Palliative care in India: current progress and future needs

Rural-urban disparity in cancer burden and care: findings from an Indian cancer registry

BACKGROUND

Cancer incidence and mortality vary across the globe, with nearly two-thirds of cancer-related deaths occurring in low- and middle-income countries. The rural-urban disparity in socio-demographic, behavioural, and lifestyle-related factors, as well as in access to cancer care, is one of the contributing factors. Population-based cancer registries serve as a measure for understanding the burden of cancer. We aimed to evaluate the rural-urban disparity in cancer burden and care of patients registered by an Indian population-based cancer registry.

METHODS

This study collected data from Varanasi, Uttar Pradesh, India, between 2017 and 2019. Sex and site-specific age-standardised rates for incidence and mortality per 100,000 population were calculated. Rural-urban disparities in cancer incidence and mortality were estimated through rate differences and standardised rate ratios (with 95% confidence intervals). Univariable and multivariable regressions were applied to determine any significant differences in socio-demographic and cancer-related variables according to place of residence (rural/urban). Crude and adjusted odds ratios with 95% confidence intervals were calculated.

RESULTS

6721 cancer patients were registered during the study duration. Urban patients were older and had better literacy and socioeconomic levels, while rural patients had higher odds of having unskilled or semi-skilled professions. Diagnostic and clinical confirmation for cancer was significantly higher in urban patients, while verbal autopsy-based confirmation was higher in rural patients. Rural patients were more likely to receive palliative or alternative systems of medicine, and urban patients had higher chances of treatment completion. Significantly higher incidence and mortality were observed for oral cancer among urban men and for cervical cancer among rural women. Despite the higher incidence of breast cancer in urban women, significantly higher mortality was observed in rural women.

CONCLUSIONS

Low- and middle-income countries are facing dual challenges for cancer control and prevention. Their urban populations experience unhealthy lifestyles, while their rural populations lack healthcare accessibility. The distinctness in cancer burden and pattern calls for a re-evaluation of cancer control strategies that are tailor-made with an understanding of urban-rural disparities. Context-specific interventional programmes targeting risk-factor modifications, cancer awareness, early detection, and accessibility to diagnosis and care are essential.

Oral health in cancer palliative care: cross-sectional study

OBJECTIVES

Patients on anticancer therapy attending palliative care services often have oral health problems, but not enough is known in this regard (in India). This cross-sectional study aimed to elucidate this issue.

METHODS

Participants were 98 patients with metastatic cancer (52 males, 46 females) who attended the palliative care clinic and were assessed by a multidisciplinary team consisting of dental health professionals working alongside the palliative care team, between August 2021 and October 2022. Their demographic and medical details were collected from the charts. Details about oral health were assessed using the National Cancer Institute Common Terminology Criteria for Adverse Events for dysphagia and xerostomia, Dental Caries Decayed, Missing, and Filled Teeth (DMFT) index, and the WHO Mucositis scale. Quality of life was assessed using the European Organisation for Research and Treatment of Cancer Quality of Life Module for Oral Health (EORTC QLQ-OH15).

RESULTS

Patients had an average age of 58 years, with 46.9% having an Eastern Cooperative Oncology Group score of 1, and 61 (64.9%) receiving anticancer treatment along with palliative care. Dental issues were prevalent, with 39.5% classified as DMFT score grade 2. Subgroup analysis showed higher mean DMFT scores in head/neck cancers, particularly in those receiving radiation therapy (2.3) versus without (1.7), and older age (p<0.05).

CONCLUSION

Patients with cancer on anticancer treatment attending a palliative care clinic, especially those with head/neck cancers and older age, had poor oral health. Further prospective research with a dentist on the team is warranted to assess its impact.

Beneficiary's Satisfaction with Primary Palliative Care Services in Kerala - A Cross-Sectional Survey

Objectives

Kerala was the first state to implement a community-based, sustainable primary palliative care (PC) home care (HC) model. Beneficiary satisfaction, an important indicator to assess the quality of service provision with the HC program, has not been assessed since the programme was launched 14 years ago. This study tried to assess the satisfaction of beneficiaries receiving primary PC services through the Kerala State PC programme and the factors associated with the same.

Materials and Methods

The cross-sectional survey was conducted among 450 patients registered under the Kerala State Primary PC Programme. Data were collected using a semi-structured questionnaire from October 2022 to January 2023. We summarised the data as proportions and performed Chi-square tests to make comparisons wherever applicable.

Results

Most of the beneficiaries (69.1%) were satisfied with HC services. The mean age of the beneficiaries was 65.51 ± 17 years. More than 80% of the participants (88.4%) were married, and the primary caregivers were wives (31.8%) and daughters/daughters-in-law (35.3%). The primary diagnosis of the beneficiaries was a cerebrovascular accident (27.4%), cancer (18.8%), and spinal cord injury (13.2%). The study examined the needs of beneficiaries and found that the top three requirements reported by the patients were the inclusion of doctor visits in HC (71.8%), medicine distribution at home (67.4%), and physical rehabilitation services at home with a minimum of three sessions per month (52.3%). The study found a statistically significant association (P < 0.05) between the Beneficiary's satisfaction and behaviour of PC nurses and certain services, including physiotherapy, procedural care specifically catheterisation and wound dressing, and health check-ups received through the HC program. Satisfaction was reported more in Thiruvananthapuram district, followed by Malappuram.

Conclusion

The overall satisfaction with the Kerala State Primary PC Programme was found to be high at about 69%. Despite the fact that the study identified significant relationships between nurses' behaviour, services provided (physical therapy, procedures, and health checks), and satisfaction, the findings suggested expanding the scope of the HC programme by including doctor visits and medicine delivery at patient's home.

Empowering nurses: exploring self-managed organizations in Indian healthcare

BACKGROUND

Given India's high patient load on the existing healthcare setup, as well as political, social, and organizational challenges, the nursing sector is facing various problems, therefore leading to substandard nursing experiences leading to poor patient care at the parallel healthcare setups, specifically homecare. This paper presents self-managed organizations (SMOs) characterized by a horizontal management structure as an effective alternative to existing hierarchical management structures overladen with bureaucracy. Therefore, we are exploring the strategies at self-managed homecare organizations that can make nursing a better and more productive experience.

METHOD

This study utilized Constructivist Grounded Theory (CGT), employing semi-structured interviews to explore nursing dynamics in horizontal organizational structures. It delved into crucial aspects like finances, organizational structure, value systems, information flow, and conflict resolution within SMOs. The methodology involved theoretical sampling, prioritizing expert self-management knowledge over mere representativeness. Seven nurses, twelve management members, and fifteen patients from self-managed homecare organizations contributed to the examination of nursing experiences. Constant comparative analysis of data led to the identification of the Qualitative Success Enablers (QSEs), revealing three themes: Insightfulness, Enhancing Nursing Experience through Job Enrichment, and Autonomy-Enabled Intrapreneurship.

RESULTS

The findings indicate that the horizontal management structure represented by the studied organization in India has shown considerable success in times laden with uncertainties during the COVID-19 pandemic, especially during the delta wave, which revealed the frailty of existing healthcare infrastructure. The organization successfully maintained a better nursing experience and gained patient and employee satisfaction, as revealed by in-depth semi-structured interviews and constant comparative analysis.

CONCLUSION

In a world of unique challenges, we stand on the brink of significant transformations. SMOs are vital in India's homecare sector for enhancing nursing experiences and overall organizational performance. Fostering a trust-based environment within SMOs is integral to delivering effective services. The autonomy to design nursing jobs, insightfulness, and innovativeness in the nursing job through suitable training activities, various job enrichment methods, and finding meaningfulness in a job through softer aspects of caregiving result in an enhanced nursing experience at SMOs. This groundbreaking approach can be extended to other homecare organizations in India, relieving the strain on the existing healthcare system.

