.
Conclusions: Above study reflect the immediate need of creating awareness about early detection of cancer, avoiding unnecessary delays at initial phases of disease. We are planning to continue this study in large number of patients.
OD 06 (Free paper session)
Living with cancer - An audit of symptom control in patients with residual/recurrent malignancy
Sushmita Ghoshal, Minni Arora, Soumik Ghosh, Annu Sharma and Firuza Patel
Department of Radiotherapy, PGIMER, Chandigarh, India.
E-mail: [email protected]
Introduction: Our centre has a high volume of cancer patients requiring symptom control and not all of them can be seen in the Palliative Care OPD. Since the concept of palliative care was introduced here more than a decade ago, the radiation oncologist often manages these patients in their routine OPD.
Objective: To analyse symptom control in patients who are not receiving cancer directed treatment and to identify areas of potential improvement in the care of these patients
Materials and Methods: Fifty consecutive patients who had residual/ recurrent disease after specific cancer directed treatment were selected. The patients were asked about their symptoms, relief with the treatment prescribed, their insight about the illness and their socio-economic status. Patients were encouraged to express their emotional and spiritual concerns. The data was analysed using SPSS version 10.
Results: The age of the patients ranged from 30-80 years and there was a male preponderance. Half of these patients were not aware of the exact nature of their illness and likely prognosis. More than 90% had adequate family support but 40% had economic problems which interfered with the health care of the patient. Pain, weakness, anorexia and insomnia were the commonest symptoms. Physical symptoms were adequately controlled in 90% patients. Approximately 1/3 of the patients had some emotional problems but spiritual issues were difficult to elicit.
Conclusion: Control of physical symptoms was achieved in most of these patients but emotional and spiritual concerns need to be addressed more effectively. Economic constraints remain the biggest hurdle for patients in our set up.
OD 07 (Free paper session)
Acceptance of death and dying by patients and their relatives in Indian palliative care
Joris Gielen, Sushma Bhatnagar 1 , Seema Mishra 1 , Harmala Gupta 2 , Ambika Rajvanshi 2 , Arvind K Chaturvedi 3 , Bert Broeckaert
Interdisciplinary Centre for the Study of Religion and World View, Catholic University Leuven, Belgium, 1 Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, 2 CanSupport New Delhi, 3 Rajiv Gandhi Cancer Institute and Research Centre, India.
E-mail: [email protected]
Introduction: Acceptance of death and dying by terminal patients can significantly reduce anxiety and depression experienced by them at the end of life. Relatives not accepting the approaching death may be greatly distressed. Some elements which can stimulate or obstruct acceptance of death and dying are contextual and culture-specific. Within the framework of a broader study on Indian palliative-care physicians' and nurses' ethical attitudes and experiences in palliative care, we had the opportunity to enquire about their experiences with the issue of patients' and their relatives' acceptance of death and dying.
Objectives: Since formal interviews with terminal patients and their relatives are impossible, we wanted to investigate which elements influence acceptance of death and dying in Indian palliative care according to the physicians and nurses.
Materials and Methods: We opted for an explorative research design based on 27 semi-structured face-to-face interviews following Grounded-Theory methodology (Glaser and Strauss). 14 physicians and 13 nurses working in different palliative-care programmes in New Delhi were interviewed from May to September 2008.
Results: Untreated physical symptoms, lack of knowledge and understanding of the disease, uncertainty about the future of those left behind, and unresolved spiritual and religious issues were noticed to impede acceptance of death and dying by patients and their relatives. Relatives who had accepted that their family member was dying were observed to cope more easily after the patient had died.
Conclusions: Acceptance of death and dying is influenced by diverse elements. Increased acceptance was associated with the holistic care provided by palliative-care teams.
OD 08 (Free paper session)
Prolonged epidural infusion of local anaesthetic (bupivacaine) using an elastometric pump in three patients of intractable back pain due to metastasis in the vertebral column
Hammad Usmani, Mozaffar M Khan, Nazia Tauheed
Department of Anaesthesiology, J. N. Medical College, AMU, Aligarh (U.P), India.
E-mail: [email protected]
Introduction: Patients of advanced malignancy with spinal metastasis often have severe back pain which was even refractory to opioids or adjuvant analgesics. Increasing the dose of opioids in such patients not only causes excessive sedation or drowsiness but may also produce a state of powerlessness in such patients. Continuous epidural infusion of local anaesthestic has been found to provide an adequate degree of pain relief in patients with intractable pain due to spinal metastasis without causing side effects related to high dose of opioids. However there is a high probablity of bacterial colonization of epidural catheter during prologed catheterization resulting in the spread of infection to the meninges or spinal cord.
Materials and Methods: We have analyzed the efficacy of continuous epidural infusion of bupivacaine (0.125%) at the rate of 2 ml/hr using an elastometric infusion pump under a mild antibiotic cover (co-trimoxazole) in three patients with intractable back pain due to metastasis in the lower thoracic and lumbosacral segments of vertebral column. OTFC was advised for any episode of breakthrough pain during the epidural infusion.
Results: All three patients reported a satisfactory level of pain relief with the epidural infusion of bupivacaine (0.125%). In the first patient, the infusion was continued for about 3 weeks before the death of the patient. The second patient received infusion for 2 weeks only as he developed drowsiness and severe loss of appetite. In the third patient the epidural infusion was continued for about a month after which he developed moderate degree of fever. On removal of catheter, there was superficial infection at the site of puncture which was resolved after cleaning and dressing of wound with antiseptic solution for 3 days.
Conclusions: The epidural infusion of local anaesthetic could be a useful technique in patients of advanced malignancy with spinal metastasis refractory to opioid analgesics.
OD 09 (Free paper session)
How long will I live? Can we make an educated guess?
Ramu K, Reena George, Abraham Samuel
Palliative Care Unit, Christian Medical College Vellore, Tamil Nadu, India. E-mail: [email protected]
Objective: To evaluate the Palliative Prognostic Score (PaP) and the Palliative Prognostic Index (PPI) in patients receiving palliative care.
Introduction: Palliative care professionals after face the question. "Doctor, How long do I have?
Materials and Methods: Patients were clinically assessed and scored using the (PaP) and the (PPI) scores. A family member was contacted once a month. Actual survival times were compared with PaP and PPI predictions.
