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Palliative Medicine

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Title: Palliative Medicine


1
Palliative Medicine
  • Dealing with life limiting illnesses
  • Hasala Buddhika Peiris
  • MBBS, MD (Medicine),
  • Dip. Palliative Medicine (RACP-
    Aust)

2
Objectives
  • Goals of Medical Care
  • Patient with life limiting illness
  • Development of Palliative Medicine
  • How Palliative Care can help
  • The Nature of Pain and Suffering
  • Pain control strategies
  • Value of opioids in Mod to Severe pain
  • Terminal care
  • Global situation of Palliative Care
  • Sri Lankan situation.

3
  • Curative medical treatment is clearly a blessing
    and we are fortunate to live in a time when many
    illnesses are treatable and curable.
  • There comes a time, however, when the end of life
    is inevitable. No cure is possible, no
    prolongation of life is appropriate beyond the
    days the body can sustain life on its own.
  • Death is not a failure of modern medicine but as
    inevitable as ever it was. "And one day, I too
    shall face death and not as a stranger."

4
When we are young, we think we are immortal or at
least death is remote. As we grow older, we
realize that this is a fantasy. When we are
diagnosed with a life-limiting illness, our
mortality becomes very clear. At that point,
the greatest need is to end the life in dignity
and with freedom of pain.
5
Potential Goals of Care
  1. Cure of disease
  2. Prolong life
  3. Avoidance of premature death
  4. Relief of suffering
  5. Quality of life
  1. Maintenance or improvement in function
  2. Staying in control
  3. A good death
  4. Support for families and loved ones

6
Goals May Change when a life limiting illness is
diagnosed
  • Some goals may become unrealistic
  • Some goals may take priority over others
  • Goals need to be reviewed with changes in
    patients condition

7
  • However everyone deserves to live
  • their life with quality, no matter how
  • long or short it may be, to the full.

8
Common needs and preferences of people with
life-limiting illnesses
  • freedom from pain
  • control of other symptoms
  • access to appropriate care regardless of where
    they live
  • options for care, both now and in the future
  • Free access to their family members, cares and
    loved ones
  • access to people in charge of their care who can
    answer their questions
  • support to discuss their concerns and feelings
  • dignity and respect for culture, lifestyles and
    beliefs.

9
Questions to the doctor
  • What do you think is my prognosis?
  • What choices are there to manage my pain and
    other symptoms?
  • What level of symptom management can I expect to
    receive?
  • What types of care, conventional or alternative,
    would improve the quality of the time I have
    left?
  • If I get help from palliative care team, how will
    that affect my relationship with my current
    doctors and treatment team?
  • Will I be able to afford the care you suggest?
  • What kind of support is there for my family, both
    until I die and afterwards?

10
  • Palliative Medicine was developed after it was
  • recognised that the care provided to people with
  • life-limiting illnesses in institutions, such as
    hospitals,
  • was not focused to the needs of this population
    thus not satisfactory.

11
What is Palliative Medicine
  • Palliative care is a specialised area of health
    care that's been developed to respond to the
    experiences, preferences and care requirements
    for people with life-limiting illnesses.

12
Definition of Palliative Medicine
  • There are a number of palliative care
    definitions. The World Health Organization (WHO)
    has the most well-known definition. It describes
    palliative care as
  • '... an approach that improves quality of life of
    patients and their families facing problems
    associated with life-threatening illness, through
    the prevention of suffering by means of early
    identification and impeccable assessment and
    treatment of pain and other problems, physical,
    psychological and spiritual.'

13
History of Palliative Medicine
  • Palliative care is linked synonymously with the
    hospice, because historically this is where it
    began.
  • The word "hospice" comes from the Latin word
    hospes meaning to host a guest or stranger.
  • In Medieval times, weary travelers found places
    of refuge in monasteries and nunneries. Often
    they were in ill health and many spent their last
    days cared for, by the monks and nuns and lay
    women.

14
  • Care of dying patients was done by Jeanne Garnier
    who founded the Dames de Calaire in Lyon, France,
    in 1842.
  • Irish Sisters of Charity also carried out this
    when they opened Our Lady's Hospice in Dublin in
    1879 and St Joseph's Hospice in Hackney,
    London(1905).