Navigating Compassion: A Comprehensive Review of Palliative Care in Respiratory Medicine

Palliative care has emerged as a crucial aspect of comprehensive healthcare, particularly in respiratory medicine. This review navigates the intricate landscape of palliative care in the context of respiratory diseases, including chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis (IPF), and lung cancer. The exploration begins with a comprehensive examination of palliative care's definition, significance, and purpose in respiratory medicine. It progresses to understanding common respiratory diseases, their impact on patients' quality of life, and the nuances of disease progression and prognosis. Delving into the principles of palliative care, the review highlights the importance of a patient- and family-centered approach, emphasizing the multidisciplinary collaboration required for holistic care. Symptom management takes center stage, with a detailed exploration of dyspnea, cough, and pain, covering pharmacological and non-pharmacological interventions. The psychosocial and spiritual dimensions are then unveiled, recognizing the psychological impact of respiratory diseases and the significance of addressing spiritual needs with cultural sensitivity. Communication in palliative care is explored through breaking lousy news, advance care planning, and shared decision-making. The section acknowledges the complex considerations surrounding end-of-life care, including recognizing the end-of-life phase, establishing care goals, and withdrawing life-sustaining therapies. Recognizing the indispensable role of caregivers, the review underscores the importance of caregiver support. It delineates strategies for providing emotional and practical support alongside a crucial focus on self-care for caregivers who shoulder the responsibilities of providing palliative care. As the exploration concludes, the challenges in implementing palliative care in respiratory medicine are outlined, from late referrals to communication barriers. However, the review also envisions a future marked by innovation, with emerging approaches, such as telehealth and personalized medicine, offering promising avenues for improvement. Research gaps and areas for improvement are identified, emphasizing the need for a collaborative effort to enhance the quality of palliative care for individuals facing respiratory diseases. The review culminates in a call to action, urging early palliative care integration, investment in education and training, research initiatives, advocacy for accessible services, and collaboration across disciplines. By heeding this call, healthcare providers, researchers, and policymakers can collectively contribute to the evolution and enhancement of palliative care in the challenging landscape of respiratory medicine.

State of cancer care in India and opportunities for innovation

Cancer is one of the leading causes of morbidity and mortality in India. Despite recent medical and technological advances, the cancer burden in India remains high and continues to rise. Moreover, substantial regional disparities in cancer incidence and access to essential medical resources exist throughout the country. While innovative and effective cancer therapies hold promise for improving patient outcomes, several barriers hinder their development and utilization in India. Here we provide an overview of these barriers, including challenges related to patient awareness, inadequate infrastructure, scarcity of trained oncology professionals, and the high cost of cancer care. Furthermore, we discuss the limited availability of cancer clinical trials in the country, along with an examination of potential avenues to enhance cancer care in India. By confronting these hurdles head-on and implementing innovative, pragmatic solutions, we take an indispensable step toward a future where every cancer patient in the country can access quality care.

Essential Elements of Home-based Palliative Care Model: A Rapid Review

The need for palliative care is increasing due to the rising burden of non-communicable diseases and some communicable diseases. Chronic illnesses demand patient-centred care that focuses on the patient's individual healthcare needs. Palliative care improves the patients' and caregivers' quality of life by providing pain and symptom relief through a holistic approach after the disease is diagnosed. Though there are various models followed in different countries, home-based palliative care is preferred by patients who wish to stay close to their loved ones at their end of life. For providing home-based care, there are certainly important elements that have to be taken care of before planning the implementation because every country has its own healthcare needs, system, and context. India is a developing country where isolated Palliative Care is practiced, hence the situation demands the need of addressing the essential elements that can be included in the protocol of home-based palliative care to enhance the quality of care. Therefore, this study aims to identify a few elements needed to provide home-based palliative care in the Indian context. A rapid review was conducted where seven studies were included that mentioned the elements of home-based palliative care. The electronic databases searched were MedLine, PubMed, and Cochrane databases of systematic reviews. The review was carried out over a period of 8 weeks in June and July 2022. Seven common essential themes were identified; (i) inter-sectoral and inter-professional cooperation, (ii) trust and safety, (iii) holistic management, (iv) non-academic palliative care, (v) spiritual care, (vi) support to caregivers, and (vii) funding and financial support. Our review of effective palliative care models explicates the essential elements for quality home-based care for patients with a terminal illness. The application of the elements must be relevant to the local context due to the huge diversity of the country.

Palliative care practices and policies in diverse socio-cultural contexts: aims and framework of the ERC globalizing palliative care comparative ethnographic study

Background

Palliative care as a specialist professional practice of care for people with advanced illness is becoming increasingly influential worldwide. This process is affected by global health inequalities as well as cultural dimensions of approaching death and practicing care in life-limiting illness.

Objectives

The European Research Council-funded Globalizing Palliative Care (ENDofLIFE) project aims to understand how palliative care policies, discourses and practices are translated, adapted and reconstituted in diverse socio-cultural settings and how cultural dimensions of approaching death and local practices of care shape palliative care implementation.

Methods and Analysis

Using a multi-scalar and multi-sited ethnographic approach, the project uses person-centered ethnography, participant observation, semi-structured interviewing, focus group discussions and policy and discourse analysis at transnational, national and local levels. Ethnographic case-studies are conducted in Brazil, India and Indonesia.

Discussion

The globalizing palliative care project develops a novel ethnographic methodology of studying end-of-life care trajectories through long-term participant observation with individual patients and families as they manage and practice formal and informal health care in advanced illness. By analyzing how patients and families experience and navigate care over time, complemented by stakeholder interviews, the study advances critical theoretical insight into the relation between (large-scale and dynamically traveling) palliative care models, policies and discourses on the one hand and the experience and practice of palliative care in the lives of patients and informal care givers in local health care practices on the other hand. Insights are expected to benefit culturally situated palliative care policies and practices.

Need of community-based palliative care in rural India and factors that influence its sustainability: a comprehensive exploration using qualitative methodology in rural Puducherry, India

Background

The existing palliative care services in India are concentrated in urban areas, attached to tertiary care hospitals. This poses issues relating to access and equity for people in rural locations and with low socioeconomic status. A Community-Based Palliative Care (CBPC) service named Sanjeevan has been initiated in Puducherry, a union territory of India to provide physical, social, psychological, and emotional support to incurably ill people, including older adults living in rural areas.

Objectives

To understand the social mechanisms that underpin the implementation of CBPC in rural parts of India and the challenges to its sustainability.

Design

Qualitative research using focus group discussions (FGDs) and key informant interviews (KIIs).

Methods

Community-based participatory research (CBPR) approach was used in this study, and descriptive analysis was done. Through CBPR it was possible to document and interpret local knowledge on the community concerns and assets along with the experiences of the community members. Purposive sampling was used to identify vocal participants involved in patient care and areas of the Sanjeevan program such as financial management, administration, and community mobilization. Seven KIIs and four FGDs were conducted, with 7-8 participants in each.

Results

The analysis indicated the need for a CBPC and the factors enabling its establishment. The findings revealed capacity building, resources for palliative care services, and the existing social structure of the community being the main challenges that need to be overcome for better penetration of CBPC services into society. Demand generation through sensitization and administration of services based on the need and regular follow-up remains the key strategies for the sustainability of the program.

Conclusion

The CBPC program like 'Sanjeevan' adopted in the rural area of Puducherry can be cited as an example and can be replicated in other rural settings with similar sociocultural characteristics to support people living with end-stage diseases.

Factors associated with knowledge of diagnosis, prognosis & distress in cancer patients receiving palliative care - A retrospective cohort analysis

Background & objectives

Demographic attributes of cancer patients are associated with the awareness of diagnosis, the prognosis of cancer and their associated psychological distress. This study was aimed to assess the knowledge of diagnosis, prognosis and psychological distress among patients reporting to the pain and palliative care department in a tertiary cancer hospital, south India.

Methods

Data of all patients visiting the palliative care outpatient department of a tertiary cancer centre in south India between January and June 2018 were included in the study (n=754). A structured pro forma was used to collect information on the sociodemographic details and clinical aspects and a distress thermometer was used to assess the level of distress. Information, thus collected, were analysed using descriptive statistics and logistic regression.