Results: PPI predicted 19 out of the 55 actual deaths that occurred by one month (Sensitivity 34.5%). Out of 23patients who were in PPI poor prognostic group, 19 died within one month (positive predictive value of 82.6%). PaP predicted 14 out of 38 deaths that occurred by one month (Sensitivity 36.8%). Out of 23 patients who were in PaP poor prognostic group 14 died within the month (PPV 60.9%). Patients with dyspnoea and delirium had the lowest median survival (4.4 weeks and 3.2 weeks). When Clinicians estimated survival, patients estimated to live less than four weeks had a median survival of 3.3 weeks. Those estimated to live between one to 3 months had a median survival of 13 weeks.
Conclusion: No score was superior to another. PPI was a simple score useful in very sick patients, to predict one month survival, but not accurate for predicting 3 months survival
OD 10 (Free paper session)
The quality and quantity of volunteer service in hospital networking
Bhoopathy Devapathni, Vijay Kumar, Saraswathi Devi, Linga Gowda
Kidwai Memorial Institution of Oncology, India.
E-mail: [email protected]
Background: Three Cancer Support systems, the 1) Kidwai Cancer Drug Foundation (KCDF); 2) Kidwai Venkateswara Vishranti Dhama (Dharmasala) 3) Infosys Dharmasala -exist within the campus of the Kidwai Memorial Institute of Oncology (KMIO). Volunteers raise funds to KCDF and the Dharmasalas which distribute subsidized and free medicines and provide free food and shelter to economically backward rural cancer patients. Poor out-patients who have come for radiotherapy and/or surgery follow up or medical treatment need shelter for continuation of the treatment which is provided by the above support systems.
Aim and Objective: Make the patients comfortable by appropriate communication and care so that they can continue medical treatment. Providing a source of finance for their treatment so that potential drop outs from treatment will be retained.
Materials and Methods: By counseling, we instill confidence that cancer is curable and longevity of life can be achieved by siting the examples of the cured patients. By regular entertainment (songs, dramas and magic shows), the hospitalized patients stress will be reduced. By communication methods, volunteers not only create a human environment but also induce care consciousness in the family members and community. By bringing to the notice of the doctors, nurses about certain apprehensions of the patients regarding fear of the treatment, sexual issues, physical disability, etc., we sensitize the doctors and their team.
Results and Conclusion: Patients drop out rate from the treatment is considerably reduced. There is more confidence in the patients to mange the disease by themselves and by their family members. Volunteers form an important link in the chain of hospital networking that result in enhanced patient care.
OD 11 (Free paper session)
Assessing caregiver experiences for modeling team interventions - An evidence based approach to palliative care planning and delivery
CanSupport, New Delhi, India. E-mail: [email protected]
Objective: The diversity of palliative care services has an important implication for the design of an assessment system of quality of care. Rather than a 'cast-iron' approach, palliative care assessment needs to be receptive, responsive, adaptable, multi-pronged and tailor-made to individual needs. The aim of this project was to integrate family caregiver feedback in comprehensive quality assessment and care improvement, allowing care teams to identify distinct needs, customize interventions and establish networks to bridge gaps in comprehensive care.
Materials and Methods: A caregiver feedback form was developed after review of international literature and inputs from palliative care professionals, cancer patients and their caregivers in Delhi. This 30-item questionnaire assessed overall care coordination and solicited response under six core categories; whether care was (1) Patient centered and family oriented (2) Beneficial (3) Sensitive (4) Safe (5) Timely (6) Effective. In a pilot survey, volunteers interviewed family caregivers of deceased cancer patients looked after by Home Care teams.
Results: The survey provided detailed and unbiased caregiver feedback. A graphic representation of the core categories, especially the 'benefits' in terms of symptoms, function, interpersonal, well being and transcendent (perceived as dimensions of quality of life) revealed areas of strength as well as unmet needs and deficiencies in quality of care. The study reinforced that certain process elements of team functioning are influenced by caregiver involvement, especially assessment, care planning, implementation of plans and networking for holistic care.
Conclusion: The project recognizes that the retrospective information by caregivers is an effective intervention in palliative care allowing continuous quality improvement. Integration of such evidence-based guidelines challenges and steers care teams to bridge identified gaps through personal capacity building, palliative care education for healthcare workers, and effective networks in community for mobilizing resources. Assessing caregivers proves to be a translational tool as it is based on the practical implementation of a theoretical framework of their experience.
OD 12 (Free paper session)
Efficacy of scrambler therapy in neuropathic pain in a tertiary care cancer
Nirmal Kumar, Sandeep Babbar, Shveta Katyal, Shiv Pratap Singh Rana, Seema Mishra, Sushma Bhatnagar
Dr. BRA, IRCH, All India Institute of Medical Sciences,
New Delhi, India. E-mail: [email protected]
Introduction: The Scrambler Therapy interferes with pain signal transmission, by mixing non-pain information into the nerve fibers. The machine consists of a multiprocessor apparatus able to simulate 5 artificial neurons by the application of surface electrodes on skin.
Aims: To evaluate the efficacy of scrambler therapy in the treatment of neuropathic pain in cancer patients.
Materials and Methods: Twenty five cancer patients with neuropathic pain were treated with Scrambler therapy from April 2010 to October 2010 in Dr B.R.A. IRCH, AIIMS, New Delhi. Ten sittings of scrambler therapy treatment (each session lasting 45 minutes) five days in a week for two consecutive weeks were given followed by weekly follow-up for a further 2 weeks. Patients were asked to describe their current level of pain in a VAS questionnaire immediately before starting treatment and after each 45-minute session. At follow up appointments, the efficacy and duration of the Scrambler's effects were evaluated.
Results: All patients reacted positively to the treatment throughout the whole reference period. 11 patients showed a decrease in VAS from an average of 8.2 to 4.2 at the end of treatment and 4.5 at the end of follow-up week. Pain relief of more than 50% was found in 54% of patients, 2 patients showed no pain relief and worsening of pain was found in 1 patient. No undesirable side effects were observed.
Conclusions: Results from the above study conclude that Scrambler therapy is effective in reducing pain intensity in neuropathic cancer pain patients.
