Indian Journal of Palliative Care
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   Table of Contents - Current issue
Coverpage
October-December 2020
Volume 26 | Issue 4
Page Nos. 399-552

Online since Thursday, November 19, 2020

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EDITORIAL  

Palliative rehabilitation: The essence of personalized care Highly accessed article p. 399
Raghavendra Ramanjulu
DOI:10.4103/0973-1075.300816  
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REVIEW ARTICLES Top

A narrative literature review on human resource planning for palliative care personnel Highly accessed article p. 401
Erin Raine, Majid Taghavi
DOI:10.4103/IJPC.IJPC_40_20  
A literature search was started with the objective of finding works pertaining to the use of operations research techniques in planning for human resources in palliative care. Since the search indicated that there is no such work, in this paper, we report on the literature on workforce planning and human resource planning for palliative care personnel. Using our findings, we discuss the factors that influence the supply and demand for the palliative care workforce. Our results show that the enhancement of efficiency, training more primary caregivers to deliver palliative care, and allowing for mid-career specialist training are practical ways to compensate for the gap between the supply and demand in the palliative care workforce.
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Shared decision-making and medicolegal aspects: Delivering high-quality cancer care in India p. 405
Dinesh C Doval, Prabhash Kumar, Vineet Talwar, Ashok K Vaid, Chirag Desai, Vikas Ostwal, Palanki S Dattatreya, Vijay Agarwal, Vaibhav Saxena
DOI:10.4103/IJPC.IJPC_237_19  
It is often difficult for people with cancer to make decisions for their care. The aim of this review is to understand the importance of shared decisionmaking (SDM) in Indian clinical scenario and identify the gaps when compared to practices in the Western world. A systematic search (2000-2019) was executed in Medline and Google Scholar using predefined keywords. Of the approximate 400 articles retrieved, 43 articles (Indian: 5; Western: 38) were selected for literature review. Literature review revealed the paucity of information on SDM in India compared to the Western world data. This may contribute to patientreported physical or psychological harms, life disruptions, or unnecessary financial costs. Western world data demonstrate the involvement and sharing of information by both patient and physician, collective efforts of the two to build consensus for preferred treatment. In India, involvement of patients in the planning for treatment is largely limited to tertiary care centers, academic institutes, or only when the cost of therapy is high. In addition, cultural beliefs and prejudices impact the extent of participation and engagement of a patient in disease management. Communication failures have been found to strongly correlate with the medicolegal malpractice litigations. Research is needed to explore ways to how to incorporate SDM into routine oncology practice. India has a high unmet need towards SDM in diagnosis and treatment of cancer. Physicians need to involve patients or their immediate family members in decision making, to make it a patient-centric approach as well. SDM enforces to avoid uninformed decisionmaking or a lack of trust in the treating physician's knowledge and skills. Physician and patient education, development of tools and guiding policies, widespread implementation, and periodic assessments may advance the practice of SDM.
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ORIGINAL ARTICLES Top

What is the public opinion of advance care planning within the punjabi sikh community? Highly accessed article p. 411
Amarjodh Singh Landa
DOI:10.4103/IJPC.IJPC_219_19  
Aim: The aim was to gain an understanding of what the United Kingdom (UK) Punjabi Sikh community understands and thinks about advance care planning (ACP). This is in response to evidence showing a lack of service usage by Black, Asian, and Minority Ethnic groups. Methods: Surveys containing questions about the impressions of terms, advance decisions for care, do-not-attempt-resuscitation, and lasting power of attorney were taken to targeted community groups; these included community day centers, sporting groups, temples, and social media circles. Surveys were available in both Punjabi and English languages. Results: A total of 311 surveys were received in total. There was a 50/50 gender split and a mixed group of ages; 75% were born in the UK and 15% were born in Punjab, India. Only a third had some understanding of what ACP meant. Nearly 50% of the participants did express wishes toward the end of their life, however only a third of the respondents knew how to access services. Cardiopulmonary resuscitation was felt to be mandatory by 36%. Sixty percent thought that their decision would be legally binding in relatives who do not have capacity. Conclusion: This study showed that wishes for religious rites were common, however many do not know how to make them known. If they do know about services, then people are highly likely to engage with the ACP process.