Results

Around 16.2 per cent of the patients were unaware of their diagnosis while two third (68%) were unaware of the prognosis. More than half of the patients reported significant distress (54.1%). Gender, education, not working and being diagnosed with head-and-neck cancers were associated with knowledge of diagnosis, while educational level predicted the knowledge of prognosis. Younger age group, head-and-neck cancer, haematology cancer, state of being unaware of diagnosis and prognosis were found to be associated with distress.

Interpretation & conclusions

Higher educational levels and better socio-economic status increase the likelihood of patients being aware of their diagnosis and prognosis. Being unaware of the prognosis remains associated with the higher level of distress.

Factors associated with knowledge of diagnosis, prognosis & distress in cancer patients receiving palliative care - A retrospective cohort analysis

Background & objectives

Demographic attributes of cancer patients are associated with the awareness of diagnosis, the prognosis of cancer and their associated psychological distress. This study was aimed to assess the knowledge of diagnosis, prognosis and psychological distress among patients reporting to the pain and palliative care department in a tertiary cancer hospital, south India.

Methods

Data of all patients visiting the palliative care outpatient department of a tertiary cancer centre in south India between January and June 2018 were included in the study (n=754). A structured pro forma was used to collect information on the sociodemographic details and clinical aspects and a distress thermometer was used to assess the level of distress. Information, thus collected, were analysed using descriptive statistics and logistic regression.

Results

Around 16.2 per cent of the patients were unaware of their diagnosis while two third (68%) were unaware of the prognosis. More than half of the patients reported significant distress (54.1%). Gender, education, not working and being diagnosed with head-and-neck cancers were associated with knowledge of diagnosis, while educational level predicted the knowledge of prognosis. Younger age group, head-and-neck cancer, haematology cancer, state of being unaware of diagnosis and prognosis were found to be associated with distress.

Interpretation & conclusions

Higher educational levels and better socio-economic status increase the likelihood of patients being aware of their diagnosis and prognosis. Being unaware of the prognosis remains associated with the higher level of distress.

Translation and cross-cultural adaptation of the Integrated Palliative Care Outcome Scale in Hindi: Toward capturing palliative needs and concerns in Hindi speaking patients

BACKGROUND

Culturally relevant patient-centered outcomes tools are needed to identify the needs of patients and to assess their palliative care concerns.

AIM

To translate and culturally adapt the Integrated Palliative Care Outcome Scale (IPOS) into Hindi.

DESIGN

The study applied a standardized methodology entailing six phases for translation and content validation: equivalence setting through a three-step process; forward translation; blind backward translation; expert review by a panel of the POS team; cognitive de-briefing with patients; and proof-reading of the final tool. All interviews and focus groups were audio-recorded, transcribed and analyzed using content analysis.

SETTING/PARTICIPANTS

(1) Healthcare professionals including doctors, nurses, psychologists, counselors, and volunteers working in Indian palliative care settings with expertise in both English and Hindi languages; (2) Hindi speaking patients diagnosed with cancer who were receiving palliative care in community settings. Caregivers, palliative care experts, and language translators contributed to the translation procedure.

RESULTS

Phrases like nausea, poor appetite, drowsiness, and depression were difficult to translate into Hindi. Response categories "occasional" and "sometimes" were overlapping. All items, instructions and response categories were simple to understand. A visual thermometer is a unique feature of Hindi IPOS to facilitate responses from less educated patients.

CONCLUSION

Hindi IPOS has face and content validity for use in clinical practice and research. The Hindi IPOS has implications beyond Indian palliative care settings. Millions of Hindi speakers can now respond to IPOS, and have a tool for communicating their palliative care needs in their mother tongue to inform patient-centered care.

Neuropalliative Care in India - Barriers, Challenges and Future Directions

Neuropalliative care is an emerging sub-specialty of neurology and palliative care that aims to relieve suffering from symptoms, reduce distress and improve the quality of life of people with life-limiting neurological conditions and their family caregivers. As advances are being made in the prevention, diagnosis, and treatment of neurological illnesses, there is an increasing need to guide and support patients and their families through complex choices involving immense uncertainty and important life-changing outcomes. The unmet need for palliative care in neurological illnesses is high, especially in a low-resource setting like India. This article discusses the scope of neuropalliative care in India, the barriers and challenges that impede the specialty's development, and the factors that could facilitate the development and scale-up delivery of neuropalliative services. The article also attempts to highlight priority areas for advancing neuropalliative care in India which include context-specific assessment tools, sensitization of the healthcare system, identification of intervention outcomes, the need for developing culturally sensitive models based on home-based or community-based care, evidence-based practices, and development of manpower and training resources.

Interest and Confidence in Death Education and Palliative Psychology in Italian and Indian University Students of Psychology: Similarities and Differences

Teaching death education and palliative psychology in universities has proven to be of great importance, especially in the health professions. The present study aims to evaluate the similarities and differences in interest and confidence in death education and palliative psychology between university psychology students from two culturally different countries: Italy and India. For this study, 63 Italian and 35 Indian psychology students were recruited to take part in a course on death education and palliative psychology. The results showed the positive impact of a death education and palliative psychology course on the training of professionals. In particular, this course was useful in helping students become familiar with and learn how to manage future professional situations related to death and dying. Specific differences between the two countries also emerged, particularly with regard to their approach to the end-of-life field, due to different cultural contexts. There is still much to be done by institutions to improve the dissemination and academic teaching of this area, which in turn can promote job opportunities for young people and encourage them to work in this field.

PENS approach for breaking bad news in the oncology outpatient setting: a real-world report

PURPOSE

Breaking bad news (BBN) is a vital part of oncology practice. We conducted this study to assess an abbreviated PENS protocol [Patient preference, Explanation, Next appointment, and Support] for BBN in oncology outpatient (OP) settings.

METHODS

This observational study was conducted in a university teaching hospital, including cancer patients who were unaware of their condition and willing to discuss their disease status. The duration of BBN was the primary outcome. After the BBN session, patients filled a validated questionnaire; response scores of ≤ 13 were classified as content with BBN.

RESULTS

Fifty patients (mean age 53.7 years, range 28-76) were included in the study. The average duration of BBN was 6.1 (range 2-11) min. Assessed by the response score sum, 43 (86%) patients were satisfied with BBN. Only three (6%) of the discontented patients felt that the BBN duration was too short. Most (94%) of patients reported that they understood the information imparted during the BBN session. After the session, 36 (72%) patients admitted to either feeling the same or reassured compared to before the session. The oncologists also were comfortable with PENS.

CONCLUSIONS

The PENS approach is a practical method for BBN, especially when the oncologists have higher OP workloads. More extensive trials are required to validate the protocol in other settings.

TRIAL REGISTRATION

Clinical Trial Registry of India (CTRI/2021/07/034707).

Development of Mobile Application-Based System for Improving Medication Adherence Among Cancer Patients Receiving Palliative Therapy

Objectives

Cancer patients seeking palliative care faces distressing symptoms which affect their quality of life adversely. Patients' lack of adherence to analgesics is one of the major factors contributing to the undertreatment of cancer pain. The objective of this paper is to outline the development of a mobile application-based system to develop a physician-patient relationship and to improve adherence to medications prescribed for cancer pain management.

Material and Methods

The mobile application-based system is developed using alarm and cloud based data sysncronisation for improving medication adherence and self-recording symptoms among cancer patients receiving palliative therapy at a palliative care clinic.

Results

Ten palliative medicine physicians tested the project website and the mobile application thoroughly instead of patients. The physician recoded the prescription and other details on the project website. The data transferred from website to mobile application. The mobile application reminded scheduled medication by alarm, collected medical adherence details, daily symptom observation, and their severity and SOS medication details. The data from the mobile application was transferred back to project website successfully.

Conclusion

The developed system can directly improve the physician-patient relationship, and improve better communication and sharing of information between physician and patient. This will impact the quality of life of the patient, improve the awareness of the patient about the disease, and may reduce rate of hospitalisation. This will also help physicians to treat patients efficiently. The developed system is being tested under a randomised control trial study. The findings of the study can be generalised to all patients suffering from chronic illnesses and on long-term medications.

