Despite its limited coverage, palliative care has been present in India for about 20 years. Obstacles in the growth of palliative care in India are too many and not only include factors like population density, poverty, geographical diversity, restrictive policies regarding opioid prescription, workforce development at base level, but also limited national palliative care policy and lack of institutional interest in palliative care. Nonetheless we have reasons to be proud in that we have overcome several hurdles and last two decades have seen palpable changes in the mindset of health care providers and policy makers with respect to need of palliative care in India. Systematic and continuous education for medical staff is mandatory, and a major break-through for achieving this purpose would be to increase the number of courses and faculties in palliative medicine at most universities.

The patients with chronic pain are increasingly reporting to the physicians for its management. Chronic pain are associated with head, neck and shoulder pain, spinal pain, pain in the joints and extremities, complex regional pain syndrome and phantom pain. The chronic pain is being managed worldwide. The different specialty of medicine is producing a lot of evidence through the published literature but the same is not being published in the field of chronic pain management. Though some evidence is being reported as to different aspects of pain management from different parts of the world but same is lacking from Indian subcontinent. This is in contrast to much done clinical work in this field as well. We present here the available evidence in relation to chronic pain management.

Context: Nurses are called upon to assess chronic pain in health settings and their perceptions about chronic pain are likely to influence the pain assessment and pain relief. Settings and Design: This survey as a part of chronic pain education workshop was conducted at National Institute of Mental Health and Neurosciences, Bangalore, India, by pain education group. Here we present the observations collected during the workshop on chronic pain held for nurses. Materials and Methods: A semiqualitative method was used to survey the perceptions about chronic pain among nurses. The survey form consisted of 28 statements about chronic pain with options of agree and disagree to be marked prepared by the pain education group. Statistical Analysis Used: The data were computed and frequency distribution of different statements was derived. Results: The total number of participants was 44. Two-thirds of the nurses had good knowledge about pain behaviors. About 70% of the nurses reported that severity of pain to be assessed by observing patient's behavior and felt that if a house wife complains of pain it is to avoid work. Only 11% of the nurses provided correct responses related to discussion on pain being psychological; 90% had poor knowledge about pain communication on pain to be treated only for the underlying cause. Conclusions: These observations highlight the fact that inadequacies in knowledge about chronic pain exist among nurses; the main areas include pain communication and pain treatments. It is important to include proper pain curriculum and training for chronic pain assessment and management.

Background: Fatigue is disabling and continuous phenomenon in cancer patients during and after various anticancer treatments which can continue for many years after treatment and definitely it has profound effect on Quality of Life (QOL). However, determining its severity is still underestimated among the cancer patients and also very few studies in the literature exist reporting on Cancer-Related Fatigue (CRF) among Indian population. Aims: To find out the prevalence of rate of fatigue in cancer patient receiving various anti cancer therapies. To find out the relative impact of fatigue on QOL. Materials and Methods: This cross-sectional observational study included a total 121 cancer patients receiving radiotherapy, chemotherapy, and concurrent chemo-radiation with the age group of above 15 years who fulfilled the inclusion and exclusion criteria. All the patients were assessed for severity of fatigue using Brief Fatigue Inventory (BFI) and for QOL using FACT-G scale while they were receiving the anticancer therapies as an in-patient in the regional cancer centers in Madhya Pradesh, India. Results: The severe fatigue was more prevalent in chemotherapy [58/59 (98.30%)], and concurrent chemo-radiation (33/42 (78.57%)) as compared to radiotherapy (Moderate-9/20 (45%) and Severe-9/20 (45%)). Moderate correlations were exhibited between fatigue due to radiotherapy and QOL (r = -0.71, P < 0.01), whereas weak correlation was found between fatigue due to chemotherapy and concurrent chemo-radiation (r = -0.361, P < 0.01 and r = -0.453, P < 0.01, respectively). Conclusion: Severity of fatigue was found more after chemotherapy and concurrent chemo-radiation therapy while impact on QOL was more after the radiotherapy.

