Introduction to

Palliative Care
Dr . Rajesh .T. Eapen

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The Definition
Palliative care is the active total care
of patients and their families by a
multiprofessional team at a time when
the patients disease is no longer
responsive to curative treatment and
life expectancy is relatively short.
4

Palliative Care and Life

Palliative Care is
concerned with
Quality of Life
The idea is to help
the person have a
meaningful life, not
just to live some
how till death
6

Quality of life
Quality of life is what a person says it
is.
Quality of life relates to an individuals
subjective satisfaction with life, and is
influenced by all the dimensions of
personhood - physical, psychological,
social and spiritual.
7

GH, TATA TEA

LTD

Palliative Care and Life

Physical
Social
Emotional
Spiritual

TOTAL CARE
9

Suffering in Chronic & Incurable

Illnesses
Suffering in chronic
diseases is much
more than the
problems added
together

10

Suffering

Suffering occurs
when the impending
destruction of the
individual is
perceived
Eric Cassel
11

Disease process Vs Suffering

The concept of quality of life tries
to address the suffering
caused by the disease as
against just the disease
process

FPM, August 2007

12

Quality of life in Incurable

Diseases
Improvement in quality of life
not possible with medical
interventions alone

13

Role of Health Care Professionals

Many of the
problems in
chronic diseases
are of a non
medical nature,
but health care
professionals have
a very important
definite role
14

Palliative Care as part of

Supportive Care
People at risk
Incurability

Symptoms
Death

Diagnosis

Risk modifying Disease modifying

Bereavement

Terminal care

INTERVENTION
S

Awareness /Prevention
Palliative

Curative

Supportive care
15

Palliative care only means

treatment appropriate to the
patient
The key points to bear in mind are:
the patients biological prospects
the therapeutic aim and benefits of each
treatment / investigations
the adverse effects of treatment /
investigations
availability / affordability of the treatment
16

Hope
Hope needs an
object
Setting realistic
goals jointly with the
patient is one way
of restoring and
maintaining hope
Hope of recovery is
often replaced by
an alternative hope
17

Four cardinal principles

Do no harm
Do good
Patient autonomy
Justice

18

A social problem?
Incurable cancer or
chronic disabling
condition is as
much of a social
problem as a
medical one
19

Chronic diseases and health

care institutions
Health care
institutions are
traditionally
geared to look
after patients with
acute diseases but
not chronic
conditions
20

Palliative Care as Primary Health

Care
Provision for
LTC (Long Term Care)
and
PC (Palliative Care)
need to be woven into
the community fabric
21

How do we ensure that the

patient chooses good options?
More information
on available
options?
More interactions
between health
care professional,
patient, family?
22

Training in Palliative Care

For the doctors and nurses to
improve their clinical skills and know
how so that their patients remain
more comfortable

23

General Practitioners as
Palliative Care Physicians
Over the next 20 years the number of
people diagnosed with cancer will double to
20 million cases a year
70% of these will be in the developing world
where most cancers will be diagnosed only
when the disease is far advanced
GPs and oncologists are the groups of
doctors who can play the most important
role in the care of these patients.

24

Palliative Care: Extent of the

problem globally
Annual deaths globally

56
million

Annual deaths in developing

countries

44
million

Annual deaths in the developed

countries

12
million

Estimated number in need of

Palliative Care

33
million
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Health Care in of the World

Cost of drugs and
health care going
steadily up resulting in
limiting access to any
type of health care to
fewer and fewer people

26

Skills of PC in general practice

Management of
Pain
Breathlessness
Nausea and vomiting
Intestinal obstruction
Emotional issues
27

Modes of delivery
Most of the existing palliative care services
are a combination of some of the following
components
Traditional Hospice
Hospital based inpatient unit
Outpatient clinics
Hospital based
Hospice based
Free standing
Home care units
Hospital based
Hospice based
Community based
28

Traditional Hospice
Free standing inpatient unit
May have an associated home care /
outpatient clinic
Custom made Islands of quietness and
peace
Ties with the rest of the Health Care
system usually weak risk of isolation
May some times be seen by the local
community as a place for the dying
patients
Coverage poor
29

Hospital based inpatient unit

Better interactions with the medical /
nursing main stream
Better options for training and education of
the colleagues
Supportive care for the curable patients
Continuity of care when the patient moves
from curative to palliative realm
More of hospital atmosphere than
hospice atmosphere
30

Home Care units

Usually function as part of an institution
based care
Availability care to the patient and family at
a place most convenient to them
Care made available to the patient in a
familiar environment
Coverage often patchy 24hour access to
care may not be possible
Sometimes need to be supplemented with
institutionalized care
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Out patient clinics