Situational analysis of the quality of palliative care services across India: a cross-sectional survey

Objective

Palliative care services in India were established in the 1980s but there is no detailed up-to-date knowledge about the quality-of-service provision nationally. We aim to describe the current quality of palliative care provision in India, as measured against nationally adopted standards.

Method

A digital survey adapted from the Indian Association of Palliative Care Standards Audit Tool was administered to 250 palliative care centres.

Results

Two hundred and twenty-three (89%) palliative care centres participated - 26.4% were government-run, while the rest include non-governmental organisations, private hospitals, community-led initiatives and hospices. About 200 centres 'often' or 'always' fulfilled 16/21 desirable criteria; however, only 2/15 essential criteria were 'often' or 'always' fulfilled. Only 5.8% provide uninterrupted access to oral morphine.

Significance of the results

Palliative care centres in India are falling short of meeting the essential quality standards, indicating the urgent need for new initiatives to drive national change.

Prevalence of dyspnoea and usage of opioids in managing dyspnoea in advanced cancer patients: a longitudinal observational multi-centre study from India

Context

Breathlessness is one of the devastating symptoms experienced by patients with advanced cancer and can be very challenging to manage.

Objectives

To find the point prevalence of dyspnoea in advanced cancer patients presenting to palliative care out-patient clinics, and the usage of opioids in palliation of dyspnoea.

Methods

We conducted a prospective observational study among all consecutive patients presenting to the outpatient clinics of six cancer centres in India from different parts of the country. In addition to routinely documented demographic and clinical data from patient charts, study investigators collected information on the Edmonton Symptom Assessment System, Cancer Dyspnoea Scale (CDS) and European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire Core 15 Palliative Care. We calculated the prevalence of dyspnoea and documented the usage of opioids in palliation of dyspnoea using tests of differences across patient characteristics.

Results

Between May 1, 2019, and April 30, 2020, 5,541 patients were screened for eligibility, and 288 were enrolled (48 patients from each of the six centres). We analysed the data of 288 patients, of which 36.4% had dyspnoea, with 28.5% with moderate to a severe degree (>4/10). Tiredness and loss of appetite were found to have associations with dyspnoea which were statistically significant on multivariate analysis. Standard palliative care management and routine usage of opioids preceded improvement in dyspnoea scores, CDS scores and quality of life scores throughout 7 days.

Conclusion

Dyspnoea is a common symptom in advanced cancer patients, presenting to outpatient clinics, and routine documentation of dyspnoea with appropriate usage of opioids helps in mitigation.

Key message

The article suggests that breathlessness is a common problem in advanced cancer patients and opioid prescription preceded symptom improvements in such patients.

Considerations for Fostering Palliative Care Awareness in Developing Contexts: Strategies From Locally Initiated Projects in India

CONTEXT

Lack of palliative care (PC) awareness is a barrier to its utilization in developing contexts.

OBJECTIVES

To identify and understand strategies that changed awareness of the concepts and value of palliative care in a multi-site quality improvement project in India.

METHODS

The Palliative Care - Promoting Assessment and Improvement of the Cancer Experience (PC-PAICE) evaluation team conducted 44 semi-structured interviews with clinician and organization stakeholders at seven geographically dispersed sites. We used inductive and deductive approaches in this secondary analysis to identify emerging themes.

RESULTS

We identified the following strategies to improve awareness of concepts and value of palliative care. Strategy 1: Educate medical trainees, staff, and the community about palliative care and its concepts. Sub-strategies: Participate in community events. Integrate PC concepts into early medical education. Standardize training for practitioners. Strategy 2: Design and disseminate India-specific research to reinforce awareness of the value of palliative care. Sub-strategies: Publish and use India-specific palliative care research. Strategy 3: Facilitate communication between providers and departments to improve awareness of palliative care services and its concepts. Sub-strategies: Create referral frameworks and network with providers referring to palliative care to change awareness of available services and palliative care concepts.

CONCLUSION

To increase palliative care utilization, program development can include community and provider-focused efforts on awareness of the concepts and value of palliative care. These three strategies held salience across sites representing diverse Indian geographic and cultural settings; as such, they may be applicable to other contexts.

Empowering families to take on a palliative caregiver role for patients with cancer in India: Persistent challenges and promising strategies

BACKGROUND

The population of patients with cancer requiring palliative care (PC) is on the rise in India. Family caregivers will be essential members of the care team in the provision of PC.

OBJECTIVE

We aimed to characterize provider perspectives of the challenges that Indian families face in taking on a palliative caregiving role.

METHOD

Data for this analysis came from an evaluation of the PC-PAICE project, a series of quality improvement interventions for PC in India. We conducted 44 in-depth semi-structured interviews with organizational leaders and clinical team members at seven geographically and structurally diverse settings. Through thematic content analysis, themes relating to the caregivers' role were identified using a combination of deductive and inductive approaches.

RESULT

Contextual challenges to taking up the PC caregiving role included family members' limited knowledge about PC and cancer, the necessity of training for caregiving responsibilities, and cultural preferences for pursuing curative treatments over palliative ones. Some logistical challenges include financial, time, and mental health limitations that family caregivers may encounter when navigating the expectations of taking on the caregiving role. Strategies to facilitate family buy-in for PC provision include adopting a family care model, connecting them to services provided by Non-Governmental Organizations, leveraging volunteers and social workers to foster PC awareness and training, and responding specifically to family's requests.

CONCLUSION

Understanding and addressing the various challenges that families face in adopting the caregiver role are essential steps in the provision and expansion of PC in India. Locally initiated quality improvement projects can be a way to address these challenges based on the context.

Hospice care in India: A review

Palliative care is the need of the hour, especially in a country like India where the number of terminally ill patients has always been a concern, and with projections showing this number to only go up and increase exponentially, it is much more important that we now shift our focus to providing quality hospice care to the ones that are in need of it. In this article, the authors start out by defining Palliative care and hospice care, all the while maintaining the distinct features of them both. Once the foundation is set for the same, we dive into the history of palliative care in this country and how it has evolved over the years. We then move on to the present scenario of hospice care in India and try to look at it through a more contemporary lens. Further, we discuss the impact of some diseases that most adversely affect individuals and require end-of-life care in its more advanced stages. These include, but are not limited to, end-stage cancer, multidrug resistant (MDR)-tuberculosis and Human immunodeficiency virus-associated acquired immune deficiency syndrome (HIV-AIDS). We then move on to discuss the importance of academic interventions to strengthen the role of hospice care in the India and how research and education can help improve the condition of end-of-life care in all domains. We finally talk about how we can move forward and what positive changes we can bring about in order to make inroads into better and more sustainable hospice care in the Indian context. We hope that our work will cause healthcare professionals, and other people alike to better understand the role of hospice care in their own lives and livelihoods.

Bibliometric Analysis of Indian Journal of Palliative Care from 1995 to 2022 using the VOSviewer and Bibliometrix Software

Introduction:

The Indian Journal of Palliative Care (IJPC) is an open-source, interdisciplinary and peer-reviewed journal started in 1994 that publishes high-quality articles in the field of palliative care in India. The purpose of this study is to analyse the bibliometric data of its publications using bibliometric analysis to understand the key bibliometric factors affecting the journal and its contribution to the field of palliative care research.

Material and Methods:

A software-assisted bibliometric analysis of the IJPC was conducted. The dimensions database was used to mine the bibliometric data of the journal from 1995 to 2022. A total of 1046 records were analysed using the VOSviewer and Biblioshiny by Bibliometrix software.

Results:

The analysis represented a vivid and graphically elaborate picture of the journal. It gives insight into the most productive and influential authors, countries, affiliations, sources and documents along with a picture of the network among them.

Conclusion:

This study highlights a gradual upward trend in the annual production of the journal. A strong connection of the IJPC could be seen with leading journals publishing in the field of palliative care globally.