OD 13 (Free paper session)
Pulsed radiofrequency lesioning of the glossopharyngeal nerve for patients with oraopharyngeal cancer pain: A case series
Vikas Gogia, Aanchal Sharma, Arif Ahmed, Deepa Khurana, Charu Sukhlecha, Seema Mishra, Sushma Bhatnagar
Dr. B.R.A.I.R.C.H., All India Institute of Medical Sciences,
New Delhi, India. E-mail: [email protected]
Introduction: Cancers involving the oral cavity are the most debilitating of diseases. Painful mastication and deglutition make it difficult for the patients to take pain medications orally. Pain arising from the oropharynx, tonsils and posterior part of tongue is mediated by the glossopharyngeal nerve. We present a case series of 15 patients who underwent pulsed radiofrequency of glossopharyngeal nerve for intractable pain in this anatomical distribution.
Objectives: The objective of this case series is to establish pulsed radiofrequency lesioning of glossopharyngeal nerve as a safe and effective means of providing pain relief to these patients. Moreover, baseline pain may be well controlled using the WHO ladder for cancer pain relief but it is the incidental pain, i.e. pain during mastication, swallowing and talking that may not be amenable to oral pharmacotherapy.
Materials and Methods: 15 patients who either had poor pain relief with high doses of oral morphine or severe side effects underwent pulsed RF lesioning of the glossopharyngeal nerve for 3 minutes after prior successful diagnostic blocks. Patients pain scores and difficulty in swallowing was graded pre and post procedure. Patients were followed up for 2 months after the procedure.
Results: All the patients had acceptable pain relief with mean VAS of 2 at rest and marked improvement in ability to swallow. All patients appreciated marked improvement in quality of life with minimal side effects.
Conclusions: Glossopharyngeal nerve lesioning using pulsed RF is a useful and safe tool for patients with oropharyngeal cancers and may be used as an adjunct to oral medications
OD 14 (Free paper session)
Palliative care and network: The place and role of a family physician
DNB Family Medicine in Madhya Pradesh, India.
E-mail: [email protected]
1. Primary care, palliative care, and family medicine
The Alma-Ata Declaration of 1978 was a major milestone in the field of public health. It affirmed that health, which is a state of complete physical, mental and social wellbeing, is a fundamental human right and identified primary health care as the key to the attainment of 'health for all.' In 2008, on the 30 th anniversary of the Alma-Ata Declaration, the World Health Organization (WHO) reiterated the values enshrined in the Alma-Ata Declaration by issuing a document entitled, Primary health care: now more than ever.
The Alma-Ata Declaration described what primary care is in the following words: "Primary health care is essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination".
Family physicians, physicians with a specialization in family medicine, are specially trained physicians in primary health care. According to WONCA, the world organization of national colleges and academies of family physicians, the aim of family medicine is to provide personal, comprehensive and continuing care for the individual in the context of the family and the community. So primary care and family medicine are intimately connected.
Now coming to palliative care, family physicians have an integral part to play. Care of palliative patients and their families is part of family medicine. Although palliative care is being increasingly recognised as a specialty, primary palliative care delivered by family physicians cannot be discounted. A family physician tries to provide family and community based palliative care.
2. Palliative care and family medicine in the Indian context
One of medicine's noble missions is to care for the terminally ill patients and allow them to die with as much dignity, comfort and control as possible. Owing to social and economic reasons, medical institutions in India are unable to take up the responsibility of looking after patients with progressive and non-communicable diseases for a longer period. At the same time, patients with chronic and incurable illness need a regular system of support. It is very true of palliative patients. This calls for a family and community based palliative care. In order to achieve this, we need a network of persons and resources. Without active participation of family members, care givers, doctors, community nurses and volunteers, we cannot have a good palliative care in place. The role of family physicians is crucial in this regard.
In the palliative care network, a family physician's role may be the following:
3. Palliative care: Personal experience
As we consider and discuss today about network in palliative care, I feel that I myself am and should be a network, which is very much effective and is needed in palliative care. A family physician interacts not only with patients and their families but also with community volunteers, nurses, referral doctors, and primary and community heath centres.
After my MBBS graduation until I went for post-graduation in family medicine, I had the opportunity to work with community-based primary palliative care. Mr. K.P. Narayan and his team at Karinthalam in Kazhargode district, Kerala, do a marvellous job in family/community based palliative care. When I worked with them I realized that a primary care physician is an indispensable link in the palliative care network.
My experience with family medicine convinced me further of the importance of family medicine and family physician in palliative care. A family physician is trained to treat most common medical problems in people of all ages. They (family physician) are able to prescribe adequate doses of medicine to children and adults and they will notice indications and contraindications of different groups of medicine to different people. A family physician makes referrals to specialists, when required. A family physician can facilitate communication between different links of the palliative care network and improve the quality of care we give to palliative patients. In short, a family physician can be a great support to patients in their illness and death and to families before, during and after the death of their loved ones.
4.Family physician in the palliative care network: A model
Family physician in relation with people and institutions
OD 15 (Free paper session)
Evaluation of a home care triage system for patients on palliative care at the Tata Memorial Centre
Balaji P Duriasamy, Ma Muckaden, Manjiri D, Sunil D, Prajakta T, Shalaka C, Kiran M, Melba C, Nikita S, Sharayu D
Palliative Care Services, Tata Memorial Centre, Mumbai, India.
E-mail: [email protected]
Aims: To evaluate a new triage system introduced at the Palliative care services (PCS), to prioritize the patients currently receiving Home care service (HCS).
Materials and Methods: From May 2010, the PCS introduced a system of triaging the patients on home care as "high", "medium" or "low" by the clinicians at index visit and at follow up visits/phone calls based on assessment of patients or of report given by the primary care givers. Data of patients currently on HC were analyzed using SPSS to identify factors that could affect the coding.
Results: Of 65 patients currently on HC, 48 were coded. 15 (31%) were coded as "high", 7 (15%) as "medium", 26 (54%) as "low". 9 of 15 patients coded "high", received HC in a median time of 9 days; 4 of 7 patients coded "medium" in a median 13.5 days; 14 of 26 patients coded "low" in a median 10 days. The rest (19/48) have not received home care yet. On Pearson's correlation, higher priorities significantly correlate with combined physical & psychosocial distress, higher fatigue, depression, anxiety or higher total symptom score (P<0.05). There is a tendency for patients with low total symptom score or staying far away to be not coded. Though there is no correlation between geographic proximity and whether a patient received HC or not, patients who are located far away were more likely to be coded as "low priority".