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Perception and quality of life in family caregivers of cancer patients p. 415
Vidya Nidhi, Asha Basavareddy
DOI:10.4103/IJPC.IJPC_225_19  
Introduction: Cancer has been most feared among all the significantly increasing chronic diseases, and is widely assumed to be fatal. The quality of life (QOL) of the patient pertaining to physical, psychological, social, and spiritual well-being is altered, which ultimately affects the QOL of the family caregivers. The study was conducted to assess the QOL among family caregivers of cancer patients and how cancer changes and alters the vision about life for the patient as well as the family caregivers. Objective: The objective was to assess the QOL among family caregivers of the cancer patients. Methodology: A cross-sectional, questionnaire-based study was conducted after the protocol was approved by the institutional ethics committee and obtaining written informed consent from the participants. Two sets of validated questionnaire were used to assess the awareness and QOL of the family caregivers of the cancer patients. The filled questionnaires were received from the participants, and data were analyzed using descriptive statistics. Results: Nearly 74% (148/200) of the participants responded, with majority of the caregivers being females (71.62%). Majority (72.9%) expressed that cancer cannot spread from one person to another and were positive (70.9%) toward cancer cure. The caregivers (76.3%) opined that the diagnosis of cancer should be informed to the family members. Approximately 50% of the participants were aware that environmental toxins and tobacco would predispose to cancer. Although most of them (87.8%) believed that the cancer treatment cause ill effects, they (93.2%) were satisfied with the hospital facilities. Among the QOL parameters, most of the participants had complaint of decreased general physical health, difficulty to cope, reduced concentration, anguish over the first treatment, disease, and interference in household activities. Among the spiritual parameters, the participants expressed sufficient support from religious activities, prayer, and general spiritual well-being. Conclusion: Majority of the caregivers had awareness regarding the cancer and carcinogens from the environmental toxins. The QOL among caregivers of cancer patients is affected in all dimensions of life, with more emphasis on the social and psychological dimensions.
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Experiences of living with intestinal ostomy: A qualitative meta-synthesis p. 421
Mamta Choudhary, Harmeet Kaur
DOI:10.4103/IJPC.IJPC_21_20  
Aims and Objectives: The aim and objective of the study was to identify, compare, and synthesize published qualitative evidence to have in-depth understanding of experiences of patients living with intestinal ostomy. Background: Over the past two decades, there have been numerous qualitative studies published depicting intense experiences of stoma patients brought about by the need to adapt with changing conditions following stoma creation. Synthesizing the findings of these studies can improve the understanding among health-care providers of needed support and care for ostomates. Design: This was a qualitative meta-synthesis. Methods: Published articles were identified from the Medline, CINAHL, SciELO, PsycINFO, PubMed, WOS, Google Scholar and a hand search through selected journals published since 2000, and from references lists. Thirteen articles were selected using the predefined criteria. Results: A total of 222 patients, aged between 14 and 83 years from 13 studies, were identified for data collection. Ninety-seven were male and the rest of them were female. The themes identified were physical problems, psychological issues, social relations, environmental impact, and coping and adaptation to stoma. Conclusions: The findings of the study identified numerous challenges and limitations in the life of patients with stoma. However, improving their skills of using problem-solving coping strategies and their interactions with other ostomates can help them to live a better and well-adjusted life.
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Effect of progressive muscle relaxation therapy on fatigue and psychological distress of cancer patients during radiotherapy: A randomized controlled trial p. 428
P Jaya, Ajay Thakur
DOI:10.4103/IJPC.IJPC_236_19  
Background: Patients with cancer receiving radiotherapy experiences fatigue and psychological distress. Now a days there has been growing interest towards managing these symptoms with non-pharmacological treatments, But researches related to effect of progressive muscle relaxation therapy on fatigue and psychological distresses related to admitted patients are limited hence the aim of the study to evaluate the effect of progressive muscle relaxation therapy on fatigue and psychological distress in Cancer patients during Radiotherapy. Aims and Objectives: Aim of the study to evaluate the effect of progressive muscle relaxation therapy on fatigue and psychological distress in Cancer patients during Radiotherapy. Materials and Methods: The study design was single blinded randomized control trial. Total of 50 patients, for both intervention and control group 25 patients were included. The intervention group patients received P.M.R. therapy of 20 min. given for 3 times/week of total period of 3 weeks, whereas the control group received conventional treatment with no added intervention. Fatigue symptom inventory and hospital anxiety and depression scale used as an outcome measures. Results: Paired t-test used for FSI to compare among intervention and control group and results were showing statistical significant difference (P < 0.05), similarly pre and post improvement was observed in both the groups for HADS. Between group comparison showed no superior improvement one over the other. Conclusion: Based on the above findings, P.M.R. and conventional treatment were similarly efficacious in decreasing fatigue and psychological distress related to cancer patients who were hospitalized undergoing radiotherapy.
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Impact of prognostic nutritional index on terminal cancer patients p. 433
Amrallah A Mohammed, Omar Al-Zahrani, Fifi Mostafa Elsayed
DOI:10.4103/IJPC.IJPC_18_20  
Background: In terminal cancer patients (TCPs), one of the most important things is to define the survival to help the main responsible physicians, patients, and main caregivers make decisions, set goals, and work across the end-of-life strategies. Patients and Methods: We retrospectively reviewed the medical files of TCPs, who died during September 2011 and December 2017, to recognize the correlation between prognostic nutritional indices (PNIs) and survival in those subtypes of patients. The receiver operating characteristic (ROC) curve was used to identify the cutoff value of PNI. Results: A total of 858 TCPs were eligible and included, the median age was 62 years (range: 18–107). The most common primary cancer sites were colorectal cancer in 151 patients (17.6%), hepatobiliary in 129 (15%), lung cancer in 115 (13.4%), breast cancer in 114 (13.3%), and genitourinary in 80 (9.3%). The mean value of PNI for all cancer types was 32.9 ± 6.7. The values showed different levels across cancer types. For patients who lived >2 weeks, PNI was 36.7 compared with that who died within 2 weeks was 29.3, which was a statistically significant (P < 0.001). By the ROC curve, the cutoff value of PNI was 32.3 and area under the curve was 0.888. The sensitivity, specificity, positive predictive value, and negative predictive value were 91.28% (95% confidence interval [CI]: 88.2–93.8), 71.09% (95% CI: 66.5–75.4), 76.5% (95% CI: 73.7–79.2), and 88.8% (95% CI: 85.3–91.5), respectively. Conclusion: The PNI is an easy and an applicable biomarker to estimate life expectancy in TCPs.