Estimating the Need for Palliative Care in an Urban Resettlement Colony of New Delhi, North India

Objectives:

This study was aimed to estimate the need for palliative care in an urban resettlement colony of Dakshinpuri Extension, New Delhi.

Material and Methods:

This was a community-based cross-sectional study conducted in New Delhi. We trained four multipurpose workers to screen the households during their routine household-to-household visits. The screening for the need for palliative care was done using three questions – that is, (1) presence of a bedridden patient or (2) person in need for help in activities of daily living or (3) not able to go for work due to any physical chronic illness. If the answer to any of the three screening questions was yes for any member in a household, then these households were visited by a community physician trained in palliative care and a medical social service officer to confirm the need for palliative care. Patients were administered a semi-structured questionnaire containing the sociodemographic details and an assessment of disease status and review of health records was done. The patient and his/her caregiver were also assessed for awareness regarding palliative care.

Results:

A total of 2028 households were screened and the need for palliative care was found to be 1.5/1000 population (95% CI: 0.9–2.1). The mean age (SD) of patients who need palliative care was 60 years (SD–12.9). The common diseases which required palliative care were stroke with a focal neurological deficit (45.8%), osteoarthritis with marked dependence (20.8%) and cancer (12.5%). None of the patients was receiving palliative care as patients and their caregivers were not aware of the term palliative care/end of life care/home care for bedridden people/community-based care.

Conclusion:

The need for palliative care in an urban resettlement colony of North India was found to be 1.1/1000 population. Further studies are required to estimate the need for palliative care in North India.

Perceptions of Healthcare Workers Regarding Palliative Care Services in a Tertiary Care Teaching Hospital in North India – A Mixed Methods Observational Study

Background:

Cancers and various terminal illnesses need integrated palliative care with curative management, but, unfortunately, our health care system mainly focuses on the treatment of disease. Lack of awareness, difficulty in pain management and untrained staff are some of the challenges in palliative care services.

Objectives:

The study was done to explore the perception of healthcare workers regarding availability, utilisation and challenges in the delivery of palliative care services.

Material and Methods:

A mixed method study was conducted at tertiary care teaching hospital in North India. Qualitative approach using interviews and focus group discussions (FGDs) among healthcare workers was done to understand their knowledge, perception, barriers and challenges in implementing palliative care services. One hundred and thirteen healthcare workers were interviewed using a semi-structured questionnaire and FGD was conducted to gain more insight into the issues of palliative care. The data obtained was analysed with the help of computer software Microsoft Excel and SPSS version 23 for windows. The data was presented as proportion and mean (S.D.) as deemed appropriate for qualitative and quantitative variables respectively. Thematic analysis was done with the data of FGD.

Results:

The knowledge, attitude and practices regarding palliative care were poor across the HCW. During FGD with faculty and residents, the participants showed great concern about the absence of palliative care across many specialties while expressing an acute need for the establishment of a separate interdisciplinary unit on palliative care to improve the quality of life in patients.

Conclusion:

The study shows that there are gaps that need to be addressed to make palliative services available in our hospital.

Development of Palliative Care Services at a Tertiary Care Teaching Hospital in Pakistan: Retrospective Analysis of Existing Palliative Care Program

CONTEXT

Palliative care (PC) is an important aspect of providing holistic care to patients and their families who are dealing with a serious or life limiting illness. Medical community and public poorly understand the implications and benefits of these services. Unfortunately, because of this, PC remains a neglected area of healthcare in the most institutions of Pakistan.

OBJECTIVES

We sought to review the current structure, barriers in context of growing need for PC, possible means to overcome these challenges and future perspectives at tertiary care hospital.

METHODS

Retrospective longitudinal cross-sectional study was done using data from 2017 to 2019 in the section of PC at Aga Khan University Hospital (AKUH).

RESULTS

PC program has been self-sustainable and serving 3747 patients in 2017-2019. The results show that palliative care services (PCS) are well integrated for oncology with all three models of PCS delivery. Most of the patients opted for comfort code during hospital stay and preferred end-of-life-care at home. We received less referral from outside the hospital and other specialties but received more self-referrals surprisingly. Home-based-palliative-care was also a key aspect of the program. PCS providing quality of care and nearly reaching target goal of quality indicators.

CONCLUSION

The enormous burden of life-threatening illnesses is associated with physical and psychosocial sufferings, which explains the illustrious need for PC in developing countries such as Pakistan. PCS at AKUH initiated in 2017. Nevertheless, there are challenges to service expansion and progress, which are being addressed.

Status of Palliative Care Services in Tamil Nadu – A Descriptive Report

Objectives:

Advanced cancer patients attending tertiary cancer centres from rural places are referred back to local physicians for symptom management. Due to lack of networking with palliative care centres (PCCs), the referred patients do not receive appropriate palliative care (PC) services. Hence, an attempt was made to map the PCCs in Tamil Nadu to make the referral system efficient.

Material and Methods:

PCCs in Tamil Nadu were identified from the National Health Mission directory, online sources and from morphine license annexure of drug control department. The details regarding nature of facility, PC model, service type, procedures, cost, morphine availability and type of personnel involved in their PCCs were collected from government and private centres. The data were analysed using descriptive statistics and geomapping of all the centres identified was created.

Results:

A total of 371 PCCs were identified, of which 32 were government headquarter hospitals (GHQH), 281 were government community centres and 58 were private. Eighty-three of the 90 centres (including GHQH and private) were active and 60 responded to the survey. More than half of the centres were hospital-based (61.7%) and 28.3% were community-based. The majority of the PCCs had in-patient (75%) and out-patient (63.3%) facilities and 63.3% had regular home visits. Forty-six centres provide PC service free of cost. Nearly 80% provide morphine for pain management, wherein 41 have obtained a license. In total, ten centres had a social worker and four had a psychologist.

Conclusion:

The number of PCCs is disproportionate, in which majority of the centres are clustered in urban areas. Integrating PC services into the existing health system is the way forward.

“Building palliative care capacity in cancer treatment centres: a participatory action research”

Introduction

There is a significant lack of palliative care access and service delivery in the Indian cancer institutes. In this paper, we describe the development, implementation, and evaluation of a palliative care capacity-building program in Indian cancer institutes.

Methods

Participatory action research method was used to develop, implement and evaluate the outcomes of the palliative care capacity-building program. Participants were healthcare practitioners from various cancer institutes in India. Training and education in palliative care, infrastructure for palliative care provision, and opioid availability were identified as key requisites for capacity-building. Researchers developed interventions towards capacity building, which were modified and further developed after each cycle of the capacity-building program. Qualitative content analysis was used to develop an action plan to build capacity. Descriptive statistics were used to measure the outcomes of the action plan.

Results

Seventy-three healthcare practitioners from 31 cancer treatment centres in India were purposively recruited between 2016 and 2020. The outcome indicators of the project were defined a priori, and were audited by an independent auditor. The three cycles of the program resulted in the development of palliative care services in 23 of the 31 institutes enrolled in the program. Stand-alone palliative care outpatient services were established in all the 23 centres, with the required infrastructure and manpower being provided by the organization. Morphine availability improved and use increased in these centres, which was an indication of improved pain management skills among the participants. The initiation and continuation of education, training, and advocacy activities in 20 centres suggested that healthcare providers continued to remain engaged with the program even after the cessation of their training cycle.

Conclusion

This program illustrates how a transformational change at the organizational and individual level can lead to the development of sustained provision of palliative care services in cancer institutes.

Feasibility of a Palliative Care Intervention Utilizing Community Health Workers to Facilitate Delivery of Home-based Palliative Care in India

Objectives:

The purpose of this study was to evaluate the feasibility of a home-based palliative care program delivered by community health workers (CHW) in rural areas outside of Kolkata, India. The specific aims were to assess CHWs’ ability to implement the intervention protocol and maintain records of care, to characterize patient problems and CHW activities to assist patients, and to assess change in patient pain scores over the course of the intervention.

