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Palliative Care – 1 – concepts

Palliative Care PART – 1

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

Question:  Last time we discussed SVC Syndrome as an emergency. 1. Not a TRUE emergency in most cases, but needs rapid evaluation for underlying diagnosis and treatment. Empiric steroids should not be given, as underlying lymphoma diagnosis can become very difficult. 2. Most common causes are lung cancer, lymphoma, catheter related. 3. Prognosis of lung cancer with SVC syndrome is poor, generally less than six month survival. 4. SVC stent should be considered in appropriate cases. Anticoagulation should be done carefully if at all, or only antiplatelet agents. Not all patients require anticoagulation, such as those with only external compression, but not thrombosis.

What is the next oncologic emergency?

Ans: We have covered most essential oncology specific emergencies. Let us shift gears now from very fast lane of emergency to the slow lane of PALLIATIVE CARE OR SUPPORTIVE CARE OR HOSPICE CARE.

This is another extremely important part of oncology. We discussed in last part also that SVC syndrome patients should be considered for palliative care. Palliative care is something delivered not only by oncologist but also by patient’s family doctor, physician, surgeon, pediatrician, gynecologist etc. More often in India, these are the doctors caring for advance oncology patients, rather than oncologist. In fact, most patients then stop going to oncologist. Common words used in Gujarat at advance cancer stage are “seva karo”. When an oncologist or patient’s doctor says “seva karo”, usual interpretation is nothing more can be done for this patient. And most people take it as an indication that now there will be only “suffering” for remaining time. A lot of such misconceptions exist about Palliative care, among society as a whole and doctors as well.

Our goal in this series is to discuss mainly following:

  1. Clarify what is palliative care and who can deliver it
  2. Main areas covered in palliative care, and when to start
  3. Benefits like improvement in survival, quality of life, cost reduction, family’s quality of life
  4. Myths related to palliative care, morphine
  5. Specific symptom management

Que: Thank you. Yes this is very important. In my practice too, I have dealt with lot of cancer patients. These are families I have been caring for many years, decades and now one of them has a cancer. They come to me for various symptoms, more often when they are in advance stages and they have stopped going to oncologist. And I find it very difficult to handle these issues. Not just their symptoms but even psychologically. With some of them even financially exhausted. I think this topic is very relevant, probably most important so far for us.

Ans: We have touched upon Palliative care multiple times throughout our series, mentioning its importance. But now we will go in more detail, especially with regard to what you can do. Many conceptual quotes or FAQs are directly taken from PalliumIndia.org. Apart from that NCCN palliative care guidelines and various other sources, coupled with my own experience of treating cancer patients since 1999. We have learned a lot since we started Karunalay, cancer palliative care center, for over 8 years. This center as you well know, provides FREE palliative care to all patients.

Que: First of all then, what is palliative care and for which patients?

Ans: At Karunalay, our statement is “we add life to days” (weeks, months, years).  Goal is primarily to improve quality of life, not extend life. In traditional sense, palliative care has been applied to patients with very advance stages of cancer, when specific anticancer therapies are no longer possible. Basically for a patient who has now few weeks or days to live. This concept is more appropriately now called HOSPICE CARE. Palliative care is a much bigger umbrella, however, which includes Care of patients from diagnosis to end. Even when active anticancer therapies are ongoing, patients do have need for symptom relief, such as pain, cough, psychosocial distress…There is no need to wait till last few weeks to provide proper relief. Cancer patients have many important issues affecting quality of life: Cancer related symptoms; Psychological issues like anxiety, depression; Social concerns related to family, stigma; Spiritual concerns like Why me, what did I do to deserve this, what will happen to me after death; Financial. These issues need to be addressed from the time of diagnosis. This is a very important understanding. Hence palliative care training is now required part of curriculum in medical colleges and oncology training programs, in Western countries.

September 12th 2020.  Dr Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. drchiragashah@gmail.com

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