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The benefit of zinc sulfate in oropharyngeal mucositis during hyperfractionated accelerated concomitant boost radiotherapy with concurrent cisplatin for advanced-stage oropharyngeal and hypopharyngeal cancers p. 437
P Anandhi, Rahamathulla Mudassar Sharief, C Rahila
DOI:10.4103/IJPC.IJPC_20_20  
Background: Radiation-induced oropharyngeal mucositis is a major problem causing widespread clinical symptoms and may interfere with treatment plans, ultimately jeopardizing patient outcome. Zinc supplementation may be considered beneficial in preventing acute toxicity during chemoradiation. Aims and Objective: The aim of the study is to determine the effect of zinc supplementation on radiation-induced oropharyngeal mucositis in Stage III and IV-A oropharynx and hypopharynx cancers treated by hyperfractionated accelerated concomitant boost radiotherapy with weakly cisplatin. The objective behind the study is to know any changes in the onset, duration, and severity of oropharyngeal mucositis by implementation of oral zinc sulfate. Materials and Methods: The study is double-blinded randomized controlled assessment involving 120 patients (60 – control and 60 – experimental) treated with chemoradiation for oropharyngeal and hypopharyngeal cancers. The experimental group received oral zinc sulfate 150 mg once daily during and after treatment, whereas the control group patients were given placebo. The categorical data were analyzed using the Chi-square test and Pearson correlation. The Friedman test was used for comparison of oral mucositis grading between the groups. Results: A statistically significant difference was found in the zinc-supported experimental group showing delay in onset, decrease in severity, and duration of oropharyngeal mucositis. Conclusion: Zinc supplementation could be beneficial in managing oropharyngeal mucositis during chemoradiation of head-and-neck cancers with no untoward side effects.
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Nonpharmacological interventions for pain management in lung cancer patients: A systematic review p. 444
Jayaprakash Kumar, Mohammad Masudul Alam, Karen Chandler Johnson
DOI:10.4103/IJPC.IJPC_24_20  
Background: The presence of lung cancer is almost always associated with pain, a symptom that causes severe distress in patients. Although many pharmacological methods are available to manage pain in this oncologic population, the medications often cause undesirable sideeffects and inadequate relief. Nonpharmacological interventions can be used as adjuvants to pharmacological interventions in reducing pain and increasing quality of life. Objectives: The purpose of this review is to compare the efficacy of nonpharmacological interventions in reducing pain in lung cancer patients. Materials and Methods: This is a systematic review study guided by the Preferred Reporting Items of Systematic reviews and Meta-Analysis Protocol. Interventions identified in the present systematic review have been categorized as physical treatment, technologybased, cognitive behavioral, coping, and coaching. Results: Results indicate that the nonpharmacological interventions such as physical treatment interventions, selfmanagement and coaching interventions, cognitive behavioral interventions, and technologybased interventions or coping skills interventions had limited and shortterm effects on alleviating pain among the patients. However, previous studies have provided limited evidence regarding nonpharmacologic therapy due to the lack of a comparison group, small sample sizes, and lack of longterm followup periods to determine whether sustained effects are feasible. Conclusion: Healthcare professionals should consider additional research on the added advantage of utilizing the nonpharmacological interventions as an adjunct option while managing pain in lung cancer patients.
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The process of pain management in cancer patients at home: Causing the least harm – A grounded theory study p. 457
Forough Rafii, Fariba Taleghani, Marzieh Khatooni
DOI:10.4103/IJPC.IJPC_8_20  
Background: Cancer pain management at home is a complicated and multidimensional experience that affects the foundational aspects of patients and their families' lives. Understanding the pain relief process and the outcomes of palliative care at home is essential for designing programs to improve the quality of life of patients and their families. Objective: To explore family caregivers and patients' experiences of pain management at home and develop a substantive theory. Design: The study was carried out using a grounded theory methodology. Setting/Participants: Twenty patients and 32 family caregivers were recruited from Oncology wards and palliative medicine clinics in the hospitals affiliated to Iran University of Medical Sciences using Purposeful and theoretical sampling. Results: The core category in this study was “pain relief with the least harm. ”Other categories were formed around the core category including “pain assessment, determining the severity of pain, using hierarchical approaches to pain relief, assessing the results of applied approaches, determining the range of effectiveness, and barriers and facilitators of pain relief. ”The substantive theory emerged from these categories was “Pain management process in cancer patients at home: Causing the least harm ”that explains the stages of applying hierarchical approaches to pain relief, family care givers try to make decisions in a way that maximize pain relief and minimize damage to the patient. Along with using a hierarchical pattern, the process is featured with a circular pattern at broader perspective, which reflects dynamism of the process. Conclusion: The inferred categories and theory can expand knowledge and awareness about the stages of pain relief process, the pattern of using pain relief approaches, and the barriers and facilitators of pain relief process at home. Health-care professionals may use these findings to assess the knowledge, skill, capability, problems, and needs of family caregivers and patients and develop supportive and educational programs to improve the efficiency of pain relief process at home and improve the patients' quality of life.