Materials and Methods:

Four CHWs were hired to facilitate delivery of home-based palliative care services. CHWs were trained using the Worldwide Hospice and Palliative Care Alliance’s Palliative Care Toolkit. CHWs provided care for patients for 3-months, making regular home visits to monitor health, making and implementing care plans, and referring patients back to the cancer center team for serious problems.

Results:

Eleven patients enrolled in the intervention, with ten of these patients participating in the intervention and one patient passing away before starting the intervention. All ten participants reported physical pain, for which CHWs commonly recommended additional or higher dose medication and/or instructed patients how to take medication properly. For two patients, pain levels decreased between baseline and end of study, while pain scores did not decrease for the remaining patients. Other symptoms for which CHWs provided care included gastro-intestinal, bleeding, and respiratory problems.

Conclusion:

The study findings suggest that utilization of CHWs to provide palliative care in low-resource settings may be a feasible approach for expanding access to palliative care. CHWs were able to carry out the study visit protocol and assess and document patient problems and their activities to assist. They were also able to alleviate many common problems patients experienced with simple suggestions or referrals. However, most patients did not see a decrease in pain levels and more emphasis was needed on the emotional aspects of palliative care, and so CHWs may require additional training on provision of pain management and emotional support services.

Felt Needs of Cancer Palliative Care Professionals Working in India: A Qualitative Study

Objectives:

Cancer palliative care professionals face a plethora of challenges related to death, dying and suffering apart from limited workforce and other resources in India. However, the grief held by them is underappreciated and psychological needs are under explored. The aim of the present study was to explore felt needs of cancer palliative care professionals working in India.

Materials and Methods:

The study was cross-sectional, qualitative and in-depth in nature. It was conducted across four cancer palliative care centers in Bengaluru city of India. sample consisted of 15 professionals (mean age = 42 years and standard deviation = 8.41) with at least six months of experience, involved in direct patient care who gave an additional consent for audio-recording. The tools used were sociodemographic and professional datasheet and semi-structured interview guide, which were developed for the present study and validated from five experts. Thematic analysis was used to generate and analyze patterns within the qualitative data.

Results:

Five themes were identified, namely, death and grief; challenges in practice; strategies for self-care; positive professional experiences; and vision for palliative care.

Conclusion:

The cancer palliative care professionals need regular support in coping with death and grief, regular trainings and supervision across workplace to deal with occupational challenges, and to address their self-care and spiritual needs. The study highlights need to introduce more specialized training courses in handling pediatric patients, increase palliative care workforce, and hospice units. This can have implications in future research and training with development of innovative interventions to address these needs and challenges.

Effect of Early Palliative Care on Quality of Life of Advanced Head and Neck Cancer Patients: A Phase III Trial

BACKGROUND

Early palliative care (EPC) is an important aspect of cancer management but, to our knowledge, has never been evaluated in patients with head and neck cancer. Hence, we performed this study to determine whether the addition of EPC to standard therapy leads to an improvement in the quality of life (QOL), decrease in symptom burden, and improvement in overall survival.

METHODS

Adult patients with squamous cell carcinoma of the head and neck region planned for palliative systemic therapy were allocated 1:1 to either standard systemic therapy without or with comprehensive EPC service referral. Patients were administered the revised Edmonton Symptom Assessment Scale and the Functional Assessment of Cancer Therapy for head and neck cancer (FACT-H&N) questionnaire at baseline and every 1 month thereafter for 3 months. The primary endpoint was a change in the QOL measured at 3 months after random assignment. All statistical tests were 2-sided.

RESULTS

Ninety patients were randomly assigned to each arm. There was no statistical difference in the change in the FACT-H&N total score (P = .94), FACT-H&N Trial Outcome Index (P = .95), FACT-general total (P = .84), and Edmonton Symptom Assessment Scale scores at 3 months between the 2 arms. The median overall survival was similar between the 2 arms (hazard ratio for death = 1.01, 95% confidence interval = 0.74 to 1.35). There were 5 in-hospital deaths in both arms (5.6% for both, P = .99).

CONCLUSIONS

In this phase III study, the integration of EPC in head and neck cancer patients did not lead to an improvement in the QOL or survival.

Public Health Perspectives of Geriatric Mental Health Care

BACKGROUND

In older adults (aged 60 years and above), mental health problems are gaining public health importance because of the increasing prevalence, disease burden, disability, morbidity, and mortality. Epidemiological studies on major mental health disorders such as depression and dementia in older adults have contributed to a better understanding of the distribution and determinants of these conditions. Identifying potential risk factors has stimulated interventional research on preventing these conditions under the public health framework towards their management. The increasing burden of geriatric mental health conditions like dementia in developing countries like India can contribute to significant challenges if there is no adequate strengthening of the public health response. This includes scaling up the measures of prevention, public awareness, early diagnosis, and quality health and social care equitably available to all sections of the population. The Decade of Healthy Ageing (2021-2030) provides the opportunity for concerted and coordinated initiatives to improve intrinsic capacity (physical and mental) and offer an age-friendly environment to enhance the functional ability of all older adults.

METHODS

This article reviews the critical public health issues related to geriatric mental health in India.

The Universality of Palliative Care Philosophy

The modern hospice movement, which is the origin of what is now known as palliative care, derived strong inspiration from Christianity. Given this original Christian inspiration, the global spread of palliative care even to countries where Christianity is only a minority religion may look surprising. In line with the theory of the “secularization of hospice,” it could be argued that palliative care has spread globally because its underlying philosophy has become secular, allowing it to become universal. However, given the continuing importance of religion in many areas of palliative care, we could wonder how secular contemporary palliative care really is. This article argues that the universality of palliative care philosophy resides in its susceptibility to contextualization. Palliative care has become a global success story because people all over the world committed to palliative care’s principles and ideas have contextualized these and developed models of palliative care delivery and even philosophy that are adapted to the local socio-economic and cultural-religious contexts. This article analyzes palliative care in India to illustrate this point, describing contextualized models of palliative care delivery and showing that palliative care physicians and nurses in India draw inspiration from their local context and religiosity.

Barriers, Facilitators and Recommended Strategies for Implementing a Home-Based Palliative Care Intervention in Kolkata, India

BACKGROUND

40 million people in the world are in need of palliative care, but only one-seventh of that population receive services. Underuse of palliative care in low resource countries exacerbates suffering in patients with life limiting illnesses such as cancer.

OBJECTIVES

The current study was conducted to identify barriers, facilitators and recommended strategies for informing development of a home-based palliative care intervention for poor and medically underserved rural patients in Kolkata, India.

METHODS

Semi-structured interviews were conducted with 20 clinical and patient stakeholders in Kolkata, India. Questions queried current practices for delivering palliative care, along with barriers, facilitators and optimal strategies for implementing homebased palliative care.

RESULTS

We identified some key barriers to palliative care delivery in rural areas: lack of access to palliative care till late stages; patients unaware of their cancer stage; lack of affordability of medication and treatment costs; transportation challenges to access care; strict morphine distribution regulations making it challenging for patients to obtain morphine; cultural factors discouraging patients from seeking palliative care; resistance from medical community to use "rural medical practitioners (RMPs)" to deliver care. We also identified important facilitators, including availability of existing palliative care infrastructure at the cancer center, network of RMPs to serve as CHWs to facilitate palliative care delivery, low morphine cost and family support system for patients.

CONCLUSION

Our findings provide evidence that a palliative care intervention which leverages an existing CHW infrastructure may be a feasible model for expanding the reach of palliative care to rural underserved patients.

Why is hospice care important? An exploration of its benefits for patients with terminal cancer

Background

Palliative care has proven over time that it can help prolong life spans with the use of hospices. The literature reports that most patients with cancer are diagnosed in the later stages and since there is no cure, they will require palliative care at some point during their illness. However, most developing countries, including India, have failed to establish hospices; as a result, large numbers of cancer patients are still deprived of palliative care. To initiate better access to hospices, it is important to understand the benefits of the same. Therefore, the present study aims to explore the advantages of hospice care from the perspectives of advanced cancer patients living in hospice centres.

