Palliative Care PART – 12
(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Last time we covered many aspects of wound care. 1. Wounds in oral region. Importance of nasogastric tube in case of orocutaneous fistula. 2. How to reduce cost. 3. How to manage at home. 4. Maggots in wound. 5. Foul Smell – how to manage. 6. Bleeding wounds. 7. Minimize antibiotics. 8. Minimize pain during dressing.
This was a very practical discussion, giving many specific tips on how to manage cancer related wounds. Additionally, thank you for your offer for guidance by Karunalay Palliative Care team at 07926754002; 917405044001. Also interested readers can read the handbook by IAPC (Indian Palliative Care Association). Readers please feel free to contact Karunalay team, or Dr Chirag for any guidance on palliative care. Also, if you need guidance for setting up a center in your town or village, to provide palliative care. Training one of your staff is also a good start, even without a formal palliative care center. For example, if you are working in an area where you see a fair number of advance cancer patients, even if once or twice a week, but you would like to improve their quality of life. Then you can work with Karunalay or GCRI to gain some knowledge. Formal training of various durations is available at GCRI, under guidance of Dr Geetaben Joshi, Dr Pritiben. If someone would like informal exposure and tips, they can also come to Karunalay. All medical colleges, trust hospitals should have at least one or two staff with some training or exposure in field of palliative care. Remember palliative care applies to all cancer patients, not just end of life care.
Ans: Thank you for specifying the last line. That reminds me of some symptoms faced by cancer patients during active treatment or early after treatment. These include nausea, vomiting, diarrhea, Cancer Related Fatigue, weight loss, loss of appetite, constipation, sleep disturbances. These symptoms are fairly common and may go on for few weeks to several months after completion of cancer treatment. At this time, patients are not visiting their oncologist frequently. We will briefly touch upon these symptoms. Some of these points are from NCCN.
- Nausea. Mild to moderate nausea is fairly common. Vomiting is now fairly uncommon, at least in our practice, with new antiemetics. Such as use of aprepitant or intravenous fosaprepitant, palonosetron. If your patient is having significant vomiting after chemotherapy, make sure they are getting these medicines. Additionally, dexamethasone, olanzapine, metoclopramide can be added. Palonosetron is newer much more potent drug compared with ondansetron. Some patients have nausea related to acid peptic disease. They need liberal use of drugs like PPI (for example esomeprazole, pantoprazole), sucralfate, ranitidine, other antacids. Dietary modifications are also useful. Such as avoiding spicy foods, fried foods. In addition, a lot of home remedies may help. If nausea is persistent, long after treatment is over, it may be important to rule out other causes directly related to cancer or some complication. Or some drug related nausea.
A number of patients on chemotherapy have nausea related to Heightened Sense of Smell, known as Dysguesia. For this cause, most important tip is avoiding foods with strong smell i.e. cooked foods. Most cooked foods in our culture such as Roti, Vegetables, Dal have strong smell due to spices that we add or the way they are cooked. This smell is sufficient for these patients to develop nausea, and end up not eating at all or poor food intake. Even to maintain their nutrition status, it is important to advice them not to worry about eating only cooked food. They can eat properly washed fruits, salads, fruit juice; dry fruits; dry snacks such as puffed rice (mamra), biscuits, chocolates, khakhra etc; milk products like milk (hot milk may have strong smell effects. Cold preferred in such a case), curd (with added sugar, honey if required for taste and extra calories), buttermilk, milkshake, ice cream. Joining family members eating cooked food may also be enough for many patients to have strong nausea. This is not the time to focus too much on healthy food habits. Loss of weight, weakness from poor intake can lead to treatment delays and more side effects. Hence chocolates, ice creams, biscuits are allowed if patient cannot eat other things.
- Loss of appetite, weight loss: see guidance as above. In addition, a low dose of dexamethasone can be tried for few days. This should be done in consultation with oncologist preferably, if ongoing cancer treatment. Make sure to rule out issues like thyroid dysfunction; swallowing issues especially mechanical or due to dry mouth or mucositis; infections like oral candidiasis or anerobic infection; pancreatic enzyme deficiency in patients with surgery of pancreas. Some patients need nasogastric tube. Silicone tubes are more comfortable. There may be psychological issues like depression requiring initiation of an antidepressant.
- Fatigue: cancer related fatigue is a very peculiar symptom, unlike regular tiredness. This fatigue may not improve even after rest, may come suddenly. Patients may continue to have fatigue many months or even years after treatment. Medicines have practically no role in this fatigue. This is not depression! Proven treatments are exercise, Yoga, Meditation, Physiotherapy etc physical measures. One of the first randomized controlled trial in USA and in the world, for Cancer Related Fatigue that proved Yoga works was initiated by me in year 2000. NCCN and other guidelines today recommend Yoga as category 1 intervention. Patients and family members need to understand this entity, limit activity and prioritize according to capacity.
October 15, 2021 Dr Chirag A. Shah; M.D. Oncology/Hematology (USA), 9998084001. Diplomate American Board of Oncology and Hematology. Ahmedabad. firstname.lastname@example.org