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Families' experiences of end-of-life care at home for Iranian older adults: A qualitative study p. 468
Manijeh Dehi Aroogh, Kian Norouzi, Farahnaz Mohammadi Shahboulaghi, Reza Negarandeh
DOI:10.4103/IJPC.IJPC_10_20  
Aim: While the care of dying elderly patients at home is very complex and ambiguous, it has not been studied in Iran so far. Hence, this study aimed to explore the experience of a representative sample of the Iranian family caregivers from the end-of-life (EOL) care for their elderly relatives. Methods: The present study was conducted using a qualitative content analysis method. Twelve family caregivers caring for the chronically ill dying elderly were selected using purposeful sampling. The purposive sampling method was applied with an extreme variation in sampling, and data gathering was pursued until data saturation was achieved. Semi-structured interviews were utilized for data collection. Interviews were recorded and instantly transcribed verbatim. Inductive content analysis was used to analyze the data. Results: Four core themes and 13 subthemes emerged from the experiences of family's caregiver as fallow: (1) Committed to care: This is related to encounter with the end of stage disease of the relative, accepting the care role and priority of care, (2) challenges of Care: Caregivers, despite their efforts, provided ineffective care, so they sought to empower themselves and at the same time provide compassionate care, (3) the crisis of care including the complexity of care, fear, and wandering, helplessness, devastating tension, and vacuum of supporting, and (4) conditions after death that family members involved with a sense of loss and Tension control. Conclusion: When families had to take care of their elderly patients at home, although their wish to give the best care, they are completely powerless to provide care, and in an atmosphere of the vacuum of supporting, they encounter severe challenges and crisis. It is vital that palliative care centers in the society are arranged to care for EOL elderly with comprehensive insurance services.
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Symptoms in nepali patients with incurable cancers: Implications for interventions p. 476
Richard R Love, Bishnu D Paudel, G M Tanimul Ahsan, Sheikh I Ahamed
DOI:10.4103/IJPC.IJPC_221_19  
Aim: The poor quality and limited extent of palliative care services are of concern across the globe. To identify and measure patients' symptoms in Nepal, using a cell phone questionnaire platform, the investigators conducted and previously reported a cross-sectional study of Nepali adults. The unreported details of pain and other symptoms in these study data are here considered together with possible explanations and implications for interventions to lessen these symptoms. Methods: In a “snapshot ”cross-sectional study of patients under regular care in three tertiary care Nepalese centers, we questioned 383 patients with incurable cancers using a 15-item cell phone-validated instrument to describe their major current symptoms and their intensities. The distributions of 11 symptom-level scores and the correlations between pain and different symptom scores were determined. Results: Thirty-eight percent of the population (142/383) had maximal pain scores which were in the severe range, and 25% (97/383) had such scores where they were evaluated. Patients reported moderate-to-severe tiredness 48% (183/383), depression 45% (172/383), anxiety 56% (217/383), poor appetite 64% (246/383), sleep quantity 64% (246/383), and sleep quality 64% (247/383). Conclusions: The significant fractions of patients with severe maximal and at-evaluation pain scores suggest that inadequate recognition and treatment of such symptoms characterized care of these regularly seen patients. The high fractions of patients with mood and sleep disturbances support this reading, suggesting helplessness and hopelessness, all addressable with psychosocial, environmental, and nontoxic, inexpensive pharmacological interventions.
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A descriptive study to assess the knowledge, attitude, practices, perceived barriers, and support regarding palliative care and end-of-life care among critical care nurses of tertiary care medical institute p. 479
Anjani Walia, Kamlesh K Sharma, Rakesh Garg, Smita Das
DOI:10.4103/IJPC.IJPC_227_19  
Introduction: The role of nurses working in critical care setup is one of the key members for optimal provision of the palliative care and end-of-life care (EOLC). This study aims to assess knowledge, attitude, practices, and perceived barriers regarding palliative and EOLC among critical care nurses. Methods: A cross-sectional study was conducted among 386 critical care nurses of a tertiary care center, selected through convenience sampling technique. Data related to knowledge, attitude, practices, and perceived barriers were collected using a standardized tool. The collected data were analyzed using SPSS version 24. Results: We observed that mean knowledge, attitude, and practice scores of critical care nurses were 9.83 ± 2.50 of 20, 104.91 ± 13.04 of 150, and 17.61 ± 4.36 of 27, respectively. One of the major barriers in providing palliative and EOLC was being called for attending to other newly admitted patients. The mean knowledge score of nurses was found to be significantly higher among female nurses (P = 0.016). Nurses who had additional training pertaining to palliative and EOLC had significantly higher mean knowledge (P = 0.001) and attitude scores (P = 0.02) than those who did not have such training. The mean practice (P = 0.02) and attitude score (P = 0.002) was significantly higher among postgraduate nurses as compared to nurses with lower qualification. The mean attitude score was significantly higher among nurses of lower age group (P = 0.04) along with a negative correlation of age of nurses with attitude (P = 0.01). Nurses' practice was positively correlated to the attitude (P = 0.001) and knowledge (P = 0.01). Conclusion: There is a considerable gap between critical care nurses' knowledge and practices, in spite of having a good attitude regarding palliative and EOLC. This necessitates the strengthening of both preservice and in-service education for nurses.