Outpatient clinics and day care units are
usually made available with other services
Out patient clinics usually for symptom relief
Out patient clinics are usually doctor run
Short term trouble shooting
Day care units to manage short procedures
or non medical aspects of care
Outpatient clinics and day care units can
fulfill most of the institutional tasks in a
community based palliative care program
32

Community based programs

A network of trained professionals and non
professionals in the locality
Care delivered at home to the patient
24 hour access to care
Closest to the concept of total care
Ideal safety net for patient discharged from
the institution
Needs to be supported by referral centers

33

Reasons for admission

Symptom relief
Respite care
Terminal care

34

PAI N
Pain management is an
essential component of
comprehensive medical care

Pain

37

CANCER PAIN:
MOST COMMON SYMPTOM
MOST EMOTIONAL SYMPTOM
MOST TREATABLE SYMPTOM

Cancer pain remains

undertreated today
Patients with metastatic cancer and
severe pain:
42% were NOT GIVEN ADEQUATE
PAIN THERAPY!*
* Cleeland, et.al., NEJM 330:592-6, 1994

Around-the-Clock Dosing
Best way to manage chronic pain
ATC Dosing

PRN Dosing

From: Whitten, Donovan, Cristobal. Treating chronic pain: new knowledge, more choices. The Permanente Journal
2005; 9: 9-18.

Morphine is the drug of

choice for

Cancer pain
at any
of theonly for
Morphine
shouldstage
not be reserved
Terminal stages.
disease.

GH, TATA TEA LTD

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Complimentary therapy

FUNGATING WOUND
Definition:

It is a primary or secondary
malignant growth in the skin
Which has ulcerated
and difficult to heal

PHYSICAL PROBLEMS
Pain
Malodor
Infection
Bleeding
Exudates
Infestation with maggots

PSYCHOLOGICAL PROBLEMS

Altered body image

Sexuality
Fear of death
Depression & anxiety
Shame
Isolation

SOCIAL PROBLEMS
Family isolation
Social isolation
Social stigma /fear of contagion
Effects on family
Effects on sexual relationship &
marital disharmony

SPIRITUAL/RELIGIOUS
PROBLEMS
Interference with religious rites
Punishment from god ?
Fear of impending death
Existential dilemmas

TRAINING FOR CARERS

Knowledge, attitude and practice assessed
Practical demonstration of wound care
Regular follow up
Realistic goals of care,( improving quality
of care and palliation of symptoms )
Teaching NS preparation & sterilization of
dressing materials

PRESSURE SORES
Definition
Pressure sores are localised tissue
death and is the result of impairment of
vascular & lymphatic system of the
skin and tissues caused by
compression, tension or shear

Fatigue

Slide 51

Anorexia
and
Cachexia

Slide 52

Nausea
and
Vomiting

Slide 53

Constipation,
Bowel
Obstruction

Slide 54

Delirium

Slide 55

Dyspnea

Slide 56

Problems contributing to
suffering
Pain
Breathlessness
Nausea / vomiting
Fungating wounds
Anorexia
Fatigue
Financial
Social Isolation
Neglect

Loss of social roles

Sadness
Depression
Anger
Anxiety
Personality changes
Change in faith
/beliefs

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58

END OF LIFE CARE

60

Definition
The period when day to day
deterioration, particularly of strength,
appetite and awareness
are occurring.

Aim
Ensure holistic comfort to the patient,
conscious/unconscious.
A peaceful and dignified death.
Support to the patient and family
through this transition.

Possible Signs and

Symptoms
Profound weakness
Diminished intake of food and fluids
Drowsiness and increased sleep
Reduced cognition
Distressing vocalization
Loss of consciousness

Difficulty in swallowing
Escalation of pain and
symptoms/sudden peacefulness
Pallor/Cyanosis/Peripheral shut
down.
Altered breathing pattern-periods of
apnoea, noisy/moist.

Increase in restlessness/twitching.
Agitation
Decreased elimination/sudden
incontinence of bowel/bladder.
Fluctuations in body temperature.

Interventions
Treat reversible causes. (e.g.
restlessness- full bladder, medication)
Continuous reviewing of symptom
management(amount,route and
drugs)
Stopping unnecessary drugs
Uphold patients wishes
Alleviate any fear and anxiety

Emotional support, reassurance &

continual updating of patients
condition with family.
Consider spiritual/cultural needs.
Prevention and treatment of new
problems developing(e.g. Bed sore)

Your Palliative Care Unit

The priorities of the service should be
those relevant to the region
Which all components of service
need to be incorporated into your
palliative care unit depends on what
is relevant in your region

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Why do you want to get

involved in PC?
It would be humanly and socially
grotesque if our passion for the
poor stopped at helping them to
die well.
David J Roy (J Palliat Care 1999, 15:1; 3-5)

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But I have promises to keep, and miles to go

before I sleep.
Robert Frost

FOR YOUR LISTENING