Background: Despite efforts to maintain the intestinal tissue and treat gastrointestinal disease, a large number of patients undergo ostomy surgery each year. Using stoma reduces the patient's quality of life (QOL) greatly. Although there are approximately 3000 patients in Iran; there is little information about the impact of stoma on their QOL. Aims: The study aims to evaluate QOL of stoma patients using a special measurement tool. Settings and Design: This survey was a cross-sectional study that was conducted on 102 random samples of stoma patients. Materials and Methods : The City of Hope Quality of Life-Ostomy Questionnaire was used for collecting demographic and clinical information and evaluating QOL. Statistical Analysis Used: Univariate and multiple regression analyses were performed to identify predictors of QOL. Results: The mean score for the overall QOL for stoma patients was 7.48 ± 0.9. 70% of patients were dissatisfied with sexual activities. More than half of them reported feelings of depression following stoma surgery. Univariate analysis indicated that factors such as the type of ostomy (temporary/permanent), the underlying disease that had led to the stoma, depression, problem with location of ostomy, and change in clothing style had significant effects on overall QOL and its subscales ( P < 0.05). The results of the regression analyses showed that only depression and problem with the location of ostomy were statistically significant in predicting patients' QOL and its subscales ( P < 0.05). Conclusions: The findings demonstrated that living with stoma influences the overall aspect of QOL. Education for the patients and their families is important for improving the stoma patients' QOL. Sexual and psychological consultation may also improve patients' QOL.

Objective: The aim of this study is to understand the social determinants of quality of elderly life in rural central India and describe their perspectives on various issues related to their quality of life. Materials and Methods: It was a community-based mixed-methods study in which quantitative (survey) method was followed by qualitative (Focus Group Discussion, FGD). The study was done in field practice area of a Rural Health Training Centre. We decided to interview all the elderly (>60 years) in two feasibly selected wards of village Anji by using the "WHO-Quality of Life (WHOQOL)-brief questionnaire." We used WHOQOL syntax for the calculation of mean values of four domains. Following survey, four FGDs were carried out. Results: The determinants of perceived physical health, amenable for intervention were their currently working status, not being neglected by the family, and involvement in social activities. The determinants for psychological support were health insurance, and their current working status. The determinants for social relations were membership in social group and their present working status. The determinants for perceived environment were membership in social groups and relationship with the family members. In qualitative research, factors such as active life, social activity, spirituality, health care, involvement in decision making, and welfare schemes by the Government were found to contribute to better quality of elderly life. Problems or conflicts in family environment, lack of shelter and financial security, overtapped resources, and gender bias add to negative feelings in old age life. Conclusions: There is a need for intervention at social and family level for elderly friendly environment at home and community level.

Background: Radiation mucositis is an early effect of head and neck radiotherapy. Mucositis can cause ulcers, and patients may experience pain and dysphagia which need proper management. This study was conducted in 60 patients with oral malignancy. Aim : To evaluate the effect of natural honey and 0.15% benzydamine hydrochloride on onset and severity of radiation mucositis and to compare it with control. Materials and Methods : This study was conducted in the Department of Oral Medicine and Radiology, Tamilnadu Government Dental College and Hospital, Chennai, from April to December 2010. The sample size comprised of 60 patients, of both genders, diagnosed with oral malignancy clinically and histopathologically and planned for radiotherapy. The patients were assigned into three groups by random sampling. Each group consisted of 20 patients. Group 1 patients were instructed for topical application of natural honey, groups 2 and 3 were instructed for topical application of 0.15% benzydamine hydrochloride and 0.9% normal saline respectively. The onset of mucositis and the severity of mucositis were graded during the course of the radiotherapy and two weeks after radiotherapy, with WHO mucositis grading in all the three groups and statistically analysed with SPSS version 11 software. Results: A significant reduction in mucositis in honey-received patients compared with 0.15% benzydamine hydrochloride, 0.9% normal saline applied patients occurred. The differences between the groups were statistically significant ( P < 0.001). Conclusion: Pure natural honey can be an effective agent in managing radiation induced oral mucositis. Honey could be a simple, potent and inexpensive agent, which is easily available, and it can be a better therapeutic agent in managing radiation mucositis in developing countries like India for the management of this morbidity.