15
Modern Palliative Care
  • Dr Dame Cicely Saunders, a British Physician was
    the founder of concepts of modern Palliative
    Medicine after being inspired by a patient, David
    Tasma, whom she met in 1948. David Tasma was
    hospitalised with an inoperable cancer, requested
    words of comfort and acts of kindness and
    friendship at the end of his life.
  • The two had discussed how she might one day open
    a place that was better suited to pain control
    and preparing for death than a busy hospital
    ward. When he died, he bequeathed 500 and told
    Saunders, "I will be a window in your home,
  • In 1967 Dr Saunders started St. Christopher's
    Hospice in London to provide specialized care for
    dying patients.

16
  • Dr. Saunders came to believe and to teach, "We do
    not have to cure to heal.
  • In 1964, she began teaching at Yale University
    about holistic hospice care and how it enhances
    the quality of life of terminally ill patients.
  • Since then her ideals have spread around the
    world, which gave her the reputation of being the
    founder of the modern Palliative Care.

17
  • Several years later, Dr. Elisabeth Kubler-Ross
    published her best-selling book "On Death and
    Dying."
  • Based on interviews with dying patients, she
    identified five stages of grief - denial, anger,
    depression, bargaining and acceptance.
  • The book took death out of secrecy and into
    public awareness and discussion for the first
    time.
  • "It has brought death out of the darkness." -
    Time Magazine

18
Pioneers work
  • They explored ways to improve the process of
    dying and shed light on the needs of patients
    during this important passage. Most importantly
    they brought awareness to the importance of
    patients as individual, unique human beings with
    individual needs and rights deserving of respect.

19
  • Today, Palliative care is not confined to end of
    life care but has grown to become a philosophy of
    care for the patient with a life-limiting
    illness.
  • This includes cancer patients as well as many
    other non oncological conditions in other
    specialties.
  • However the purpose remains the same - to find
    relief from pain and suffering, to be cared for
    and to gather courage to face the remaining days
    of their journey together with loved ones.

20
Development of Palliative Medicine

CARE FOR THE DYING
HOSPICE CARE (last 6 months)
PALLIATIVE CARE for cancer
PALLIATIVE CARE For many life-limiting illnesses
21
Who benefits from Palliative Medicine
  • Palliative care is provided to people, who have
    life-limiting illnesses, regardless of age.
  • cancer
  • Motor Neurone Disease
  • Muscular Dystrophy
  • end-stage dementia
  • end-stage respiratory disease
  • end-stage cardiac disease
  • end-stage liver disease
  • HIV/AIDS
  • degenerative conditions or significant
    deterioration related to ageing.

22
Broads Categories of Life Limiting illnesses
  • Conditions where potentially curative treatment
    has failed (eg. Malignancy)
  • Conditions where intensive treatment may prolong
    life but premature death occurs (eg. HIV/AIDS)
  • Progressive conditions where treatment is
    exclusively palliative (eg Muscular Dystrophy)
  • Non-progressive neurological conditions which
    result in an increased susceptibility to
    complications and premature death (eg. Cerebral
    palsy)

23
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24
Key features of Palliative Care
  • Provides relief from pain and other distressing
    symptoms
  • Patient centred
  • Consider the patient as a whole
  • Integrates psychological and spiritual aspects
  • Affirms life and regards death as a normal
    process
  • Neither hasten or postpone death.
  • Supports the patient and the family.
  • Positively influence the course of illness.
  • Enhance quality of life.

25
Who are involved in giving palliative care
  • people with life-limiting illnesses may have
    complex and multifaceted needs.
  • These needs will often be met most effectively by
    health care professionals across different
    disciplines operating as an interdisciplinary team

26
Some health care professionals who are involved
in the provision of palliative care
  • Palliative Medicine Specialist medical staff
  • Palliative care nurses ward staff
  • Physiotherapists, Occupational therapist,
    Diversional therapists,
  • Social workers community workers
  • Volunteers help groups

27
Where can you provide palliative care
  • Hospital
  • Hospice
  • Home
  • These components of Palliative Care can be
    developed in different ways, appropriate to the
    needs of patient and family and according to the
    available resources - inpatient care, hospice
    care, day care and home care.