Methods

The present study uses the method of exploratory research. Using purposive sampling, 8 participants living in a hospice in Bengaluru, India were selected and semi-structured interviews were conducted to collect data from the patients. This data was analysed using thematic analysis. Any underlying patterns were determined to identify the evident themes that emerged from the data.

Results

After thematic analysis, 4 themes were identified, namely, pain management, altruism, a good death, and overall satisfaction. Within some themes, there were specific sub-themes that have been illustrated using direct quotes from the interviews.

Conclusion

The findings of this study suggest that hospice centres play an important role in helping patients to come out of the trauma during the advanced stages of cancer. A sense of relief can be given to the patient by implementing palliative care. This is possible by building more hospice centres in the country where all individuals, irrespective of their financial status, can opt for the service. Having palliative care will provide dignified death to the patients.

The Palliative Care-Promoting Access and Improvement of the Cancer Experience (PC-PAICE) Project in India: A Multisite International Quality Improvement Collaborative

Mentors at seven U.S. and Australian academic institutions initially partnered with seven leading Indian academic palliative care and cancer centers in 2017 to undertake a program combining remote and in-person mentorship, didactic instruction, and project-based learning in quality improvement (QI). From its inception in 2017 to 2020, the Palliative Care-Promoting Accesst and Improvement of the Cancer Experience Program conducted three cohorts for capacity building of 22 Indian palliative care and cancer programs. Indian leadership established a Mumbai QI training hub in 2019 with philanthropic support. In 2020, the project which is now named Enable Quality, Improve Patient care - India (EQuIP-India) focuses on both palliative care and cancer teams. EQuIP-India now leads ongoing Indian national collaboratives and training in QI and is integrated into India's National Cancer Grid. Palliative Care-Promoting Accesst and Improvement of the Cancer Experience demonstrates a feasible model of international collaboration and capacity building in palliative care and cancer QI. It is one of the several networked and blended learning approaches with potential for rapid scaling of evidence-based practices.

Running Palliative Care Services at the Institute of Palliative Medicine, Kozhikode, Amid COVID-19 Pandemic: A Strengths, Weaknesses, Opportunities, and Threats Analysis

Context

COVID-19 pandemic and nationwide lockdown has affected the health system. Many health-care facilities are prioritizing their services, and hence, those suffering from life-limiting conditions will have difficulty in accessing health services.

Aims

The aim of the study was to perform a Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis of the palliative care (PC) services provided by the Institute of Palliative Medicine (IPM), Kozhikode, amid COVID-19 pandemic.

Settings and Design

A SWOT analysis of PC services provided by IPM.

Subjects and Methods

The data for SWOT analysis was collected by brainstorming and review of records and registers.

Results

Good prioritization and documentation system and routinely adhering to infection control practices are notable strengths. Lack of funding and interrupted supply of personal protective equipment are notable weaknesses. Availability of established communication channels with active community participation are a few opportunities available to improve the services. Working with high-risk groups, return of Non-residential Indians (NRI), lack of transparency and stigma among the general public are the threats that can affect the service delivery.

Conclusions

Having good prioritization and documentation system, reinforcing infection control practices, already established emergency homecare system, presence of a well-developed network of community-based PC services, and a vast network of community volunteers and awareness and cooperation of families had helped IPM to quickly reorganize its services and transition smoothly to continue to provide PC for those suffering from life-limiting illnesses in this pandemic situation.

"PENS" approach for breaking bad news-a short and sweet way!

India has a distinct pattern of cancer care delivery, with unique sociocultural milieu and patient characteristics. In the current era of patient-centered and personalized care, there is an unmet need for an abbreviated protocol for breaking bad news to cancer patients suitable for the Indian outpatient setting. We propose a short four-step protocol for breaking bad news effectively and caringly, in the outpatient department of oncology clinics.

Lived experiences of palliative care among people living with HIV/AIDS: a qualitative study from Bihar, India

OBJECTIVES

This study aimed to assess the lived experiences of palliative care among critically unwell people living with HIV/AIDS (PLHA), caregivers and relatives of deceased patients. It also aimed to understand the broader palliative care context in Bihar.

DESIGN

This was an exploratory, qualitative study which used thematic analysis of semistructured, in-depth interviews as well as a focus group discussion.

SETTING

All interviews took place in a secondary care hospital in Patna, Bihar which provides holistic care to critically unwell PLHA.

PARTICIPANTS

We purposively selected 29 participants: 10 critically unwell PLHA, 5 caregivers of hospitalised patients, 7 relatives of deceased patients who were treated in the secondary care hospital and 7 key informants from community-based organisations.

RESULTS

Critically ill PLHA emphasised the need for psychosocial counselling and opportunities for social interaction in the ward, as well as a preference for components of home-based palliative care, even though they were unfamiliar with actual terms such as 'palliative care' and 'end-of-life care'. Critically unwell PLHA generally expressed preference for separate, private inpatient areas for end-of-life care. Relatives of deceased patients stated that witnessing patients' deaths caused trauma for other PLHA. Caregivers and relatives of deceased patients felt there was inadequate time and space for grieving in the hospital. While both critically ill PLHA and relatives wished that poor prognosis be transparently disclosed to family members, many felt it should not be disclosed to the dying patients themselves.

CONCLUSIONS

Despite expected high inpatient fatality rates, PLHA in Bihar lack access to palliative care services. PLHA receiving end-of-life care in hospitals should have a separate dedicated area, with adequate psychosocial counselling and activities to prevent social isolation. Healthcare providers should make concerted efforts to inquire, understand and adapt their messaging on prognosis and end-of-life care based on patients' preferences.

Psychosocial Aspects of COVID-19 in the Context of Palliative Care - A Quick Review

In a resource-poor country like India, where the health-care systems are difficult to access, overburdened, and unaffordable to many, the impact of the coronavirus disease 2019 (COVID-19) pandemic can be devastating. The increased burden of serious health-related suffering can impact the well-being of health-care workers, patients, and their families alike. The elderly, the frail, the vulnerable, and those with multiple comorbidities are disproportionately affected. Palliative care, with its comprehensive and inclusive approach, has much to offer in terms of alleviating the suffering, particularly those caused by the distressing physical and psycho-socio-spiritual symptoms, the complex medical decision-making, end-of-life care issues, and grief and bereavement, and needs to be integrated into the pathway of care provision in COVID-19. Psychosocial issues contribute to and amplify suffering and are often underestimated and undertreated and not accessible to many. Empowering frontline professionals in the core concepts of psychosocial support and palliative care thus becomes an absolute necessity. This quick review was done by a group of palliative care physicians and mental health experts from India to develop recommendations for physical and psychosocial care in the context of COVID-19. This review was done as part of that process and highlights the role and challenges of the psychosocial domain of palliative care in the context of COVID-19 situation in India.

Comparison of The Hospice Palliative Care Delivery Systems in Iran and Selected Countries

Background: There is an increasing demand for Hospice Palliative Care (HPC) due to the aging population, increased incidence of cancer, and other chronic diseases, as well as recent advances in care and treatment. Objectives: The present study was conducted to examine the nature and structure of HPC services and to describe and compare them in the United Kingdom (UK), Canada, Australia, Japan, India, Jordan, and Iran to extract general conclusions and suggestions for developing HPC systems in Iran. Methods: In the current descriptive-comparative study, from 2018 to 2019, HPC delivery systems in the selected countries and Iran were reviewed based on the World Health Organization (WHO) guideline, and the similarities and differences among them were explained. Results: Developing the National HPC Program and its integration into the health system are important activities. The most common source of financing is donation. The services are mainly provided to patients with cancer. Human resource development includes curriculum reform, creating specialty, subspecialty disciplines, and holding training courses. Other activities include designing national guidelines, the free access to opioids, research development, the establishment of the national information network, and the quality control programs. Iran lacks any formal structure and program of HPC services and they are provided in a scattered and very limited manner as part of general palliative services. Conclusions: HPC services are in a mediate and low level in developed countries and Iran, respectively. Before the establishment of the HPC delivery system, a complicated range of economic, social, cultural, and political factors must be considered.