Background: Adolescents with cancer form a distinct group with special care needs. These patients are often cared in an adult supportive care setting where the special needs of adolescents are not met. Aim: To identify special issues in adolescents with cancer and to determine whether special needs of adolescents are met in an adult cancer setting Materials and Methods: 10 adolescents with cancer were randomly chosen and retrospectively studied for physical, psychoscocial and emotional issues using an internally validated tool. Results: Pain was the most common physical symptom seen in all 10 patients. 3 out of 10 patients were involved in decision making, 3 out of 10 patients had identity issues and 4 out of 10 patients had peer group isolation issues. Only 3 were aware of diagnosis and none were aware of treatment outcomes and mortality. 4 out of 10 had anxiety and depression and 3 out of 10 had body image issues. Sexuality, spiritual and existential issues were not explored in any of the patients studied. Conclusion: The outcomes of the study were in an adult oncology setting there was a poor recognition of key adolescent issues such as sexuality, body image, identity and peer group isolation. The psychosocial supports to these adolescents were minimal and spiritual and existential issues were not explored. The inferences drawn from this study suggested a need for multidisciplinary team approach oriented in handling adolescent care needs and preferably to have a dedicated space that will help the peer group to interact, bond and cope better with the illness.

Context: Metastatic bone disease is a commonly encountered problem in oncology practice. The most useful and cost effective treatment is radiotherapy (RT). Different fractionation schedule of RT can be used to treat such condition. Aims: Assessment of pain response in patients with vertebral bone metastasis after treating them with various radiation fractionations and to compare the toxicity profile in the treatment arms. Settings and Design: A prospective randomized study was designed to include total 64 patients from July 2010 to May 2011. Patients with histopathologically proven primary malignancy having symptomatic secondary deposits to vertebra were selected for the study. Patients were randomized to two arms receiving multiple fraction of RT with 30 Gy in 10 fractions and 8 Gy in single fraction RT, respectively. Materials and Methods: Patients with age >75 years, Karnofsky Performance Status (KPS) <40, features of cord compression were excluded from study. Initial pain response was assessed using Visual Analogue Scale (VAS) and compared using the same scale at weekly interval up to 1 month after treatment completion. Results: Arm A comprised of 33 patients while 31 patients were enrolled in Arm B. Baseline patient characteristics were comparable. Eleven patients were lost to follow-up. Initial pain scores were 7.23 ± 0.765 and 7.51 ± 0.55 in arm A and arm B, respectively. Pain scores reduced significantly in both the arms after 1 month (4.39 ± 1.82 in arm A; 5.25 ± 2.39 in arm B). Time of initiation of pain response was earlier in arm A ( P = 0.0281), statistically significant. Mild G-I toxicity was noted in both the arms but differences in two arms were not statistically significant ( P = 0.49), no interruption of treatment was required because of side effects. Conclusions: Different fractionation of radiation has same response and toxicity in treatment of vertebral bone metastasis. Single fraction RT may be safely used to treat these cases as this is more cost effective and less time consuming. Studies may be conducted to find out particular subgroup of patients to be benefitted more by either fractionation schedule; however, our study cannot comment on that issue.

Aim: To evaluate the effect of hollow bulb obturator prosthesis on articulation and nasalance in maxillectomy patients. Materials and Methods: A total of 10 patients, who were to undergo maxillectomy, falling under Aramany classes I and II, with normal speech and hearing pattern were selected for the study. They were provided with definitive maxillary obturators after complete healing of the defect. The patients were asked to wear the obturator for six weeks and speech analysis was done to measure changes in articulation and nasalance at four different stages of treatment, namely, preoperative, postoperative (after complete healing, that is, 3-4 months after surgery), after 24 hours, and after six weeks of providing the obturators. Articulation was measured objectively for distortion, addition, substitution, and omission by a speech pathologist, and nasalance was measured by Dr. Speech software. Results: The statistical comparison of preoperative and six weeks post rehabilitation levels showed insignificance in articulation and nasalance. Comparison of post surgery complete healing with six weeks after rehabilitation showed significant differences in both nasalance and articulation. Conclusion: Providing an obturator improves the speech closer to presurgical levels of articulation and there is improvement in nasality also.