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Effect of variables on quality of life among caregivers of patients undergoing peritoneal dialysis p. 490
M Nagarathnam, S A A Latheef, V Sivakumar
DOI:10.4103/IJPC.IJPC_35_20  
Background: Most of the studies carried out abroad showed the effect of one or two variables on the constructs of burden, coping strategies, and quality of life (QOL) but nil in India context. These constructs change by cultural factors. The evaluation of variables influencing these constructs may be helpful in fine tuning the interventions to reduce the burden and to improve the QOL of caregivers of patients undergoing peritoneal dialysis (PD). Aim: The aim of this study was to investigate the impact of demographic, social and clinical variables on burden, coping strategies, and QOL in caregivers of patients undergoing PD. Materials and Methods: In this prospective study, we recruited 100 caregivers of patients undergoing PD and made assessment on burden, coping strategies, and QOL and evaluated the effect of demographic, social, and clinical variables on these constructs. Results: None of the studied variables showed effect on burden and coping strategies. Age, gender, duration of caregiving, presence of chronic disease, and duration of the presence of chronic disease showed a significant effect on QOL. Conclusion: The impact of demographic and clinical variables on QOL suggests these variables should be given adequate attention while developing interventions for alleviating the burden and improving the QOL of caregivers of patients undergoing PD.
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Breaking the barrier: Challenges of methadone use – An introductory observation p. 495
Riniki Sarma, Prashant Sirohiya, Brajesh Kumar Ratre, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_9_20  
Background: Palliative care physicians in India have achieved access to methadone for pain relief in cancer patients. Despite being an effective drug in terms of analgesia, there are a number of reasons why this opioid medication is not as much as popular as morphine. We identified and tried to overcome a few such barriers in treating cancer pain with methadone. Methods: The clinical information of ten adult cancer patients (six males and four females), who voluntarily received methadone for their severe pain in the month of August 2019 were analysed retrospectively. We converted morphine to methadone in all ten patients under the supervision of an experienced practitioner. Results: During the methadone therapy, eight out of ten patients who were given methadone exclusively for their pain had adequate pain relief initially. The barriers identified included difficult titration methods due to distinct pharmacology, patient selection, clinical inertia, communication and co-ordination among physicians, communication among patient and physician, and patient and caregivers, and vigilant monitoring. Conclusion: Methadone is still finding its place in India for cancer pain management. As the drug is new to Indian practitioners, we have to overcome these barriers and facilitate its judicious use in cancer pain management.
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Improving access and quality of palliative care in Kerala: A cross-sectional study of providers in routine practice p. 500
AS Lijimol, Anjali Krishnan, MR Rajagopal, Bipin K Gopal, Christopher M Booth
DOI:10.4103/IJPC.IJPC_17_20  
Background: Expanding access and improving quality of palliative care in low-middle income countries is a pressing priority. Objective: The objective of the study was to describe structure and processes of care across government (GO) and non-GO (NGO) palliative care providers (PCPs) in Kerala, India. Design: This was a cross-sectional telephone survey. Setting/Subjects: This study consisted of 200 randomly selected PCPs across Kerala. The survey explored organizational structure, patient assessment, opioid availability, and explored elements considered essential to palliative care delivery in the Indian context. Results: One hundred GO and 100 NGO PCPs agreed to participate (100% response rate). The annual median number of new patients was 183 and 159 in GO and NGO PCPs, respectively. The median number of annual home visits in GO PCPs was 1398 and in NGO PCPs was 979. Median number of outpatient visits in GO PCPs was 600 and in NGO PCPs was 520. Only 24% (47/200) of the PCPs had full-time physicians with training in palliative care; 60% of GO PCPs had no full time physician with training in palliative care. Patient-reported pain was routinely documented by 21% (21/100) and 65% (65/100) of the GO and NGO sites, respectively (P < 0.001). None of the GO and only 36% (36/100) of NGO PCPs were able to prescribe oral morphine. Psychosocial and spiritual issues were documented routinely in only 4% (4/100) and 48% (47/99) of the GO and NGO PCPs, respectively (P < 0.001). Conclusions: Caution is needed against potential challenges to quality care in any new initiative. Kerala has achieved remarkable success in the coverage of palliative care through hundreds of locally active NGOs through GO machinery involving every primary health center. Yet, there are gaps such as absence of full-time physicians. This study highlights the need for periodic review to identify gaps in care.