28
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29
When to seek help from palliative care
  • With an exacerbation pain / symptoms
  • At the terminal stage
  • Pall care team may take over the patient when
    other therapies are completed or exhausted
  • Early in the illness with conjunction with other
    therapies

30
What is the best time
  • Early in the illness in conjunction with other
    therapies - Many benefits
  • This establishes continuum of care.
  • Provides time for the Pall care physician to
    build a rapport with the patient.
  • Avoids the feeling of treatment failure as the
    cause of pall care referral.
  • Avoids the feeling of signaling terminal stage
  • Easy to understand and control symptoms.
  • Easy to titrate medications. Ect. Ect.

31
Curative vs. Palliative Model of Care
32
Life limiting Illness
Actively Dying
Prognosis Can Be Difficult to Predict and
level of suffreing can fluctuate
33
Continuum of Care Model
B
D
E
Curative
Curative Intent
R
Care
E
E
A
A
V
E
M
T
Palliative
E
Care
N
H
T
Disease Progression
34
  • Transition from curative to palliative care
    should not be abrupt.
  • The shift in the focus of care
  • is gradual
  • is an expected part of the continuum of medical
    care

35
The Nature of Suffering and the Goals of Medicine
  • The relief of suffering and the cure of disease
    must be seen as twin obligations of a medical
    profession that is truly dedicated to the care of
    the sick.
  • Physicians failure to understand the nature of
    suffering can result in medical intervention that
    not only fails to relieve suffering but becomes a
    source of suffering itself. -Eric J.
    Cassell

36
Symptoms associated with life limiting illness
Cancer vs. Other Causes of Death
  • Cancer Other
  • Pain 84 67
  • Trouble breathing 47 49
  • Nausea and vomiting 51 27
  • Sleeplessness 51 36
  • Confusion 33 38
  • Depression 38 36
  • Loss of appetite 71 38
  • Constipation 47 32
  • Bedsores 28 14
  • Incontinence 37 33
  • Seale and Cartwright, 1994

37
Suffering Paradigm
  • Physical
  • Emotional
  • Social
  • Spiritual

Suffering
38
Physical Suffering
  • Pain
  • multiple non-pain symptoms
  • Disfigurement.
  • Incapacity and loss of function.

39
Emotional Suffering
  • Depression
  • Anxiety
  • Delirium
  • Loneliness

40
Social Suffering
  • Social Isolation
  • Limited Income
  • Lack of family support
  • Inadequate Housing / Facilities
  • Caregiver Fatigue

41
Spiritual Suffering
  • Loss of hope
  • Inability to sustain relations with faith and
    community
  • Search for meaning

42
The importance of relieving from pain suffering
  • We all must die. But that I can save him from
    days of torture, that is what I feel is my great
    and ever new privilege. Pain is a more terrible
    load of mankind than death itself. Albert
    Schweitzer, MD, physician, humanitarian,
    theologian (1)
  • As physicians, we understand that we cannot cure
    every patient we see. At best, we delay
    inevitable mortality. The relief of pain and
    suffering, however, is always within our
    capabilities
  • Death is going to occur, but pain does not have
    to.

43
Broad areas of palliative medicine
  • Pain assessment and management.
  • Opioids and other analgesics
  • Management of other symptoms
  • Dyspnoea, cough, haemoptasis
  • Stomatitis, Constipation, Diarrhoea,
  • Abdominal distension,
  • Bladder spasms, haematuria
  • severe headache, seizures, confusion

44
  • Muscle spasms
  • Fungating wounds
  • Mouth care, Bowel care,
  • Skin care, bladder care
  • Effective communication
  • Psychological issues
  • Social problems
  • Spiritual concerns
  • Terminal care
  • Dealing with relations and loved ones

45
ASSESSMENT of PAIN
  • Believe the patients complaint
  • Take a careful history
  • Perform a thorough medical and neurological
    examination
  • Assess the psychosocial status of the patient
  • Treat the pain while doing the diagnostic work-up
  • Personally review any diagnostic investigations
  • Score the pain using pain measurement scales

46
SCORING THE PAIN
  • NUMERICAL SCALE

0
10
No pain
Worst pain imaginable
47
  • CLASSIFICATION OF PAIN
  • Pain is considered
  • Acute
  • Chronic
  • Cancer related

