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2018-10-08

Palliation Holistic Healing - Dr. Narayana Hari Mohan

Palliation Holistic Healing - Dr. Narayana Hari Mohan

Palliation Holistic Healing 

Taking the example of cancer, modern medicine has made several new promising cancer treatments available for many cancers today. As a result, more and more people with the incurable disease are living longer. However, that has also made cancer a chronic illness, with many patients living longer with symptoms. These survivors have different physical, social, psychological, economic, and even legal concerns. Despite the advances in therapy, cancer remains a devastating illness-for the patients, for their families, the community, and health care providers. Talking of treatment, there is always hope for cure, but one also hopes to be healed during the process. If one can not be cured, the patient can still die healed.

What is important is having a sense of wholeness as a person, at any stage of the disease. Philosophy of palliative care supports the patient’s search for normalcy, dignity, and comfort. 
Therefore, it is the responsibility of health care professionals to ensure that the patient with cancer or any life-limiting illness has a chance at being both cured and healed. This is possible when there is seamless integration of palliative care and acute care through-out the trajectory of the disease. 

This calls for collaborative care between oncologists and palliative medicine experts. Such shared management can maximize comprehension of patient’s distress and optimize support provided during hospitalization.

Indian Scenario 

While the integration of palliative care with curative therapies is already a reality in developed countries, India still has a long way to go. 
Palliative care has been developing in India since the mid-1980s. 
Palliative care teams, whether in the form of NGOs or other groups, have made important contributions in improving the care of patients with incurable illnesses in the country over the past 20 years. 
At any given point of time, around 2.5 million people suffer from cancer in India. 
Every year, almost two lac new cancer cases are diagnosed, and many of these cases are detected in advanced stages. Of these cases, only 1.6 million people get any kind of treatment and only 0.4% receives relief through palliative care. 
With other chronic debilitating illnesses, like HIV, chronic renal failures, geriatric conditions, it becomes clear that compared to the magnitude of the need, only a minuscule proportion of the needy actually receive palliative care. There is an urgent need to introduce palliative care in primary, secondary, and tertiary health care facilities.
There has been a significant change in the mind-set of health care providers, and policy makers with respect to the urgency in providing palliative care. Palliative care services have acquired an increasing role in incurable diseases including cancer. 
 
CASE FOR INTEGRATION 

Out in the West, palliative care is no longer just tender loving care delivered toward the end of life but a legitimate medical speciality that seeks to enhance the effectiveness of curative treatment by controlling pain and other symptoms. 
The palliative care specialist is a member of the team responsible for a patient’s care right from the time of diagnosis. The competencies of palliative medicine are in relieving the suffering and promoting good quality of life for patients and families. 
The palliative medicine specialist, with his multidisciplinary team, adds a unique perspective in assessing and treating pain and other symptoms, and conveys clarity in ethical decision making for patients with advanced disease. Proficiency in symptom control, developed over many years in the palliative setting, has proven to be adaptable to patients in the acute-care setting.
 