Conclusions: There is a need for triaging home care patients in settings with resource limitations. The present system identifies the symptomatic patients who need urgent care but the assessment and coding are subjective, can vary and not fool proof. A continuous study and a Regression Partition Analysis would reveal more factors and patterns in the coding system. The results were discussed in a team meeting and efforts are on to improve the system with guidelines for coding.
OD 16 (Free paper session)
Community based palliative care: A metropolitan experience
Sumitha Chalil, Hamza KV, Sainuddeen AT, Anjay B
Delhiites National Inititative in Palliative Care (DNipCare). E-mail: [email protected]
Introduction: Delhi, the capital of India is characterized by world-class facilities in healthcare. However, like most other parts of the country, the focus on cure often undermines the need of palliative care for patients suffering from terminal, life-limiting and long-term illnesses. The prevailing stigma about diseases like cancer adds to the miseries of patients and families in terms of social exclusion and loneliness.
The need of community-based palliative care was identified by a group of people. They joined together under the name - Delhites' National Initiative in Palliative Care (DNipCare). Through this initiative DNipCare attempt to inculcate the discipline of palliative care in the community. The initiative has adopted a volunteer-based approach to provide care to the patients and their families. Since all volunteers of DNipCare are either employed or students, ensuring regular care for patients was a challenge faced by the organization in its initial days.
Objectives: To ensure availability of home care services for all patients registered with DNipCare on a regular basis through volunteers. To identify and support to resolve different issues faced by the patient and family which arise out of the patients ill-health. To facilitate and equip immediate family members and care givers in better care of the patient.
Materials and Methods: Care through regular home visits during holidays especially weekends and evening visits on weekdays during critical times like hospitalization, death etc.
Telephonic counseling to ensure need-based and continuous emotional support. Review meetings with experts on second Saturdays, communication between volunteers and experts through internet groups and telephone to ensure best possible care for the patient.
Results: Regular care is ensured for 60 patients registered with DNipCare. In addition, regular emotional and social support is provided to patients at Delhi State cancer institute. Currently, volunteer-base has grown above 60 including women.
Conclusion: The DNipCare model established a system of regular and effective care through local volunteer groups. The weekend visits serve as opportunities to meet the patient and immediate family members together and discuss the issues in a holistic manner. Trust built during such visits has helped the families in sharing different psychosocial issues with the volunteers. However, the system needs to be strengthened with more volunteers to cover the vast area of Delhi.
OD 17 (Free paper session)
Pleurodesis in malignant pleural effusions: A retrospective analysis of tertiary palliative care
Vinod Kumar, Vikas Gogia, Anchal Sharma, Sushma Bhatnagar, Seema Mishra
Dr. B.R.A. Institute Rotary Cancer Hospital All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.
E-mail: [email protected]
Introduction: Recurrent pleural effusions in patients with advanced cancer is a common problem that causes significant morbidity and can negatively affect patient's quality of life for their remaining months.
Objective: The aim of pleurodesis in malignant pleural effusion patients is to prevent re-accumulation of the effusion and thereby of symptoms and avoid the need for repeated hospitalization for thoracocentesis. We hypothesized that this approach would improve symptoms and quality of life at a reduced cost.
Materials and Methods: A 14F pigtail catheter was percutaneously inserted into the pleural space and connected to a closed gravity-drainage bag system. Once the drainage was <100 mL/24h, sclerosis with 60 units of bleomycin was done. Patients were graded for dyspnea and performances status using the Eastern Cooperative Oncology Group score (ECOG) and baseline and transitional dyspnea index score (BDI-TDI) before pigtail catheter placement and again at 30 days.
Results: Ten ambulatory patients, ages 41 to 79 years, were enrolled. The pigtail catheter was left in place from 1 to 7 days, draining a mean of 2,956 mL (1,685 to 6,050 mL). Only two patients were unable to undergo sclerosis owing to catheter dislodgment and minimal drainage. Six reported symptomatic improvement at 30 days confirmed by TDI and ECOG scores. One patient died and other patient had hydropneumothorax.
Conclusion: Sclerosis of malignant effusion using a small-bore catheter is a feasiblealternative to sclerosis with a large-bore chest tube. Pleurodesis of malignant pleural effusion has improved symptoms and quality of life at a reduced cost.
OD 18 (Free paper session)
24Χ7 home care project in palliative care: An experience in Kozhikode city
Pain and Palliative Care Society, Medical, Kozhikoda, India.
E-mail: [email protected]
Introduction: 24Χ7 home care project has started in Kozhikode city in June 2010 with an objective to provide palliative home care to needy patients within the city round the clock. Palliative home care was provided in Kozhikode city from 09.00am to 05.00pm in all week days. It has been noticed that, if this service is extended to 24 hours per day, more patients will get benefit. As a result 24Χ7 home care services started in Kozhikode city on 11 th June 2010. Regular home care during day time winds up at 05.00PM in the evening each day. The night home care service serves as an extension of regular day home care till 09.00 PM. After 09.00PM, the Night Home care team including a Nursing Staff stays at Institute of Palliative Medicine, Kozhikode. But they attend emergency calls from patients and visit the patient's home according to need. The service of doctors also is made available after assessing the need.
Objective: To assess the success of 24Χ7 home care project after completing six months of its operation.
Materials and Methods: Collecting data of the night home care
Taking Feed back from patients and family members
Analysing the need and service provided
Results: This helps to assess the effective ness of home care round the clock. This data helps to replicate the model in other places.
OD 19 (Free paper session)
Role of intermittent and bolus epidural 6% aqueous phenol for pain and palliative care management in pelvic malignancies
Sandeep Sahu, Kushant Gupta, RK Mehta, HD Pandey, S Jain, Anil Agarwal, PK Singh
Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, UP, India. E-mail: [email protected]co.in
Introduction: Cancer is one of the most common causes of death and pain is among the most prevalent symptoms experienced by patients. Between 70% and 90% of all cancer pain can be controlled by the WHO analgesic ladder. Rest 10% to 30% unrelieved and intractable pain managed by relatively brief application of a local anaesthetic or neurolytic agent makes invasive procedures an attractive approach in selected patients.