48
Pain Types
  • Central vs Peripheral pain
  • Somatic vs Visceral pain
  • Nociceptive vs Neuropathic pain

49
Nociceptive Pain
  • Predominantly C-fibres or A-delta fibres with
    poorly differentiated terminals
  • Normally activated by potentially dangerous or
    damaging stimuli -noxious stimuli that maybe
    mechanical, chemical or thermal

50
Neuropathic Pain
  • Nerve injury causes changes in the sensory neuron
  • Ectopic action potential discharge
  • Hyperexcitability, spontaneous C firing
  • Patients with neuropathic pain exhibit both
    paroxysmal pain, in the absence of a stimulus and
    pain hypersensitivity to a stimulus
  • Shooting, burning or lancinating

51
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52
THERAPEUTIC STRATEGY
  • DRUG THERAPY
  • NON-DRUG THERAPY
  • BEHAVIOURAL

53
DRUG THERAPY
  • THE RIGHT DRUG
  • THE RIGHT DOSE
  • THE RIGHT TIME
  • THE RIGHT ROUTE

54
THE RIGHT DRUG
  • THE THREE STEP LADDER

Step 3 Severe pain
Strong Opioid Non-Opioid Adjuvant
Pain persisting or increasing
Weak Opioid Non-Opioid Adjuvant
Step 2 Moderate pain
Pain persisting or increasing
Non-Opioid Adjuvant
Step 1 Mild pain
55
THE RIGHT DOSE
  • Drugs on step one and two of the ladder (I.e. non
    opioids and weak opioids) have maximum doses
  • Morphine has no maximum dose
  • The correct dose of morphine is the dose that
    relieves the pain

56
THE RIGHT TIME
  • Never prescribe PRN (as required)
  • Usually given four hourly
  • Always prescribe a break-through dose

Drug conc in blood
PAIN RELIEF
PAIN
12
0
6
2
4
8
10
12
0
6
2
4
8
10
hours
57
THE RIGHT ROUTE
  • Administer orally when possible
  • Subcutaneous route very valuable either with
    syringe driver or with a butterfly needle
  • Rectal
  • Sublingual
  • Transdermal
  • Intravenous

58
SUMMARY OF DRUG THERAPY
  • BY THE MOUTH
  • BY THE CLOCK
  • BY THE LADDER

THE RIGHT DRUG
THE RIGHT TIME
THE RIGHT DOSE
THE RIGHT ROUTE
59
MYTHS ABOUT MORPHINE
  • Addiction
  • Respiratory depression
  • Too soon to start
  • A maximum dose
  • Drowsiness

60
Misconception 1 Opioids are highly addictive
  • Opioids are rarely addictive in the setting
    of life-limiting illness
  • Substantial information in the literature
    backs up this.
  • In 1980 on a prospective study Porter and Jick
    reported only four cases of addictive behavior
    were found among 12,000 hospitalized patients who
    received at least one opioid preparation for
    moderate to severe pain.
  • In 1992, Schug et al reported only one case
    of addiction among 550 cancer patients who
    experienced pain and were treated with morphine
    for a total of 22,525 treatment days

61
Misconception 2 Physical dependence on opioids
is the same as addiction
  • Dependence on opioids occurs and is a
    physiological neuroadaptation.
  • Narcotics for any length of time for chronic pain
    cause dependence, abrupt withdrawal may lead to a
    withdrawal syndrome. This does not mean addiction
    but only that the patient is dependent, just as
    patients may become dependent on other
    pharmacologic agents.
  • An increase in morphine dosage is usually due to
    the progression of disease, not dependence.
  • Schug et al showed 550 cancer patients
    treated with morphine for 22,525 treatment days,
    had no practical problems due to physical
    dependence .

62
Misconception 3 Tolerance is related to
dependence or addiction
  • Tolerance - exposure to a drug resulting in a
    diminution of its effects over time
  • should suspect disease progression.
  • may be related to either side effects, impaired
    efficacy of the drug or altered metabolism.
  • True tolerance can occur but usually not
    clinically significant with chronic dosing.

