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Palliative Care An introduction


The relief of suffering and the cure of disease must be seen as twin obligations ... and adjuvant drugs in accordance with the World Health Organisation's guidelines. ... – PowerPoint PPT presentation

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Title: Palliative Care An introduction

Palliative Care An introduction
  • Dr Suresh Kumar
  • Director
  • Institute of Palliative Medicine
  • Kerala, India

The Nature of Suffering and the Goals of Medicine
- Eric J. Cassell
  • 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 (though technically adequate)
    not only fails to relieve suffering but becomes a
    source of suffering itself.

Most people with chronic diseases live and die
  • Over 30 million people suffer unnecessarily from
    severe pain and other symptoms each year. So
    much is known in the management of these
    symptoms, but unfortunately this knowledge is not
    benefiting most of those in need of it. In spite
    of all the effort over the last two decades, the
    great majority of individuals with incurable
    diseases that need care are not getting it
  • -Stjernsward J and Clark D Palliative
    Medicine-a Global Perspective in Oxford Textbook
    of Palliative Medicine, 3rd Edition Eds. Doyle D,
    Hanks G et al Oxford University Press,
    Oxford.2004 Chapter21, 20

Symptoms at the End of Life
  • Pain 67
  • Trouble breathing 49
  • Nausea and vomiting 27
  • Sleeplessness 36
  • Confusion 38
  • Depression 36
  • Loss of appetite 38
  • Constipation 32
  • Bedsores 14
  • Incontinence 33
  • Seale and Cartwright, 1994

Palliative Care
  • The active total care of patients whose disease
    is not responsive to curative treatment. Control
    of pain, of other symptoms, and of psychological,
    social, and spiritual problems, is paramount.
    The goal of palliative care is achievement of
    the best quality of life for patients and
  • (WHO, 1990)

Goals of care
  • What are the potential goals of medical

Potential Goals of Care
  • Cure of disease
  • Avoidance of premature death
  • Maintenance or improvement in function
  • Prolong life
  • Relief of suffering
  • Quality of life
  • Staying in control
  • A good death
  • Support for families and loved ones

Historically, a dichotomous division of goals of
  • Focus on curing illness
  • Little attention to relief of suffering, care of
  • Palliative care arose in response to this need

Multiple goals of care
  • Multiple goals often apply simultaneously
  • Goals are often contradictory
  • Certain goals may take priority over others

Goals May Change when the disease becomes
  • Some goals may take priority over others
  • The shift in the focus of care
  • is gradual
  • is an expected part of the continuum of medical
  • Review goals with any change in
  • health/functional status (e.g. advancing illness)
  • setting of care
  • treatment preferences

Prognosis Can Be Difficult to PredictChronic
Progressive Illness Actively
Sudden death, unexpected cause
  • lt 10, MI, accident, etc

Health Status
Protracted life-threatening illness
  • gt 90
  • predictable steady decline with a relatively
    short terminal phase
  • cancer
  • slow decline punctuated by periodic crises
  • CHF, emphysema, Alzheimers-type dementia

Steady decline, short terminal phase
Slow decline, periodic crises, sudden death
Palliative Care
  • Interdisciplinary care that aims to relieve
    suffering and improve quality of life for
    patients with advanced illness and their
  • It is offered simultaneously with all other
    appropriate medical treatment.

Palliative Care
  • Relief from symptoms
  • Emotional support
  • Social support
  • The approach and skills relevant in the
    management of all diseases, curable or incurable

What Do Patients with Serious Illnesses Want?
  • Pain and symptom control
  • Avoid inappropriate prolongation of the dying
  • Achieve a sense of control
  • Relieve burdens on family
  • Strengthen relationships with loved ones

Singer et al. JAMA 1999281(2)163-168.
What Do Family Caregivers Want?
  • Study of 475 family members 1-2 years after
  • Loved ones wishes honored
  • Inclusion in decision processes
  • Support/assistance at home
  • Practical help (transportation, medicines,
  • Personal care needs (bathing, feeding, toileting)
  • Honest information
  • 24/7 access
  • To be listened to
  • Privacy
  • To be remembered and contacted after the death
  • Tolle et al. Oregon report card.1999

Palliative Care...
  • Focuses on relieving suffering, improving quality
    of life
  • affirms life, sees death as a personal and
    natural process
  • many diagnoses
  • appropriate early in course of illness
  • patient and family preferences respected
  • may be combined with curative therapies or may be
    the focus of care

...Palliative Care
  • Interdisciplinary care of the patient and family
  • Pain and symptom management
  • May include disease-modifying treatments
  • Psychological, social, spiritual support
  • Bereavement support

Benefits of Palliative Care The Evidence Base
  • Reduction in symptom burden
  • Improved patient and family satisfaction
  • Reduced costs

Global need for Palliative Care
  • All figures in million
  • Annual Deaths globally 58
  • Developing countries 45
  • Developed countries 13
  • Projected rise- in 2015 64
  • in 2030 74
  • Cancer burden- new cases/year-
  • in 2003 10
  • in 2020 16
  • in 2050 24
  • Elderly aged 60 and above
  • in 2000 600
  • in 2025 1200
  • in 2050 2000
  • AIDS -mortality projections-
  • in 2003 3
  • in 2015 4
  • in 2030 6

Communicable and non communicable Diseases
  • What will be the common diseases of the
    twenty-first century? As a group, the
    non-communicable diseases (cancer,
    cardiovascular, diabetes) will increase from 27
    to 43 per cent of the global burden of diseases
    by 2020, while communicable diseases (infections
    and tropical and parasitic diseases) will
    decrease from 50 to 22 per cent.
  • Sepúlveda, C., Marlin, A., Yoshida, T., and
    Ullrich, A. (2002). Palliative care the World
    Health Organizations global perspective. Journal
    of Pain and Symptom Management 24 (2), 916.

Non Communicable Diseases in resource poor
  • Only 20 of chronic disease deaths occur in high
    income countries
  • 80 occur in low and middle income countries
  • The age-specific death rates from
    non-communicable diseases are higher in
    developing than developed countries.
  • (Preventing chronic diseases a vital investment
    WHO global report. World Health Organization
    Geneva 2005)

Cancer Care (National Cancer Control Programs
Policies and Managerial Guidelines. World Health
  • Roughly 80-90 of pain due to cancer can be
    relieved relatively simply with oral analgesics
    and adjuvant drugs in accordance with the World
    Health Organisation's guidelines. The remaining
    10-20 can be difficult to treat.

Meaningful Palliative Care
  • Meaningful palliative care requires a
    combination of socio-economic, cultural, and
    medical solutions. All three must be addressed.
    Not purely a medical issue, the cultural and
    socioeconomic factors determine what kind of
    death we face. Todays overemphasis on medical
    approaches can be balanced only by the people
    taking ownership Dr Jan Stjernsward

The challenge
  • The challenge before physicians anywhere in
    the world is to find a way to assure continuous
    and meaningful care to most of those who need it
  • How successful are we in meeting this challenge?

A proposed system of care for chronically and
incurably ill patients
  • Specialists have a definite but small role
  • Primary care physician in the periphery to be
  • Massive involvement from the local community

Thank you!!