Materials and Methods: After ethical committee approval and written informed consent forty patients of pelvic malignancies of both sexes with intractable pain who were not responding to conventional pharmacological therapy were randomly divided into two groups:
Group I - Aqueous 6% phenol injected epidurally in intermittent doses.
Group II - Aqueous 6% phenol injected epidurally in bolus injection.
History regarding duration, severity and site of pain was taken and thorough general and systemic examination was done. Site of epidural injection (with18 G set with aseptic condition, performed in OT) for sciatic type of pain at L2-3, for sacral pain, e.g. cancer cervix and rectum at L4-5 and for pain in perineum at L5-S1 level after confirming the desired segments found to be anaesthetized, the desired dose of drug (6% aqueous phenol) injected slowly and patient kept in same position for 20-30 minutes. After the block vital signs, complete sensory and motor system examination of the segments blocked, degrees of pain relief were assessed using VAS and complications and quality of life were recorded.
Results and Conclusion: Intermittent epidural phenol provides better pain relief and incidence of complications is also less than bolus epidural phenol as the dose can be titred according to the pain response and complication in the patient.
OD 20 (Free paper session)
Pain and palliative care in a tertiary care setting: Our experience
HM Iqbal Bahar
Head, Pain and Palliative Care, Cachar Cancer Hospital and Research Centre, India. E-mail: [email protected]
Introduction: The Cachar Cancer Hospital and Research Centre is a 63 bed rural centre dealing with comprehensive management of cancer patients including Palliative Care. This hospital serves the population of Barak valley which is extremely poor, underserved and geographically remote. In this context, the Pain and Palliative department which was started under the grant from Indo-Americal Cancer Association have been rendering hospital based palliative care. This study intends to highlight the effectiveness and shortcomings in delivering effective palliative care in our set-up.
Aims: To determine whether hospital-based palliative care teams improve the care for patients.To assess the effectiveness in delivering effective palliative care.
Materials and Methods: In this one year prospective study, conducted at CCHRC, we considered following factors: Socio-economic status, geographical location, frequency of hospitalization & follow-up, symptom control at discharge using ESAS, duration of palliative care and morphine consumption.
Results: Till now our study included 427 cases for palliative care. Socio-economic data showed 60% of patients earning less than Rs 2000/month. Also, 2/3 rd of the total patients hailed from remote areas. Patients were also analysed in respect factors mentioned above.
Conclusion: Our study revealed the following factors in relation to hospital based care, viz: cost of treatment, logistic problems (beds, etc) and loss in family income while at hospital. This makes hospital based palliative care less effective. As such hospital based palliative care is not an ideal model for effective palliative care delivery. Therefore, we need to reach out pro-actively by different approach including modern communication tools like telephones, internet, home-visits, satellite camps and liasioning with local medical and paramedics.
OD 21 (Free paper session)
Mechanism-based classification and physical therapy management of upper extremity complex regional pain syndrome type 1: A case series
Senthil Paramasivam Kumar, Prem Kotian, Anup Kumar
Kasturba Medical College (Manipal University), Mangalore, India.
E-mail: [email protected]
Introduction: Complex regional pain syndrome (CRPS) type-1 or reflex sympathetic dystrophy is a chronic disabling painful condition occurring secondary to trauma that presents commonly in palliative care. Mechanism-based classification (MBC) of pain involved five mechanisms: central sensitization, peripheral sensitization, nociceptive, sympathetically maintained and cognitive-affective.
Objective: To report the effectiveness of MBC-based physical therapy management of patients with unilateral upper extremity CRPS type-1.
Materials and Methods: Six patients (4 female; 2 male) with age 48.16 (6.4) years, all right-handed, with affected side (4 left, 2 right) upper extremity, medically diagnosed with CRPS-I and fulfilled the IASP diagnostic criteria were treated with mechanism-based physical therapy treatments. Home programme of self-treatment was prescribed and patient log was given to ensure compliance. The outcome measures included pain on 0-10 cm visual analogue scale (VAS), Radboud skills questionnaire (RSQ), Patient satisfaction with therapy questionnaire (PSTQ) and patient- and clinician-rated global clinical impression scales (GCIS) for pain, grade of hand tenderness, emotion, function, activity limitation and participation restrictions according to the International classification of functioning, disability and health (ICF core set) were taken at four levels: pre-treatment (t1), post-treatment (1-week)- t2, post-treatment (2-weeks)- t3 and post-treatment (3-months)- t4.
Results: Pair-wise comparisons using paired t-test in SPSS version 11.5 showed statistically significant changes (P<0.05) in all the measures at t3 and t4 compared to t2/t1 and t3/t2/t1 respectively. The clinical improvements correlated well with GCIS measures (r=0.68) suggesting clinically meaningful improvement in the outcomes.
Conclusion: Physical therapy treatment techniques can be specifically prescribed along a mechanism-based approach to pain.
OD 22 (Free paper session)
Review of referral practices to a specialist pediatric palliative care service at Tata Memorial Center India
Manjiri Dighe, Maryann Muckaden, Balaji PD, Sunil Dhiliwal, Prajakta Tilve
Tata Memorial Centre, Dr. Ernest Borges Road, Parel, Mumbai, India. E-mail: [email protected]
Introduction: Paediatric palliative care is an integral part of any cancer setup. Knowledge of referral patterns is essential to improve patient care.
Aims: To present referral patterns to Pediatric palliative care services (PPCS) at our centre.
Materials and Methods: Data were gathered by reviewing records of 99 consecutive patients registered over 12 months. 4 patients with incomplete case records were excluded from analysis. Demography, referral patterns, symptom load and follow up patterns were studied in 95 patients. Data were analyzed using the SPSS software to assess factors that determined the time of referral.
Results: 45% had metastasis at presentation to the primary oncology unit. 30% were referred while they were on some disease modifying therapy. Symptoms were scored as follows- presence (1) or absence (0) of pain, fatigue, nausea, psychological distress, dyspnoea, anorexia, sleep disturbance, neurological dysfunction, loss of wellbeing. Symptom load was determined by adding individual scores. (min 0 max 9). The median symptom score was 4. Pain (70%) and loss of wellbeing (75%) were most common. Median follow up duration was 39 days- including clinic (70%) home care visit (15%) or telephonically (55%). Simple Pearson's correlation and linear regression tests were performed to assess correlation between variables. Follow up duration correlated negatively with symptom load (r=-0.246; P=0.016) (F=6.006; P=0.016). Metastasis at presentation correlated positively with referral (r=0.269; P= 0.008) (F=7.246; P=0.008). There were no other significant correlations.