63
Misconception 4 Respiratory depression is
common
  • respiratory depression with opioids in the
    setting of life-limiting illness is rare. (Bruera
    and MacEachern)
  • Slowing of respiratory rate may be due to pain
    relief.
  • If respiratory arrest were to occur, it would
    normally be preceded by other features of opioid
    toxicity (Drowsiness, confusion, muscle
    twitching) and would be a gradual development.
  • If the respiratory rate drops to less than 6 or 8
    breaths per minute, clinicians may consider
    holding the opioid dose and seeing if the effect
    wears off. In patients with life-limiting
    terminal illness, naloxone use should be rare. If
    it is used, the effect should only be partially
    reversed.
  • opioids are safe and effective for the treatment
    of dyspnea or pain in patients with chronic
    obstructive pulmonary disease and heart failure
    (Jennings et al).

64
Misconception 5 Opioids have a narrow
therapeutic range
  • Opioids actually have a very broad therapeutic
    range.
  • In fact, opioids are the safest and most
    effective pain medicine for most moderate to
    severe pains. (in both non-terminal and terminal
    diseases).
  • They are much safer than NSAIDS.
  • Unlike other pain relievers, opioids do not
    appear to have a ceiling effect.

65
Misconception 6 Opioids are ineffective by mouth
and cause too much nausea
  • In fact, opioids are very effective orally.
  • However as they undergo first-pass metabolism in
    the liver, dosages will often need to be adjusted
    between parenteral and oral.
  • Nausea can be a problem but many patients develop
    a tolerance to it. If this prevents a patient
    from using opioids, an antinauseant along with
    the opioid can help.

66
Common errors in opioid prescribing
  • Failure to accurately assess the pain.
  • if we do not assess the problem correctly, we
    are not likely to treat the problem effectively.
  • Errors in dosage and timing.
  • too small dose, too great dosing interval,
    unnecessary complexity.
  • Errors in opioid conversion calculations.
  • Failure to recognize and treat side effects /
    toxicity. Odering a laxative and an
    antinauseant.
  • Inadequate use of adjuvants.
  • adjuvants may have an opioid-sparing effect.
    NSAIDS, Steroids and anti-neuropathic agents.

67
Adjuvant Drugs
  • Steroids
  • NSAIDS
  • TCA- Amitriptyline
  • Anti-convulsants Carbamazipine
  • NMDA-receptor channel blocker

68
NON-DRUG THERAPY
  • Radiation therapy
  • Local anaesthetic blocks
  • Tens (transcutaneous electrical nerve
    stimulation)
  • Trigger point injections
  • Physiotherapy
  • Massage
  • Aromatherapy
  • Reflexology
  • Neurosurgical approaches

69
BEHAVIOURAL TECHNIQUES
  • Psychological support
  • Meditation
  • Relaxation
  • Music or art therapy
  • Religious activities

Individualise According to Patient
70
Relaxation
71
Music Therapy
72
REASSESMENT
A Continuing Necessity
Old pains may get worse and new ones may develop
Review
Review
Review
Review
73
Terminal Care
74


  • The dying process
  • The terminal phase of illness.
  • The body begins to shut down as major organs fail
    to continue functioning.
  • This is usually an orderly and undramatic
    progressive series of physical changes which are
    not medical emergencies requiring invasive
    interventions.
  • Relatives need to know that these physical
    changes are a normal part of the dying process.
  • It is very important that families are well
    supported at this time as this is a very
    emotional and difficult time.

75
  • Restlessness and agitation
  • Generally an increasing in sleeping, - due to
    progressive disease, changes in the bodys
    metabolism, sedation from opioids.
  • Some remain alert and responsive until the moment
    of death. Others may become confused,
    semiconscious and unconscious for several hours
    or days.
  • Restlessness and agitation during the terminal
    phase is not uncommon and may be due to
    increasing pain, hypoxia, nausea, fear and
    anxiety.

76
  • Communication
  • A calm peaceful environment and the presence of
    family will assist in relieving the patient's
    anxiety.
  • Speech may become increasingly difficult to
    understand and words confused. Even though the
    patients may not be able to communicate, they may
    be aware of people around them.
  • Hearing is the last sense to be lost and the
    family should be encouraged to talk to the dying
    patient and touch him so the patient knows that
    he is not alone.

