Palliative care – 8 – other aspects

Palliative Care PART – 8

(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)

Question:  Last time we covered few more aspects of covid and cancer. Now that second wave has resolved, and covid cases are extremely low, let us get back to our topic of palliative care. Last time in palliative care, in March, we covered some important aspects related to opioid usage. 1. Advantages of Fentanyl patch, especially for those patients who cannot swallow medicines, or when the caretakers cannot manage timely administration of morphine orally or titrate doses well. 2. Tramadol and Tapentadol were discussed. More easily available in India and more frequently prescribed than morphine. Advantages and disadvantages compared to morphine. 3. Buprenorphine patch and codeine briefly covered.

Government of India has apparently created a short online course for those who want to prescribe morphine.

Now that we have covered pain management fairly well, what other aspects of palliative care do we discuss?

Ans: As discussed in first two parts, palliative care is a comprehensive care. Patients, family members, friends have suffering that involves not only physical concerns, but also psychological, social, financial, spiritual. Comprehensive discussion is not the goal here, but for readers to understand that treating only symptoms will not provide adequate results. Many of these aspects are actually handled by a good family doctor who knows family for a long time. But today many patients are under care of doctors whom they know for few months to few years, when they think of palliative care.

Let me remind you again, however, that palliative care need not wait till end of life. End of life care is part of palliative care. But palliative care requirement is from diagnosis itself. In fact, with good palliative care, patients are more likely to come regularly for main cancer treatment and have overall better results.In August 2010, New England Journal of Medicine, published a randomized trial in patients with metastatic non small cell lung cancer. Patients were randomized to early palliative care from time of diagnosis along with standard oncologic care Versus standard oncologic care alone. Key findings were:

1. Better quality of life in first group, as measured by standardized measure i.e. FACT-L score
2. Less depressive symptoms in first group
3. Higher survival – most surprisingly, first group lived few months longer which was statistically significant. (Many of new anticancer medicines improve overall survival in this range and get approval on this basis. Same magnitude of benefit added by early addition of palliative care).
4. Less aggressive end of life care in first group. Means less use of ICU, chemotherapy in last few weeks to months of life. And yet they had better survival. With better relief of symptoms; less fear of physical, and other sufferings, perhaps patients have better acceptance of death. Hence they are able to avoid aggressive care in last few months of life and focus on other things.

These four points clearly highlight how important it is to incorporate palliative care early. These are the four points that most doctors also discuss, not just oncologists, when they criticize aggressive cancer care, costly care, suffering in ICU with ventilator dialysis etc. And that the goal should be quality of life rather than just extend life by few months. Here is your chance to provide that to your patients, what you already believe in. Refer them for palliative care early after diagnosis – don’t think of this only towards end of life. Early involvement of palliative care service will improve their end of life too. It will reduce cost of care. It will reduce burden on family and you as well on psychological front. And while doing this, it may also improve length of life with good quality at the same time.

Que: This is very heartening to know. Yes this study actually shows what we demand for patients with stage 4 or metastatic cancer. Where can we avail of this service?

Ans: Thank you for asking this practical question. As the awareness is low, providers for such service are also few. But the numbers are improving. Ask your oncologist.

Many cities, cancer centers now have palliative care service. Or at least a psychologist, social worker, pain specialist. With more demand, more places will have a formal service. Many such independent centers (generally free, run by NGO) or experts also provide services. Home care service providers also partially cover these aspects. Few states have palliative care centers in each district with trained personnel, by law. Gujarat has more and more people getting trained in this field, by GCRI. Other training options may be available. Short courses (few weeks long) can be done by going out of state as well, at pallium India in Kerala, Cipla center in Pune, likely at Tata cancer center, and others. Many pharmaceutical companies provide free services online for psychologist.

Home care is an important part of extending palliative care to people with low resources for travel or low social support. As doctors, you can also try asking local NGOs in your city, town, village to start informal or formal palliative care service. They may be able to hire a trained person, or send a local person for short course. Nowadays online guidance can also be taken from palliative care centers in city, most of which any way provide free services. They can be connected to a local NGO or other interested doctor in your village, town. Over several months, he/she may pick up many important tips on how to manage major aspects. Treating oncologist of your patient may also help in providing such a contact.June 14, 2021. 

DrChirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. drchiragashah@gmail.com