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Chemotherapy-induced peripheral neuropathy and its impact on health-related quality of life among multiple myeloma patients: A single-center experience p. 506
Naila A Shaheen, Maha Alqahtani, Nada S Alawbthani, Abin Thomas, Ahmed Alaskar
DOI:10.4103/IJPC.IJPC_233_19  
Aim: Chemotherapy-induced peripheral neuropathy (CIPN) is a long-term neurological health issue in patients diagnosed with multiple myeloma (MM). The aim of this study was to assess CIPN symptoms and health-related quality of life (HRQOL) among MM patients. Methods: A cross-sectional survey was conducted among patients diagnosed with MM in a tertiary care hospital using a self-reported Arabic questionnaire, European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire for CIPN scale (QLQ-CIPN20). The HRQOL was assessed using EORTC multiple myeloma module (QLQ-MY20). Categorical variables were reported in frequency tables and percentages. Age and duration of MM diagnosis were reported as mean and standard deviation. Survey responses were presented using descriptive statistics. Results: In total, 62 patients had participated. Males were 60%. The average age was 58.74 ± 11.49 years. On sensory scale, 20% reported “quite a bit”/”very much ”tingling in fingers/hands, 23% in toes/feet, 39% numbness in fingers/hands, 37% in toes/feet, and 43% reported trouble standing or walking. On motor scale, 40% reported trouble walking and 60% had difficulty in climbing stairs/standing up from chair. On autonomic scale, 27% reported orthostatic hypotension and only 13/37 (46%) males reported erectile dysfunction. For HRQOL, 50% reported bone aches/pain, 42% reported back pain, 57% reported feeling ill, 33% reported lost hair, 35% had been thinking about their illness, whereas 28% were worried about future health and 22% had reported being worried about dying. Conclusion: MM patients encounter CIPN symptoms with impaired HRQOL. Capturing CIPN as a patient-reported outcome needs to be considered in routine clinical practice.
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Effect of celiac plexus neurolysis for pain relief in patients with upper abdominal malignancy: A retrospective observational study and review of literature p. 512
Anurag Agarwal, Anuj Gautam, Shivani Rastogi, Deepak Malviya, Praveen Kumar Das, Mamta Harjai
DOI:10.4103/IJPC.IJPC_37_20  
Background: Abdominal pain from primary cancer or metastatic disease is a significant cause of pain for patients undergoing treatment for the disease. Patient's pain may be resistant or non-responsive to the pharmacological management, hence minimal invasive pain intervention like celiac plexus neurolysis or splanchnic nerve rhizolysis may be required to relieve pain of such patients. Objective: The aim of this retrospective study is to assess the effect of celiac plexus neurolysis for pain relief in patients with upper gastro-intestinal malignancies. Study Design: This is a retrospective, observational study with short review. Methods: This retrospective observational study was done in the Pain Medicine unit from 2016 and November 2018. Ninety-four patients with upper abdominal malignancy and unrelenting pain, non-responsive or poorly responsive to pharmacological treatment as per WHO ladder of analgesics, received fluoroscopy-guided celiac plexus neurolysis (CPN). All the patients underwent celiac plexus neurolysis through Trans-Aortic approach and the primary outcome measure was pain as assessed with Visual Analogue Scale (VAS) ranging from 0 to 10; the secondary outcome measures were morphine consumption per day (M), quality of life (QOL) as assessed by comparing the percent of positive responses and complications, if any. These were noted and analyzed prior to intervention and then on day 1, and months 1, 2, 3, 4, 5, 6 following CPN. Results: Follow up was completed 6 months after the procedure. VAS score, daily morphine consumption, and the quality of life showed improvement for the duration of the study. There was some relapse in pain and deterioration in QOL during the fourth to sixth month of pain intervention due to disease progression. Some transient known side effects also occurred. Conclusion: Trans-Aortic celiac plexus neurolysis with low volume of alcohol is a safe procedure providing up to 6 months of pain relief and is an effective, well established, minimally invasive procedure for abdominal pain due to primary malignancy or metastatic spread.
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The concept of do not resuscitate for the families of the patients at king abdul-aziz university hospital p. 518
Bashaer Abdulrahim Alsaati, Maram Nader Aljishi, Sunds Salah Alshamakh, Hadeel Ahmed Basharaheel, Nujood Shawqi Banjar, Rawan Saleh Alamri, Shadi Alkhayyat
DOI:10.4103/IJPC.IJPC_228_19  
Aim: Do not resuscitate (DNR) is an order in medical practice for the patients who are suffering from a grave medical condition, and their life is in danger to end. DNR decision-making varies from one hospital to another. This study is aimed to assess the knowledge of the patients' relatives about DNR concept and their opinion about the DNR decision-making. Materials and Methods: This was a nonintervention cross-sectional study conducted, during 2016, among 420 patients' relatives in the Emergency Department at King Abdul-Aziz University Hospital in KSA. Data were collected by interviewing the participants. Data were further analyzed using SPSS software. The Chi-square test was used to determine the associations. Results: Variation in responses related to the DNR concept was observed. Around 44% of participants thought that DNR involved maximum intervention in the hospital, including intensive care. Further, the majority (55.2%) of the participants were assured about the quality of the services the patient would receive. Furthermore, 51% of the participants believed that ultimately, it should always be the doctor who decides on a DNR decision. Meanwhile, 36.4% of the relatives opined that the family members should be involved in the discussion regarding the DNR order. Conclusion: We observed a gap in the understanding of the concept and decision-making of DNR-order among the participants. Health-care providers should provide a greater explanation about DNR orders to the families of the patients to avoid any misunderstandings, and also support them psychologically to avoid any stress they might encounter in such situations.