77
family should be encouraged to talk to the dying
patient and touch him
78
  • Food and Drugs
  • Nutrition is not important at this stage, oral
    sips of water if tolerated or making the mouth
    moist is enough.
  • At this stage oral medications may not be
    tolerated and alternative routes of medication
    are essential.
  • Drug charts should be reviewed leaving only
    essential agents for the comfort.
  • Pain relief should be maximised.
  • Noisy / rattly breathing
  • Generally in the terminal phase but also in
    neurodegenerative diseases or where swallowing is
    impaired.
  • Positioning, Anticholinergic drugs
    (Hyosine,Glycoporrolate), explanation to the
    family

79
  • Incontinence
  • Due to relaxation of the muscles of the
    gastrointestinal and urinary tracts resulting in
    incontinence of stool and urine.
  • Use incontinence pads or disposable incontinence
    draw sheets
  • Circulatory changes
  • the heart slows and the heartbeat is irregular,
    circulation of blood is decreased to the
    extremities.
  • Hands, feet and face may be cold, pale and
    cyanotic. may also sweat profusely and feel damp
    to touch.
  • keep them warm with a blanket.
  • Respiratory changes
  • Breathing may be rapid, shallow and irregular.
    Respirations may slow with periods of apnoea -
    Cheyne-Stokes breathing and is common in the last
    hours or days of life.

80
Alive Dead
81
  • Dead
  • Gone



82
  • Death is not a failure of modern medicine but
    as inevitable as ever it was.

83
  • Careful attention to the science and art of pain
    management and comfort is every bit as important
    as cure, for as long as we are mortal, cure of
    the human condition must ultimately fail. Death
    is inevitable suffering is not.
  • "And one day, I too shall face death and not as a
    stranger."

84
  • Sir William Osler stated that the goal of
    physicians is to cure sometimes, to relieve
    often, to comfort always.

85
Benefits of Palliative Medicine
  • Some patients in the terminal phase of illness
    are known to suffer significantly from inadequate
    recognition and treatment of symptoms, aggressive
    attempts at cure, fear and sadness.
  • The trauma experienced by the family from the
    death of their loved one is also profound with
    increased potential for complicated grief
    reactions and impaired long-term adjustment. 
  • The long-term negative effects of grief have been
    powerfully confirmed through recent studies.
  • Effective palliative care provides a direct
    benefit to the patient as well as being an
    important preventive health intervention for the
    family, with long term implications for family
    functioning, mental health, education and
    employment.

86
  • Global Situation of Palliative
  • Medicine and End of Life Care

87
Palliative Care in the western world
  • In UK
  • The modern hospice concept was started in the UK
    after the founding of St Christophers Hospice in
    1967. The hospice movement has grown dramatically
    since then. In the UK in 2005 there were just
    under 1700 hospice services consisting of 220
    inpatient units for adults with 3156 beds, 33
    inpatient units for children with 255 beds, The
    service is always free to patients.
  • In USA
  • 1974 The first hospice legislation was
    introduced to provide federal funds for hospice
    programs. 
  • 1978 A U.S. Department of Health, Education, and
    Welfare task force reports that the hospice
    movement as a concept for the care of the
    terminally ill and their families is a viable
    concept and one which holds out a means of
    providing more humane care for Americans dying of
    terminal illness while possibly reducing costs. 
    As such, it is the proper subject of federal
    support.
  • 1992 Congress passes the Indian Health Care
    Improvement Act of 1992, calling for a hospice
    feasibility study.
  • There has been a dramatic increase in palliative
    care programs, now numbering more than 1200.
  • In Australia
  • Governor-General Her Excellency Ms Quentin Bryce
    AC emphasised the importance of end-of-life care
    In a letter of support for a new Palliative Care
    Australia publication, I see palliative care as
    an assurance to our society, at the deepest
    level, that we are honouring our value for the
    worth and dignity of every human being.

88
Palliative Care in Asia
  •      Palliative Care Network - Global
    International,
  • China , Mongolia , Hong Kong ,
  • Myanmar , India , Indonesia ,
  • Nepal , Japan .
  • Pakistan , Korea , Malaysia ,
  • Philippines
  • Republic of Tajikistan ,
  • Singapore ,
  • Taiwan ,
  • Thailand ,
  • Vietnam ,

 
89
  • About IAPC  The Indian Association of Palliative
    Care was formed in 1994 in consultation with
    World Health Organisation and Govt. of India to
    form a forum for activities aimed at the care of
    people with life limiting illness such as Cancer,
    AIDS and end-stage chronic medical disease. The
    mission of IAPC is to promote affordable and
    quality palliative care across the country
    through networking and support to palliative care
    institutions.