CONTRIBUTIONS BY PALLIATIVE CARE SPECIALISTS 

In symptom control, decision making, and management of treatment complications, communication, psychosocial care, and coordination of care have resulted in improved care of terminally ill hospitalized patients. 
When these patients are discharged from the hospital, appropriate referrals are made to community-specialized services. This assures continuity of care when the patient is shifted from acute hospital to community palliative care service and enables the full spectrum of services for patients and their families from the time of diagnosis throughout the course of the illness.
In India, most patients with cancer and other terminal illnesses are diagnosed and treated in acute hospitals. Acute hospitals are also the most common setting, where people die. 
Thus, there is a need for skilled and compassionate care of the dying in the acute hospital setting. It is necessary that medical professionals who care for the dying on a day-to-day basis must have training in palliative care. This is important, given the unpredictability of the terminal phase of diseases. Admission to a remote palliative care unit becomes difficult given the unpredictable prognosis. Formal recognition of palliative medicine as a speciality would help people realize that palliative care too is a relevant goal of medicine when it comes to dealing with life-limiting illness. So, there is a dire need for collaboration of palliative medicine with other specialties, allowing communication and exchange of ideas on issues relevant to the medical care of patients with incurable disease.
There are proven benefits of integrating palliative services with hospitals.
 By including palliative services, hospital staff benefit from on-the-job training in end-of-life care and critical communications. Palliative care team can take advantage of the organizational resources of the hospital to provide greater care to a larger number of people. Serious and terminally ill patients can get better quality of holistic care covering social, spiritual and psychological aspects. The hospital gets an enhanced positive image in the community for providing better care that encompasses not only the patient, but also the relatives. Sometimes there is reduction in cost of care through shortened duration of stay and patient-specific care.
Such a partnership may bridge acute care and palliative care, while multiplying the strengths and eliminating the limitations of both. With current and updated knowledge, there is continuity of care that enhances the ability of both partners to tailor care plans to meet patient and family needs and preferences. Hospitals may contribute to the partnership by acute care expertise across multiple specialities, management and marketing capabilities, and library and information system resources. Palliative care centres can contribute to the partnership by facilitating advance care planning, end-of-life care clinical services, bereavement support, and volunteer training and integration. Thus, both partners bring strengths to the development and implementation of the optimum patient care program.
The term Palliative care in medicine has made a slow but sure paradoxical change from Terminal care to care for those with no cure 

CONCEPT OF PALLIATIVE CARE IN ONCOLOGY 

Cancer treatment involves several complex situations from diagnosis, the long process of treatment and follows up and in those with incurable cancers the complexities are multiplied manifold.
From diagnosis to different stages in treatment and during complications to phase of best supportive and terminal care the support of a palliative care team has been found to go a long way in the best interests of the patient and family 
Home based palliative care in those who are unable or have no more need to make hospital visits, Acute care needs in those with chronic ailments and in end stage also need hospital based management to offer relief and improve quality of life.
Community palliative care alone may not meet this objective.
The advantages of therapeutic and medical skills to reduce pain and other symptomatology use of communication and counselling in a trained fashion to provide social and emotional support to the patient and relatives is where the palliative team can be a support system in an oncology centre whereby the busy professionals managing medical oncology and radiotherapy to a large extent are relieved of this burden and work 
In India, a few cases of successful collaboration between palliative care centres and hospitals already exist. Now, more and more people are realizing the importance of palliative care. 
These professionals correctly perceive palliative care as an integral part of care from diagnosis to death, rather than being limited to the terminal phase. 
Palliative care is also expanding its scope beyond cancer care and beyond terminal care. 
At least in pockets, there are emerging subspecialties like geriatric palliative care, paediatric palliative care, etc. So, in order to further palliative care services in India, all the specialities should come together and embrace palliative care as an approach, rather than as a competitive speciality. Just as it is incorrect to perceive death as the “failure” of medicine, it is wrong to look at palliative care as the last optional step before death. 
For the sake of better health care, the focus should be on the whole-person quality of the patient and the family right from diagnosis to death and beyond. 
Shared decision making and advance care planning facilitated by integrated care can make this happen every single time, without any extra effort. 
Integrated care can serve patients without denying the inevitability of death and do all that is necessary to achieve relative comfort. Clinicians in such joint teams are in a better position to acknowledge and appreciate the lifelong human capacity for growth. And as many clinicians have acknowledged, they have been happily surprised by their own well-rounded growth, simply by being part of the team that helps discover afresh the value of dying within the mystery of life

PALLIATIVE DEPARTMENT IN VPS LAKESHORE HOSPITAL 

VPS Lakeshore hospital today has been acknowledged as a Quaternary care multispecialty hospital and is renowned for its oncology services both Medical Oncology, and Haematology   adult and Paediatric under Dr V.P Ganghadharan and Radiotherapy Department 
It has an existing palliative service for last many years offering great relief to the patients who need it. With increasing life spans post several advances in treatment in cancer more patients today require palliative services in its whole gamut.
At present their acute needs in the hospital are managed by the medical oncology department.
There is a great need for a dedicated palliative care department with a ward to accommodate such patients needing hospitalisation 
 
