Information that drastically alters the life world of the patient is termed as bad news. Conveying bad news is a skilled communication, and not at all easy. The amount of truth to be disclosed is subjective. A properly structured and well-orchestrated communication has a positive therapeutic effect. This is a process of negotiation between patient and physician, but physicians often find it difficult due to many reasons. They feel incompetent and are afraid of unleashing a negative reaction from the patient or their relatives. The physician is reminded of his or her own vulnerability to terminal illness, and find themselves powerless over emotional distress. Lack of sufficient training in breaking bad news is a handicap to most physicians and health care workers. Adherence to the principles of client-centered counseling is helpful in attaining this skill. Fundamental insight of the patient is exploited and the bad news is delivered in a structured manner, because the patient is the one who knows what is hurting him most and he is the one who knows how to move forward. Six-step SPIKES protocol is widely used for breaking bad news. In this paper, we put forward another six-step protocol, the BREAKS protocol as a systematic and easy communication strategy for breaking bad news. Development of competence in dealing with difficult situations has positive therapeutic outcome and is a professionally satisfying one.

Not for resuscitation in India still remains an abstract concept with no clear guidelines or legal frame work. Cardiopulmonary resuscitation is a complex medical intervention which is often used inappropriately in hospitalized patients and usually guided by medical decision making rather than patient-directed choices. Patient autonomy still remains a weak concept and relatives are expected to make this big decision in a short time and at a time of great emotional distress. This article outlines concepts around ethics and medico legal aspects of not for resuscitation, especially in Indian setting.

Most of the needs of elders for support and assistance in the later stages of life are fulfilled by informal helpers. The position of a large number of older persons has become vulnerable due to which it cannot be taken for granted that their children will be able to look after them when they need care in old age, specially in view of the longer life span implying an extended period of dependency and higher costs to meet health and other needs. The condition of the rural elderly is even more pitiable, contrary to our beliefs, as availability, affordability and accessibility to medicare facilities are poor. We undertook the task of organizing a health camp in a rural set-up with the idea of implementing our concept of "preventive palliation" in which excellent palliative care was coupled with a pinch of prevention, like routine checks of blood pressure, routine physical check-ups, etc, so that any aberration can be detected early and necessary rectification measures can be implemented. These periods of routine check-ups can also be used to assess the psycho-social, cultural and emotional problems, if any. Such an approach, say every monthly, gives the elderly something to look forward to and ensures a high degree of customer satisfaction and greatly reduces the burden on the current health system. The challenges faced and the data obtained from this study were shocking. The elderly living in rural areas of the tribal state of Jharkhand suffer from poor physical and mental health, a factor which was rather unexpected in the Indian cultural system in the rural setting. Simple strategies like implementing routine health check ups with provision of "nutritious meal program" can go a long way in mitigating these problems in a cost-effective and simple manner. To make the government-based programs accessible and available to the end-users, participation of local bodies like NGOs is mandatory. Preventive palliation, a concept introduced by Kosish, is the way forward for providing palliative care to the rural-based elderly in most parts of India. This concept takes into account the local cultural, social, financial and long term feasibility and sustainability aspects of the care process.

The palliative doctor gives the 'touch of God' as he/she takes care of the terminally ill patient. The oncologist encounters great difficulties in managing oral cavity problems of these patients. A trained dental doctor can help other doctors in dealing with these situations. But the general dental surgeon does not have enough idea about his part in these treatments. The community is also unaware of the role that a nearby dentist can play. Adequate training programs have to be conducted and awareness has to be created. A trained dentist will be a good team mate for the oncologist or radiotherapist or other doctors of the palliative care team. In this paper, a brief attempt is made to list a few areas in which a palliative care dentist can help other members of the palliative care team and also the patient in leading a better life.

The article aims to explore and discuss the occupational care giving conditions pitting them against human rights. The article's objective is to initiate discussions and generate literature pertaining to occupational care giving load and assessing the human rights challenge it poses. The article uses analysis of the literature review from an array of eclectic data sources. The following factors were found besetting the caregivers' human rights: (1) Aging; (2) Cultural and community attitudes towards care giving; (3) Risk of contagion; (4) Health hazards and lack of compensation. Recommendations: (1) Adoption of grandparents/grandchildren care symbiosis system; (2) Government remuneration policy for caregivers; (3) Mainstreaming of gender education to encourage men and youth develop an interest in care giving; (4) Institution of laws and policies by countries to provide for the compensation of caregivers' occupational hazards and risks.

Background and Context: Treatment of terminally ill cancer patients always poses great challenges especially when these critical patients are admitted in intensive care unit (ICU). The severity of their diseases throws a clinical and ethical dilemma to the treating intensivist. Aims and Objectives: To evaluate the benefits of intensive care treatment in terminally ill cancer patients and also to find out whether optimal utilization of critical care resources has got any positive financial, psychological and clinical outcome. Materials and Methods: A retrospective evaluation of 53 terminally ill cancer patients, who got admitted to ICU of our department, was carried out. Majority of these patients presented with terminal phase of illness involving multi-organ pathologies with diverse range of symptoms. These patients were provided ventilatory, symptomatic and supportive treatment on patient-to-patient basis. Strict and vigilant monitoring of all vital parameters was carried out. At the end of study, all the data was compiled systematically and was subjected to statistical analysis using non parametric tests. Results: The demographic profile of such patients was highly variable with regard to educational, social and financial status (P<0.05). The most common group of cancer was hematological malignancies (24.53%) followed by lung cancer (18.87%), uteri-ovarian (15.09), colorectal (13.2%) and others. Significant number (P<0.05) of patients (64.15%) required mechanical ventilation and ionotropic support (79.24%). Mortality increased with increasing number of organ system involvement and reaching up to 100% with involvement of 5 or more organ systems. Conclusions: ICU care is the best form of treatment for terminally ill but resources should be used optimally so that a young deserving patient should not be sacrificed for the scarcity of resources.

Objective: Our world is rapidly becoming a global community, which creates a need to further understand the universal phenomena of death and professional caring for dying persons. This study thus was conducted to describe the meaning of nurses' experiences of caring for dying people in the cultural contexts of Iran and Sweden. Materials and Methods: Using a phenomenological approach, phenomenon of caring for dying people was studied. Eight registered nurses who were working in oncology units in Tehran, Iran and eight registered nurses working in hospital and home care in North part of Sweden were interviewed. The interviews were analyzed using the principles of phenomenological hermeneutics. Results: The findings were formulated based on two themes included: (1) "Sharing space and time to be lost", and (2) "Caring is a learning process. Conclusions: The results showed that being with dying people raise an ethical demand that calls for personal and professional response, regardless of sex, culture or context. The physical and organizational context must be supportive and enable nurses to stand up to the demands of close relationships. Specific units and teamwork across various personnel seem to be a solution that is missing in Iran.

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

Metastatic phyllodes tumor has very few treatment options. Phyllodes tumor in metastatic setting has limited role of surgery, radiotherapy and chemotherapy or combined treatment. Most of the patients receive symptomatic management only. We present a case of metastatic phyllodes tumor managed with aggressive margin negative resection of primary tumor leading to palliation of almost all the symptoms, which eventually led to improved quality of life and probably to improved survival. The improved quality of life was objectively assessed with Hamilton depression rating scale. Surgery may be the only mode of palliation in selected patients that provides a better quality of life and directly or indirectly may lead to improved survival.