Conclusion: Most referrals are based on intent to treat (palliative versus curative) rather than symptom load. This practice may lead to late referrals and inadequate symptom control.
OD 23 (Free paper session)
Pediatric palliative care: A best practice model for India
Can kids. E-mail: [email protected]
Introduction: In India there are approximately 50000 new cases of childhood cancer with 60-80% of cases becoming palliative. With this astonishing number, it is vital to incorporate appropriate palliative care for pediatric cancer patients. This however, is not the case throughout most of India. When a case becomes palliative, few resources are available for a patient to ease their pain and maintain a high quality of life. This lack of emphasis and understanding of the importance of palliation has often meant that children will not receive proper treatment and therefore may suffer unnecessarily.
Objectives: Can kids ultimate goal is to provide holistic care encompassing the entirety of cancer treatment.
Materials and Methods: CanKids has initiated a pediatric palliative care project which will serve as a low cost model for other cancer institutions and organizations alike. This initiative outlines a set protocol for patient tracking and navigation, pain management, resource mapping, bereavement support, informational tools for patients and caregivers, capacity building/sensitization workshops, and eventually, the acquisition our own Palliative Care Team and Center.
Results: Measurable results will include advanced support services. Sensitization and increased knowledge for those concerned with pediatric palliative care and advocacy for an enhanced standard of pediatric palliative care in India.
Conclusion: In providing a pediatric palliative care model that works in collaboration and bridges the gap between palliative care experts, pediatric oncologists, cancer care centers, organizations, caregivers, patients, volunteers and supportive resources, CanKids Pediatric Palliative Care Project will serve as a Best Practice Model for pediatric palliative care in India.
OD 24 (Free paper session)
Radiofrequency treatment for occipital neuralgia in malignant cancer patients: A prospective study
Shiv Pratap Singh Rana, Arif Ahmed, Deepa, Charu, Rahul, Seema Mishra, Sushma Bahtnagar
Dr. B.R.A.I.R.C.H., All India Institute Of Medical Sciences, New Delhi, India. E-mail: [email protected]
Introduction: Occipital neuralgia (ON) typically presents as pain in the distribution of greater and lesser occipital nerves usually localized unilaterally. Occipital nerve block by using a local anesthetic agent such as lidocaine with or without steroids is valuable not only for the diagnosis of occipital neuralgia but also provides immediate pain relief with varying long-term success.
Materials and Methods: Patients fulfilling the diagnostic criteria for Occipital Neuralgia were selected. Those whose head pain was relieved by anesthetic blockade were confirmed to have ON and were assessed for pulse radiofrequency ablation. We performed local anaesthetic blockade and later pulse radiofrequency ablation (PRFA) of the greater occipital nerve (GON) and lesser occipital nerve (LON) in 30 patients. A needle was inserted at the base of the skull at the level of superior nuchal line, paraesthesia obtained with the help of nerve stimulator. An anesthetic block of the nerve was practiced using 4 ml of bupivacaine 0.25%. The occipital nerves were identified using a 22 gauge, 50mm needle providing a 50 Hz, 0.5 V current. Correct needle position was confirmed by the presence of paraesthesia. PRF current consisted of 20msec bursts with a frequency of 2 Hz and 45 V and was applied for 120 secs per nerve.
Results: There was a decrease in VAS at all point of time (1.4 at 1 week, 0.8 at 1 month, 1.8 at 3 month and 2.6 at 6 month. There was significant pain relief following the PRFA of the two nerves. Patients were followed up for 6 months and their pain relief was significant with improved quality of life. The Karnofsky score improved from the baseline of 60 to 90 subsequently. Neck movements improved in all directions. These improvements were maintained at 6 month of follow up.
Conclusion: Results from the above study conclude that radio frequency ablation of greater and lesser occipital nerves can be used for treatment of occipital neuralgia.
OD 25 (Free paper session)
Palliative surgery for advanced gastrointestinal cancers - surgical oncology, aiims0 experience
SVS Deo, NK Shukla, Ashwin K Sushma Bhatnagar
Dr. B.R.A.I.R.C.H., All India Institute of Medical Sciences, New Delhi, India. E-mail: [email protected]
Introduction: Cancer is one of the common causes of death in developing countries. Cancer care involves many forms of treatment intended for either cure or palliation, including chemotherapy, radiation therapy, as well as surgical therapy. Gastrointestinal cancers constitute one of the leading cause of cancer-related mortality. Surgery plays an important role in the curative management of GI cancers. However a significant number of GI cancer patients are not suitable for curative resection. Palliation for obstructive symptoms, bleeding, perforation and nutritional care remains a core component in the overall management of GI cancers. This paper describes the incidence and profile of various palliative surgical procedures for advanced GI tumors performed at a tertiary care centre in India.
Materiala and Methods: A retrospective review of the prospective maintained computerized database of the Surgical oncology department was performed and the data of the GI cancer patients undergoing palliative surgical intervention were identified and analyzed. Between november 1995 to January 2009 a total of 274 out of 882 G.I. cancer patients had palliative surgical intervention. Surgical palliation was offered for obstruction, bleeding, perforation and nutritional needs. Palliative surgical procedures for GI cancers were analyzed pertaining to the frequency, type of procedure and outcomes.
Results: Thirtyone percent (274/882) of GI cancer patients had only palliative surgical intervention and 69% underwent curative resections in the Department of Surgical Oncology, All India Institute of Medical Science. Out of these 274 patients with GI cancer upper gastrointestinal cancer constituted 155 patients, colorectal cancers 91, and hepatobiliary tumors 28 patients. There were 150 (54.9%) men and 124 (45.1%) women. The age ranged from 14 to 93 years (mean, 48.14 years). As far as the type of procedure is concerned, bypass or diversion was done for 143 patients, resection in 11 and feeding procedures in 118 patients. The mean duration of admission was 13.40 days. Ten patients (3.64%) had morbidity and the operative mortality was 2.55% (7/ 274).