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To assess the prevalence and predictors of cancer-related fatigue and its impact on quality of life in advanced cancer patients receiving palliative care in a tertiary care hospital: A cross-sectional descriptive study p. 523
Shilpi Agarwal, Rakesh Garg, Varnika Minhas, Sushma Bhatnagar, Seema Mishra, Vinod Kumar, Sachidanand Jee Bharati, Nishkarsh Gupta, Maroof Ahmad Khan
DOI:10.4103/IJPC.IJPC_223_19  
Introduction: Cancer-related fatigue (CRF) is one of the adverse outcomes of cancer and its treatment. Despite its high prevalence; the data are scarce from the Indian population on the prevalence of CRF and its predictors in advanced cancer patients. Hence, we aim to find the prevalence of the fatigue, its impact of fatigue on quality of life (QOL), and possible predictors. Methods: This study was conducted after approval of the ethical committee in adult patients of advanced cancer receiving palliative care. The data collected included demographic details, nutritional status, any comorbidities involving cardiorespiratory, renal, pulmonary, and neurological system, type and stage of cancer, site of metastasis, any previous or ongoing chemotherapy or radiotherapy, history of drug intake, hemoglobin, and albumin. The study parameters included assessment of fatigue, QOL, and symptom assessment as per the validated tools. The primary objective of the study was to find the prevalence of fatigue in advanced cancer patients receiving palliative care. The secondary objectives were to find predictive factors of fatigue, its impact on QOL of patients, and the relation between the fatigue and QOL receiving palliative care. The correlation between fatigue score and QOL was analyzed using Pearson's correlation coefficient. Multiple linear regression analysis was performed for identifying the predictors of CRF. Results: The fatigue was observed in all 110 patients in this study. Of these, severe fatigue was seen in 97 patients (Functional Assessment of Chronic Illness Therapy [FACIT]-F < 30). The median (interquartile range [IQR]) FACIT-F score was 14 (8–23). The median (IQR) of the overall QOL was 16.66 (16.6–50).The correlation between the fatigue (FACIT-F) and QOL was + 0.64 (P < 0.001). The predictors of fatigue included pain, physical functioning, Eastern Cooperative Oncology Group, tiredness, and the level of albumin. Conclusion: We conclude that the prevalence of fatigue in Indian patients with advanced cancer receiving palliative care was high and it has a negative impact on QOL. Pain, physical functioning, performance status, and albumin were found to be independent predictors of CRF.
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Need of palliative care services in rural area of Northern India p. 528
Sheronpreet Kaur, Harpreet Kaur, Komal Komal, Parampreet Kaur, Daljeet Kaur, Vijay Laxmi Jariyal, Kavita Kavita, Latika Bajaj, Jarnail Singh Thakur
DOI:10.4103/IJPC.IJPC_226_19  
Background: Palliative care is comprehensive care that provides symptomatic relief and enhances the quality of life for people experiencing serious health-related suffering. There is an increasing need for palliative care services in India. Estimates for population requiring these services are essential in order to meet the increasing need for palliative care services. Objectives: The objective was to assess the proportion of population requiring and receiving palliative care services. Materials and Methods: A descriptive cross-sectional research design was adopted for the study. The study was carried out in the village, Dhanas, Chandigarh. All the residents residing in the selected rural area were included in the study. Tools used for data collection were a screening questionnaire consisting of three questions, a sociodemographic sheet, a clinical profile, the Barthel Index of activities of daily living (ADL), and a pain rating scale. Analysis of the data was done using SPSS version 19 (IBM SPSS Statistics for Windows, Version 19.0.: IBM Corp). Results: A total of 10,021 people from 884 households were screened in the study. The results revealed that the prevalence of need for palliative care services was 2/1000 population. None of the 19 participants with unmet palliative care needs were receiving any home- or institutional-based palliative care services at the time of assessment. Nearly, one-fourth of the participants had total dependency on caregivers for ADL. Conclusion: The study concluded that there is a need of palliative care services in the studied rural community of Chandigarh. These data can be used for planning and implementing community-based palliative care services in the studied area.
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PRACTITIONER SECTION Top

Effects of exercise training during concomitant chemoradiation therapy in head-and-neck cancer patients: A systematic review p. 531
Macrina Dsouza, Stephen Rajan Samuel, P U Prakash Saxena
DOI:10.4103/IJPC.IJPC_14_20  
Existing literature suggests that cancer survivors present with high rates of morbidity due to various treatment and disease-induced factors. Research has shown exercise to be beneficial in improving treatment outcomes and quality of life (QOL). This review was done to collect the current state of exercise-based interventions for cancer survivors in India. From the summarized data, exercise interventions were categorized into resistance training, aerobic training, and home-based walking program in head-and-neck cancers. A broad range of outcomes showed improvement in muscle strength, functional capacity, and QOL and hence supported the benefits of exercise-based interventions in this population. All the data retrieved, therefore, conclude that exercise-based interventions are safe, feasible, and beneficial in patients with head and neck cancer receiving chemoradiation therapy.