Context: For the first time in India, a Pain and Palliative Care policy to guide the community-based home care initiatives was declared by the Government of Kerala state. In Kerala, majority of the panchayats (local self-governments) are now conducting home-based palliative care as part of primary health care. National focus domain areas in palliative care research are structure and process, the physical aspects, and also the social aspects of care. Aims: The study was conducted to assess the patient's status and the services provided by palliative home care. Settings and Design: The descriptive study was conducted at Mavoor panchayat-Kozhikode district of Kerala, India by collecting information from the case records, nurses diary notes of all enrolled patients. Materials and Methods: Collecting information from the case records, nurses diary notes of all enrolled patients. Statistical Analysis: The data were entered using Microsoft excel for Windows XP and analyzed using SPSS 16.0 (Statistical Package for Social Sciences; SPSS Inc., Chicago, IL, USA). Results: Totally, 104 patients were enrolled. Diagnosis wise major category was degenerative diseases. There were 27% persons suffering from cerebrovascular accidents, 15.3% with malignancies, 8.7% with coronary artery disease, 5.8% with complications of diabetes, and 8.7% were with fracture of bones. The major complaints were weakness (41.3%), tiredness (31.7%), and pain (27%). Twenty-five percent persons complained of urinary incontinence, 12.5% complained of ulcer, 10.6% of edema, and 9.6% of mental/emotional agony. The activity of daily living status was as follows. Twenty-five percent subjects were completely bed ridden. 5.8% were feeding through Ryles tube, 16.3% had urinary incontinence, 9.6% were having no bowel control. Conclusions: The service could address most of the medical, psychosocial, and supportive needs of the patients and reduce their pain and symptoms. The interface between institutional-based care and home care needs more exploration and prospective studies.

Background: HelpAge India has been facilitating community-managed palliative care program in the villages of Tamil Nadu, India. Objective: To evaluate the effect of perceived quality of life in the elderly in the project villages in rural Tamil Nadu. Materials and Methods: It was a community-based evaluation study. Considering the mean difference of 0.6, design effect-2, precision-5%, power 80%, and 10% non-response, a sample size of 450 elderly persons (more than 60 years) was adequate. Sample was selected by two-stage cluster sampling. Tamil version of "WHO-Quality of Life-brief questionnaire" was used. Trained interviewers made house-to-house visits and obtained information by personally interviewing the subjects. Results: The mean score for perceived physical quality of life in the project area was (10.47 ± 1.80 SD) high than the mean score (10.17 ± 1.82 SD) in the control area ( P = 0.013) and the mean score for psychological support (10.13 ± 2.25 SD) in project area was high than the mean score (9.8 ± 2.29 SD) in control area ( P = 0.043). There was no effect on domain of social relationship and environment. Conclusions: In the project villages, the perceived physical quality of life and psychological support among elderly persons was significantly better than the control villages.

Being an Oncologist, I have seen many patients suffering from cancer. It pains a lot looking at them fighting the battle of life, though knowing that they would lose miserably and surrender meekly as majority of the patients report to the hospital at an advanced stage of disease and only palliative care may be the option. There is an urgent need to create - Cancer Awareness in the villages and also about the end of life care in all terminally ill patients. 20 patients in the terminal phase were questioned regarding end of life care. The common questions they asked are, why has God punished me like this? Why me on earth? Should I die so early? Why should I leave my near and dear ones and go far away, from the point of no return? Do I ever see them again? With deep sorrow and sigh, they suffer till the last breath, having the feeling of insecurity as what would happen to their dear ones. In the terminal phase, the patients wishes must be respected and their needs must be fulfilled. The health care professionals should plan an appropriate care for each patient. Most of them feel that the best place to be in end of life is the home. Research has shown that Hospice care may improve the quality of life of a patient who is dying and of the patient's family. Communication about end of life care and decision making during the final moments of a person's life are very important. The patients suffering are mainly due to the physical, psychological, social and spiritual issues. Death of a terminally ill patient should never be a sudden loss. All healthcare professionals, Social workers and Non-Governmental Organisations must install the life after death of the person, who has struggled for every breath and assure that he/she shall rest in peace and shall smile seeing their near and dear ones living with dignity and pride in the society. Ultimately, the patient must have dignity in dying.