Conclusion: Most patients with advanced gastrointestinal cancer have a poor prognosis and may not be suitable for curative resection at presentation. There are no clear guidelines for indication or type of palliative surgical procedures in literature. Recent advances in endoscopic palliative measures have diminished the role of surgical palliation to some extent. But still in our experience 30% of GI cancers required surgical palliation mainly for relief of obstruction or nutritional needs.
OD 26 (Free paper session)
BSc in palliative care: A degree for Africa
Mhoira Leng, Flavia Bakundana, Anne Merriman, Consilous Rywanongo, Grace Kivumbi, Alfred Duku, Jo Dunn, Elly Katabira, Karen Frame, Mike Basler, Julia Downing
Makerere University, Uganda. E-mail: [email protected]
Introduction : Training is essential to build a critical mass of clinically competent practitioners that will offer national leadership to palliative care developments. Few opportunities exist for graduate and postgraduate training in palliative care in Africa and the former is particularly important for many health care workers in sub-Saharan Africa who only hold a Diploma.
Objectives : To develop and deliver a BSc in palliative care.
Materials and Methods : Building on a previous Diploma level course, Makerere University via its affiliated institution Hospice Africa Uganda (HAU) and in partnership with the African Palliative Care Association and supported by a UK faculty via a THET link, developed a 3 year modular, competency based, distance learning mode, blended learning Bachelors degree in palliative care. Flexibility of allows for students to exit year 1 with a Diploma and prescribers certificate or to progress. Students holding an existing Diploma in palliative care may enter directly to year 2.
Results : Following an approval process via the University Senate and National Council for Higher Education, development of course materials students have been recruited. To date 46 students from 8 sub-Saharan African countries have completed 1 to 2 semesters. This includes a 4 week learning period at HAU. Feedback has been very positive with one student from Malawi saying 'This has been a life changing experience'
Conclusions : Offering graduate level training is a significant undertaken requiring investment of resources, academic credibility, partnership working and committed enthusiastic students. Funding remains a challenge. A Masters level course is being planned.
OD 27 (Free paper session)
Development of an academic palliative care service in Makerere university /Mulago hospital, Uganda
Elizabeth Namukwaya, Mhoira Leng
Makerere University, Uganda, E-mail: [email protected]
Introduction: Barriers to integrating palliative care within an institutional setting includes lack of knowledge and and credibility for palliative care. Institutions need ownership of sustainable palliative care services that can change values and offer leadership and clinical modeling.
Objectives: To develop a palliative care unit (PCU) within Makerere University situated in the department of internal medicine. The aims of the PCU are: to develop a centre of excellence and model for hospital based palliative care, to deliver clinical care to patients and their families in the national referral hospital Mulago, to enhance advocacy and raise credibility for palliative care, to support and deliver education and training in palliative care and to support and initiate research
Materials and Methods: A steering group with local stakeholders and academic leads asked for external review. This was followed by wide consultation, appointment of lead clinician and multidisciplinary team, provision of office space, involvement in curriculum development, participation in departmental activities and exploring of clinical partnerships. Referral patterns were established within Mulago Hospital as well as with services in the community; in particular Hospice Africa Uganda.
Results: The PCU was established in October 2008 with 2 doctors and 5 nurses; to date more than 800 patients have been seen, significant progress in curriculum delivery, development of a research agenda and functioning clinical partnerships.
Conclusion: To be successful in setting up an academic palliative care unit, it is important to integrate the culture of the institution, establish relationships, use key allies, demonstrate what you are talking about and influence those in authority
OD 28 (Free paper session)
The importance of networks in building palliative care capacity and ultimately in institutional development
Nicholas Mellor, Mhoira Leng
Palliative Care Partnership, E-mail: [email protected]
Introduction: Networks in palliative care are important not only in building capacity but may also lead to transformational 'institutional development' which is pre-requisite for to scaling up services, raising awareness and changing attitudes and values regarding to end of life care.
Objectives: To compare and contrast palliative care initiatives in Kerala and Uttar Pradesh.
Materials and Methods: Literature review was undertaken explore issues of capacity building, social capital, institutional development and the evolution of palliative care services in resource poor settings. Interviews were carried out and case studies developed to explore the narrative and networks behind each initiative.
Results: Training has the potential to contribute to institutional development in many more ways than just the transfer of knowledge. It has the potential for creating a virtuous circle that brings together palliative care services, community participation and active political engagement. Social capital and more specifically social networks provide a useful lens for looking at progress towards the 'tipping point' when capacity building can translate into the systemic institutional development needed to support and scale up a palliative care service.
Conclusion: Recognising more explicitly the indirect ways in which such networks can contribute to our understanding of the resilience and sustainability of palliative care initiatives, can help us provide more effective capacity building, and ultimately the institutional development needed to lay the foundations for scalable and sustainable palliative care services.
OD 29 (Free paper session)
Quality of life in advanced cancer patients
Barathi B, Mary Ann
Department of Pain and Palliative Care, St. John's Medical College Hospital, E-mail: [email protected]
Aim : To assess the quality of life (QOL) in advanced cancer patients receiving palliative care compared with those who receive routine oncology care only.
Materials and Methods: Cross- sectional study: In-patients with advanced cancer at St. John's Medical College Hospital Inclusion criteria : In- Patients with advanced cancer above 18ys, willing to participate in the study and able to comprehend
Sample size: Group I - Twenty patients with advanced cancer patients receiving palliative care. Group II- Twenty Patients receiving routine oncology treatment only. Study instrument: The European Organization for study and Research for cancer Treatment, quality of life questionnaire 30 item - EORTC QLQ-30 was used to assess the quality of life in these two groups. Statstical analysis: SPSS software, version,17.0 (SPSS)Functional scores between two groups - independent-samples Student's t-test. Symptom scores were assessed with the use of two-sided Fisher's exact tests.
Results: The functional scores and symptom control of group I was statically significant compared with group II. In patients receiving palliative care the global QOL was statically significant with the P value of <0.01 and confidence interval is <0.01.
Conclusion: This study concludes that palliative care improves quality of life in patients receiving palliative care, compared with those receive routine oncology treatment only. We recommend integrating palliative care in the routine oncology would significantly improve the quality of life of advance cancer patients.