SERVICES UNDER DEPARTMENT 

Outpatient services 
1 ) Consults and counselling regarding plan of management when best supportive care is advised. The shift from active treatment to best supportive care is at many times traumatic for both patient and family who are used to treatment of any medical problems as a solution, to make them aware that in the best interests of the patient treatment would no more involve anti-tumour treatment but management of symptomatology by all means feasible is the prime responsibility of a palliative team 
To make patient and family understands that by deciding not to treat tumour anymore does not mean that the institute or department has absolved itself of taking care of the patient but it’s just a shift to a department where all medical knowledge would be used to provide a good quality of life but at the same time there would be no heroic or aggressive measures inadvisable and senseless in that state of the patient 

2 ) Pain relief is a most important concept of palliative medicine 
The knowledge on the use of therapeutic armamentarium and use of opioids judiciously for the wellbeing and pain relief of the patient is one of the most vital responsibilities of a good palliative department 
Pain relief by oral medications, parenteral infusions, especially for acute pain management follow up and modifications and monitoring of relief of one of the most dreaded symptoms of cancer.
Use of non-pharmacological methods to relieve cancer pain like yoga , music therapy acupuncture , will also be used judiciously 
Use of interventional pain management by skilled Anaesthesia colleagues as and when the need arises to relieve intractable pain .
 
3 ) Management of other symptoms like Fatigue which is associated in oncology patients with advanced disease Anorexia ,nausea ,vomiting , constipation ,dyspnoea are all important issues to be addressed.
The use of needed invasive procedures like paracentesis of fluids as and when required to provide relief 
4 ) Care of patients with medical problems as complications or as a natural process of worsening of disease 
The care of patients with liver dysfunction and encephalopathy or with renal dysfunction 
The palliative care department will have the advantage of a highly skilled departments of nephrology cardiology pulmonology anaesthesiology gastroenterology cardiology Geriatric s surgery infectious diseases etc to provide their skills to improve the quality of life of patients and reduces his symptoms 
5 ) Research in palliative medicine is a big  lacuna 
The advantage of a department in a super speciality centre with academic inputs and experience of conducting clinical trials would in the future address this vacuum in palliative medicine research too 
6 )Education of health professionals and society in the concepts of palliative care by media articles in house training and conducting workshops and course can all be part of the future of such a department  
 7 ) Encourage  advocacy of patients and families 
8 ) Coordination of the services of clinical psychologists social workers religious support etc for a patient with an incurable disease 
The department can also hold get together of patients their families as a venue for addressing their grievances mass counselling and support services form society 
9 )Terminal care and end of life care as far as possible should be in one’s own home with family presence but for the many who want the security of a hospital setting to manage the end of life crisis situation the department can provide the same 
10 ) Bereavement support for the family 
11 )Home care to patients who find it difficult to come to hospital and community service would also reflect the charitable side of a corporate hospital and its giving back to society 
 
DEPARTMENT COMPONENTS 

Out patient 
Consulting rooms where physicians can meet family and patient and hold family conferences to counsel them address their issues and keep following them up 
The availability of social worker onco psychiatrist psychologist dietician physiotherapist and occupational therapist pharmacist’s support and religious support is essential 
Basic lab and imaging services from hospital will be used form the hospital as and when  needed with the knowledge the aim is more for improving quality of life rather than to prolong life span or attempts to cure. Availability of trained nurses in palliative medicine and opioid management and accounting and in communication and also in basic nursing techniques 

Day care ward 
One or two beds for patients who come with acute pain or dehydration of for paracentesis etc and can go home once relieved 

In patient ward
To look after patients with more acute problems and for a select few with end of life situations 
In the begging in this ward could have approximately 5 beds which can be increased as needed.

Home care services
Can be started as a second stage to reach out to the homes of patients