90
Situation in India
  • He was dying of cancer, with lots of tumors on
    his face and scalp, His family asked if I could
    help, and I couldnt I was just a medical
    student with no idea of cancer pain relief. Dr.
    Rajagopal founder of Pallium India clinic in
    Kerala.
  • Today, the same neighbor with the same cancer
    would almost certainly die the same way They
    end up like millions of the worlds poor spending
    their last days writhing in agony, wishing death
    would hurry.
  • Although opium was one of the chief exports of
    British India and the country still produces more
    for the legal morphine industry than any other
    country, few Indians benefit.
  • About 1.6 million Indians endure cancer pain each
    year. Because of tobacco and betel nut chewing,
    India leads the world in mouth and head tumors,
    and has high rates of lung, breast and cervical
    cancer. Tens of thousands also die in pain from
    AIDS, burns or accidents.
  • But only a tiny fraction Dr. Rajagopal
    estimates 0.4 percent get relief.

91
What do we have in Sri Lanka
  • We have a dedicated pain service at CIM run by a
    Consultant Anesthetist over ten years.
  • We have a very active voluntary organization
    Sri Lanka Cance Society since 1948.
  • We have Shantha Sevana Hospice houses over 35
    beds for terminally ill patients.
  • We have a councelling service at CIM.
  • But unfortunately we do not have a Palliative
    Care Service.

92
  • Shantha
    Sevana

  • Hospice
  • 35 bed facility for
  • terminal care

93
What should we do?
  • Improve knowledge about dealing with life
    limiting illnesses.
  • Educate and train staff on care for the dying and
    Palliative Medicine.
  • Increase awareness about pain and suffering
  • Promote appropriate use of pain relief for
    moderate to severe pain.
  • Establish Palliative Care services in major
    health care institutions.

94
  • References
  • 1.
  • Schweitzer A. Campion CT, trans. New York
    Macmillan 1948. On the Edge of the Primeval
    Forest and More from the Primeval Forest
    Experiences and Observations of a Doctor in
    Equatorial Africa.
  • 2.
  • Clark D. Total pain, disciplinary power and the
    body in the work of Cicely Saunders, 19581967.
    Soc Sci Med. 199949(6)727736. 3.
  • Porter J, Jick H. Addiction rare in patients
    treated with narcotics. N Engl J Med.
    1980302(2)123.
  • 4.
  • Kanner RM, Foley KM. Patterns of narcotic drug
    use in a cancer pain clinic. Ann N Y Acad Sci.
    1981362161172. 5.
  • Perry S, Heidrich G. Management of pain during
    debridement a survey of U.S. burn units. Pain.
    198213(3)267280.
  • 6.
  • Schug SA, Zech D, Grond S, Jung H, Meuser T,
    Stobbe B. A long-term survey of morphine in
    cancer pain patients. J Pain Symptom Manage.
    19927(5)259266.
  • 7.
  • Zenz M, Strumpf M, Tryba M. Long-term oral opioid
    therapy in patients with chronic nonmalignant
    pain. J Pain Symptom Manage. 19927(2)6977.
  • Savage SR, Covington EC, Heit HA, Hunt J,
    Joranson DE, Schnoll SH. Definitions Related to
    the Use of Opioids for the Treatment of Pain. A
    Consensus Statement from the American Academy of
    Pain Medicine, the American Pain Society, and the
    American Society of Addiction Medicine Glenview,
    IL, 2001.
  • 9.
  • Bruera E, MacEachern T, Ripamonti C, Hanson J.
    Subcutaneous morphine for dyspnea in cancer
    patients. Ann Intern Med. 1993119(9)906907.
  • 10.
  • Jennings AL, Davies AN, Higgins JP, Gibbs JS,
    Broadley KE. A systematic review of the use of
    opioids in the management of dyspnoea. Thorax.
    200257(11)939944.

95
  • Thank You
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