OD 30 (Free paper session)
Developing palliative ccwhri0 by networking
Department of Palliative Care, Cancer Centre Welfare Home & Research Institute, Thakurpukur, Kolkata, India.
E-mail: [email protected]
Introduction: Cancer needs multidisciplinary management. Although medical/surgical oncology and palliative care are often distant dimensions in the treatment of patients with cancer, it is a common notion that integration could improve the outcome in a comprehensive assistance to the patient. The delivery of optimal palliative care requires an integrated and coordinated approach of many health care providers across the continuum of care.
Objective: Cancer Center Welfare Home and Research Institute's initiative to improve End-of-Life Care charged its Palliative Care Department with developing hospital-based palliative care interdisciplinary and multidisciplinary teams in CCWHRI to provide Outpatient services, state of the art Inpatient services and free Domiciliary palliative care services to all its patients to provide integrated and a continuum of care to these patients.
Materials and Methods: We promoted the creation of a multidisciplinary team with oncologists (3, medical/surgical/radiation), palliative care specialists (2), interventional pain specialist (1), social worker (1) and nurses (5) with the aim of favouring the continuity of care along all the phases of the disease. An interdisciplinary team was also developed to provide free of cost domiciliary palliative care service to the patients. The Multidisciplinary Team gathers the competences of the oncologic and palliative care units, and is coordinated by the responses of the supportive-palliative care unit of the institute. All the patients were evaluated before entering into palliative care and classified in three levels with different care burden (physical, emotional and psychosocial). In all the patients admitted, a palliative support is planned since the early phases of metastatic disease. Three different multisectoral organizations provided with continued support to the department's initiatives. A bimonthly evaluation criterion was developed to check on the implementation of the service.
Results: The main problems referred by the patients or their families were symptoms control, pain control, the need of psychological or social support, the need of a continuity of care along the terminal phases of the disease. There is a positive impact of the shared approach against the symptoms of advanced or terminal disease, and an interesting level of satisfaction by patients and caregivers seems to be confirmed in a preliminary assessment.
Conclusions: : The continuity of care is considered an index of the quality of care and an integrated model of palliative care should be elaborated in every oncology unit; oncologic departments seem to represent the ideal dimension where favouring an integration between medical/surgical oncology and palliative care and every effort should be made to realize this kind of integration.
OD 31 (Free paper session)
To assess the effectiveness of a structured teaching on the beliefs about opioids and the opioid adherence in patients with cancer pain
Anokha Susan Roy, Sushma Bhatnagar, Ms Kamlesh Sharma
AIIMS, New Delhi. E-mail: [email protected]
Background: The study is aimed to assess the effectiveness of a structured teaching on the beliefs about opioids and the opioid adherence in patients with cancer pain.
Materials and Methods: This prospective, randomized controlled trial included 60 patients with cancer pain who came in the Pain Clinic in BRAIRCH, AIIMS, New Delhi. Subjects were randomly assigned to either experimental (n=30) or control group (n=30). Subjects in the experimental group were given one to one structured teaching and teaching material regarding opioids in addition to the routine care. Subjects in the control group received the routine care. Data regarding adherence to opioids was assessed using Morisky Medication Adherence Scale (MMAS) and beliefs about opioids were assessed using Pain opioid Analgesic Beliefs Scale- Cancer (POABS-CA) at baseline, 2 weeks and 4 weeks after baseline assessment. The collected data were analyzed using STATA (9.0) and SPSS (14) version.
Results: The two groups were homogenous with regard to all demographic variables. A highly significant improvement in adherence scores were observed after 2 and 4 weeks (P<0.05) with respect to the baseline sores in both the groups, but the improvement was significantly higher in the experimental group. The beliefs scores have improved favorably in the experimental group compared to that of the control group after 2 and 4 weeks of structured teaching (P<0.05).
Conclusion : Structured teaching is effective in improving adherence to opioids and to improve favourable beliefs about opioids in patients with cancer pain.
Pain assessment: A key to effective cancer pain mangement
Department of Anaesthesiology, Pain and Palliative Care, A.H. R.C.C, Cuttack
A single point prevalence study conducted by the IASP concluded that 90% of patients with cancer experience pain at some point during their illness. Cancer pain: A major problem, highly prevalent (30%-50% in active therapy, (75% to 90%) advanced disease, 25% those in nursing homes) and it significantly impact quality of life. Impact of pain on mood and psychological functioning is complex but numerous study points to the increased risk of anxiety, depression and suicidal ideation. Hence adequate assessment is the critical first step to define a treatment strategy of the patient with pain. Understanding of patho physiology of cancer pain coupled with availability of validated pain measurement tools facilitates such an assessment. We can anticipate that failure to assess cancer pain adequately will inevitably lead to inappropriate application of pain management options. Numerous studies document that pain caused by cancer is inadequately managed and that existing effective therapies of pain are not used to maximize pain relief. The result is a high level of unnecessary distress for patients and families, a significant impairment in quality of life and an increased use of health care systems to treat poorly managed pain on an emergent basis. Factors that lead to poor pain treatment have been well studied. Patients for a variety of reasons often are reluctant to report pain or the lack of effective treatment. The most significant practice error that health care professionals make in pain management is inadequate assessment. When patients are reluctant to report pain, inadequate assessment becomes even more of a problem for adequate pain control. Studies of Oncology professionals in several countries demonstrate that these persons are very aware that poor assessment is the greatest barrier to cancer pain management. Studies of patients document that one of the strongest predictors of poor pain management is the discrepancy of pain estimate between treating doctors and the pain report of patients.
Various authors agree that there is a co-relation between age and the prevalence of persistent pain, that 47% to 80% of elderly outpatients do not receive suitable treatment for their pain and that many patients suffering from some form dementia receive no pain relief at all, despite the presence of a concomitant painful illness. These alarming figures certainly reflect, at least to some extent they have difficulties encountered by palliative care team and doctors in assessing pain elderly patients. Studies has also proved health professionals face difficulties while assessing pain in patients who cannot communicate like preverbal children and cognitively impaired persons. Hence pain relief in this patient groups need to be addressed. This presentation highlights different barriers to pain assessment, current standard approach to initial assessment to cancer pain, use of proper assessment tools, especially for those who can not communicate and prognostic factors which assist an inexperienced clinician in anticipating the need for specialist advice while assessing cancer pain