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COMMENTARY Top

Fentanyl, morphine, and opioid-induced constipation in patients with cancer-related pain p. 535
Arunangshu Ghoshal
DOI:10.4103/IJPC.IJPC_171_19  
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CASE REPORTS Top

Sympathectomy for lymphedema: A case series p. 537
Kashinath Bangar, Nivedita Page, Gayatri Bangar, Varsha Kurhade
DOI:10.4103/IJPC.IJPC_36_20  
Breast cancer-related lymphedema (BCRL) is an increasingly common complication seen in the palliative care setting due to increased life expectancy of breast cancer survivors. It is an important determinant of the quality of life of breast cancer survivors, due to the functional impact that it has, apart from the pain and deformity associated with it. Conservative management of lymphedema with the help of physiotherapy, positioning, manual lymphatic drainage, and intermittent pneumatic compression is well known. Even then, there remains a subset of patients that fail to respond to conservative management. T2 sympathectomy is a technique which ablates the thoracic sympathetic chain and helps in improving the lymphatic drainage. We report a series of four cases of BCRL, which showed a significant reduction in the mid-arm circumference as well as pain scores after a T2 sympathectomy. We believe that T2 sympathectomy can be used as the second line of management in lymphedema patients in whom conservative treatment has failed.
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Holistic care approach for the effective management of severe radiation dermatitis using neem (Azadirachta indica) and honey after head–and-neck radiotherapy p. 540
Sabita Sahu, Yashawant Ramawat, Nitesh Kumawat, Ranjit Kumar Sahu, Vijay Kumar, Machhendra Nath
DOI:10.4103/IJPC.IJPC_32_20  
Head and neck cancer is the eighth common type among all cancer types around the world. Its treatment comprises surgery, radiation therapy, chemotherapy and /or a combination of restoration therapy and social support Conventional fraction size ranges from 1.8 to 3 Grays (Gy) per fraction over 4–6 weeks. The accumulative dose of radiation for the primary treatment of head and neck cancer treatment is 60 to 70 Gy, depending on the irradiation of the tumor. Ionizing Radiotherapy is used along with concurrent chemotherapy which is the standard treatment in locally advanced head and neck cancers. Radiation treatment is commonly delivered in the form of high energy photons through an external beam. These results in ionization of electrons that cause direct strand breaks of cellular DNA and the release of free radicals, resulting in cellular damage to both normal and tumor cells. Radiation disrupts the normal process of wound healing at various stages.
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Chronic noncancer pain and opioid addiction: Diagnostic and management challenges p. 544
Preethy Kathiresan, Ravindra Rao, Tanmay Joshi, Roshan Bhad, Sushma Bhatnagar, Koushik Sinha Deb, Rakesh Kumar Chadda
DOI:10.4103/IJPC.IJPC_232_19  
Chronic pain is associated with higher rates of psychiatric comorbidity, including substance use disorders. Patients with chronic pain often require opioids for their pain relief. Often, clinicians are reluctant to prescribe opioids to patients with chronic pain due to fear of patients becoming dependent on opioids. Diagnosing opioid addiction in chronic pain with comorbid prescription opioid use is challenging, as some of the symptoms of addiction overlap with those of physical dependence. A 28-year-old female presented with a history of recurrent abdominal pain beginning at the age of 16 years. The patient was diagnosed with chronic pancreatitis and was prescribed tramadol orally or injections for pain. The patient started experiencing craving with repeated administration of tramadol. She started using it daily and increased her dose to about 6–7 ampoules per day. She also developed complications due to injections. She was not able to work due to her pain, as well as injection use. She would go to multiple chemist shops for getting herself injected with tramadol injections. She also developed depressive symptoms in this period. Due to abdominal pain, the patient was admitted in the gastroenterology ward, from where she was shifted to the psychiatry ward for the management of opioid misuse and depressive symptoms. The patient was diagnosed to be suffering from opioid dependence syndrome with depressive episodes, for which she was provided tablet buprenorphine 14 mg/day dose along with tablet sertraline 150 mg/day. The case demonstrates several challenges in the diagnosis and management of opioid dependence and chronic pain when they occur simultaneously.
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Hypercalcemia of malignancy: An incidental finding in carcinoma cervix p. 548
Sweety Gupta, Ajas Ibrahim, Sagar Nilkanthrao Raut, Debanjan Sikdar, Nidhi Sharma, Shreeya Pabi, Rachit Ahuja, Deepa Joseph, Manoj Gupta
DOI:10.4103/IJPC.IJPC_220_19  
Hypercalcemia occurs in 30% of patients of cancer at either as apart of paraneoplastic process or due to bone metastases. It is an uncommon finding in gynecological cancers. Most common in ovarian cancers and till date very few cancer cervix with hypercalcemia have been reported. We, hereby, report patient of carcinoma cervix who was found to have incidental hypercalcemia without any associated clinical symptoms.
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LETTER TO EDITOR Top

Forecasting patients' lifespan p. 551
Md Rabiul Alam
DOI:10.4103/IJPC.IJPC_222_19  
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