Palliative Care PART – 2
(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Last time we switched gears from fast lane of oncologic emergencies to slow lane of Palliative Care. 1. Palliative care is a wide umbrella dealing with several aspects that affect patient’s life as a whole. Starting from diagnosis to cure, or diagnosis to death. It also covers patient issues even after cure, such as lymphedema in breast cancer, eating or speech issues in oral cancer, anxiety related to risk of relapse, fatigue or painful neuropathy….2. HOSPICE care is what we traditionally think of limited to last few months of life.
Amazing! It also covers people who are cured! See I always thought that it is only for advance cancer patients, and it has only a gloomy side, so to say.
Ans: Well, I am glad now you think differently. Yes, patients have symptoms and other issues from diagnosis. And they do not end with cure or end of treatment. Yes their needs may seem less acute, but nevertheless they are there. It is not that all this knowledge is very new. You have been delivering palliative care all throughout your practice. When you provide symptom relief, psychological support and encouragement to patient and family, guide them when to stop chemotherapy, counsel family after patient’s death, help patient get back to routine life after treatment is over, when you make a home visit for a dying patient…
All doctors, healthcare workers, family members have done this and continue to do.
Then what is the need for a separate branch?
Palliative care as a separate branch helps us understand these needs better, and find specific solutions. Many aspects of this care are not addressed by doctors, or only partially addressed: due to lack of expertise, or time. Following is a very small list of such aspects.
- Morphine for pain
- Psycho oncology issues
- Wound dressing – large fungating tumors, sometimes with maggots
- Disabilities like speech, swallowing, amputation related…
- What to expect in last days or hours of life and how to handle
Que: So true. Yes we have done a lot of palliative care. But not in same detail. And yes, we have hardly addressed their issues like spiritual concerns or even realized that patients have such concerns. Another big one is sexual dysfunction in cancer patients undergoing treatment, and even after treatment. I am not trained at all to handle these issues. I realized this sexual dysfunction issue when I recently came across your article on this subject online. “sexual dysfunction in breast cancer patients” as part of October Breast Cancer Awareness month.
Ans: I am glad you realize that scope of palliative care is very wide, and need is very important. And that is why we need this as a separate branch. However we don’t expect every doctor to become expert in all aspects. But same as our training in other branches. For example, we are trained to treat basic trauma, identify serious signs, diagnose heart attack, when to treat and when to refer in many other diseases. Same level of knowledge and attitude is required for palliative care. Many aspects can be treated by you. But many need to be diagnosed and referred, for example, sexual dysfunction as you mentioned or severe pain not manageable at your level. Who do you refer to is what you should know. You need to consider possibilities of certain issues, such as anxiety depression. Some of them need your reassurance only. But some need medicines and a counselor. Some issues can be brought out only by a counselor or a social worker.
Que: Very true. Our training is very little or none in these issues. Most acute need for me is good pain control for my patients. How can you help?
Ans: About 50% of newly diagnosed cancer patients, and about 90% of advance cancer patients have pain. All of them don’t need opiods like morphine. But many do.
Undertreatment of pain is very common unfortunately. Many patients do not complete treatment or come for timely treatment due to this, further compromising their chances of cure. Persistent pain leads to inadequate sleep, poor food intake, poor social interaction and other effects.
WHO has given concept of “Analgesic Ladder” since 1980s. Stepwise approach, from mild to severe pain. Start with non opioids such as paracetamol, aspirin, NSAIDs (ibuprofen, diclofenac..). Proper doses of these medicines can provide substantial relief in early cases. For example, paracetamol can be given up to 3 g per day in most cases. We will talk more about other medicines, combinations next time. And role of adjuvant medicines for pain control.
October 12th 2020. Dr Chirag A. Shah; M.D. ncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. firstname.lastname@example.org