Understanding family carer experiences of advanced dementia caregiving in India: towards a vision for integrated practice

Purpose

Many individual and family hardships are associated with poorly understood palliative care needs arising from advanced dementia within India. The purpose of this paper is to explore the experiences of people in India affected by advanced dementia and to shape educational approaches for practitioners and the local community.

Design/methodology/approach

Three focus groups with family carers of people (n = 27) with advanced dementia were undertaken with local communities in South India. One focus group was carried out in English and two in the local language (Kannada) and translated to English.

Findings

The findings of the focus groups are presented in four themes, conditions of caring, intersecting vulnerabilities, desperate acts of care and awareness of education and training needs. These themes highlight the challenges faced by family carers of people with advanced dementia and describe the potential harm, abuse and poor mental well-being facing both the person with dementia and the family carer as a result of their situation.

Research limitations/implications

There is a need to explore ways to ensure inclusivity and sensitivity in the research process and enable equal participation from all participants.

Practical implications

The findings highlight a lack of support for family carers of people with advanced dementia and demonstrate the need for dementia-specific integrated and palliative care approaches in India.

Originality/value

This paper provides insight into the experiences and challenges facing family caregivers of people living with advanced dementia in India to shape practitioner education in a way that will underpin effective dementia-specific palliation and integrated services.

Rural Elderly and Access to Palliative Care: A Public Health Perspective

In near future, the elderly population will increase to a high proportion. This will increase the burden of Age-Related Diseases (ARDs) to a significant level. Most of the ARDs need palliative care (PC) for a fairly long duration. Some statistical extrapolations are discussed to help in identifying this future burden. The existing PC centers are limited in numbers, situated mainly in urban areas, and mostly attached to cancer hospitals. Socioeconomic vulnerabilities of the elderly, especially in rural areas, are high, and access to health is also not optimal. In the coming decades, the number of needy people, as well as the demand for PC, will increase. Existing numbers indicate that exponential increment in quantum and quality of PC services is required to deal with the imminent burden. Specific suggestions are made to use existing public health programs to cater to the rural elderly.

Palliative care for people living with HIV/AIDS: Factors influencing healthcare workers' knowledge, attitude and practice in public health facilities, Abuja, Nigeria

Background

Physicians and nurses play vital roles in addressing palliative care (PC) needs of people living with HIV/AIDS (PLWHA). The healthcare workers’ (HCWs) experiences determine the success of palliative care delivery. There is paucity of data on PC for PLWHA. For this reason, we assessed the knowledge, attitude and practice of PC for PLWHA and associated factors among health care professionals.

Methods

We conducted a cross-sectional descriptive study among HCWs in public health facilities in the Federal Capital Territory, Nigeria between February and May, 2017. Multistage sampling technique with proportionate-to-size allocation was used to determine facility sample size and HCWs per professional discipline. Data were collected with questionnaires adapted from Palliative Care Quiz for Nursing, Frommelt Attitude toward Care of the Dying and practical questions adapted from PC standard guidelines. Participants' knowledge, attitude and practice were assessed by awarding one (1) point for each correct answer; incorrect or “not sure” answers took a zero (0) score. Correct responses were summed up to get a total score for each participant. Descriptive statistics was done to describe frequencies and proportions displayed on tables. Linear regression was done to determine factors associated with HCW’s knowledge, attitude and practice of PC for PLWHA

Result

With a 100% response rate, the mean age of the 348 participants was 37.5 years (SD: ±8.9), 201 (57.8%) were female, 222 (63.8) were nurses and 230 (66.0%) had a work experience of 10 years or less. Majority of the participants, 310 (89.1%) agreed that palliative care focuses on the relief and prevention of suffering and 319 (91.7%) believe that PLWHA required palliative care. Misconceptions about palliative care include “palliative care is disease-oriented and not person oriented”, 252 (72.6%) believed; “palliative care is concerned with prolongation of life”, 279 (80.6%); and “use of placebos is appropriate in the treatment of some types of pain”, 252 (72.6%). Among the participants, 52% disagreed that “palliative care should be given only for dying PLWHA” while only 18 (5.2%) were right on “family should be involved in the physical care of the dying PLWHA”. Majority of the participants, 292 (84.1%) initiated palliative care discussion during patients’ diagnosis while 290 (83.6%) informed terminally ill patients about their diagnosis. Regarding psychological issues, 22 (6.3%) participants hid the truth from the patients while 196 (56.3%) provided emotional support to the patients. Morphine 240 (69.0%) and Pentazocine 194 (55.7%) were the most commonly used drugs for treatment of severe pain by participants across all centres.

Conclusion

In-service training and undergraduate training on palliative care were associated with knowledge and practice of palliative care for people living with HIV/AIDS. We recommended continuous quality in-service training and education on palliative care for HCWs. While we ensure voluntariness of participation and other ethical principles, the high response rate could be as a result of more motivated health worker than the norm. The results are unlikely to be representative of doctors and nurses in primary health care centres.

Health-related quality of life and its socio-economic and cultural predictors among advanced cancer patients: evidence from the APPROACH cross-sectional survey in Hyderabad-India

Background

Patients with advanced cancer often experience poor health-related quality-of-life (HRQoL) due to cancer and treatment-related side-effects. With India’s palliative care landscape in its infancy, there is a concern that advanced cancer patients, especially individuals who are from disadvantaged populations experience poor HRQoL outcomes. We aim to assess HRQoL of advanced cancer patients in terms of general well-being (physical, functional, emotional, and social/family well-being), pain experiences, psychological state, and spiritual well-being, and determine the relationship between belonging to a disadvantaged group and HRQoL outcomes. We hypothesize that patients from disadvantaged or minority backgrounds, identified in this paper as financially distressed, female, lower years of education, lower social/family support, minority religions, and Non-General Castes, would be associated with worse HRQoL outcomes compared to those who are not from a disadvantaged group.

Methods

We administered a cross-sectional survey to 210 advanced cancer patients in a regional cancer center in India. The questionnaire included standardized instruments for general well-being (FACT-G), pain experiences (BPI), psychological state (HADS), spiritual well-being (FACT-SP); socio-economic and demographic characteristics.

Results

Participants reported significantly lower general well-being (mean ± SD) (FACT-G = 62.4 ± 10.0) and spiritual well-being (FACT-SP = 32.7 ± 5.5) compared to a reference population of cancer patients in the U.S. Patients reported mild to moderate pain severity (3.2 ± 1.8) and interference (4.0 ± 1.6), normal anxiety (5.6 ± 3.1) and borderline depressive symptoms (9.7 ± 3.3). Higher financial difficulty scores predicted most of the HRQoL domains (p ≤ 0.01), and being from a minority religion predicted lower physical well-being (p ≤ 0.05) and higher pain severity (p ≤ 0.05). Married women reported lower social/family well-being (p ≤ 0.05). Pain severity and interference were significant predictors of most HRQoL domains.

Conclusions

Advanced cancer patients, especially those with lower financial well-being and belonging to minority religions, reported low physical, functional, emotional, social/family, and spiritual well-being, and borderline depressive symptoms. Future studies should be directed at developing effective interventions supporting vulnerable groups such as those with financial distress, and those belonging to minority religions.

Palliative Care Program Development in a Low- to Middle-Income Country: Delivery of Care by a Nongovernmental Organization in India

Purpose

Limited data describe the delivery of palliative care services in low- and middle-income countries. We describe delivery of care by the Trivandrum Institute of Palliative Sciences (TIPS) in Trivandrum, India.

Methods

Administrative records were used to describe case volumes, setting of care, and organizational expenditures. An estimate of cost per clinical encounter was derived by dividing 2016 monthly clinical expenditures by the number of patient visits. Costs are reported in US dollars and are corrected for Organization for Economic Co-operation and Development purchasing power parity (PPP).

Results

A total of 11,620 new patients were seen at TIPS during 2007 to 2016; 59% had cancer. The average annual growth rate in case volumes was 18% (480 new patients in 2007 and 1,882 in 2016). The proportion of patients with cancer increased over time from 56% in 2014 to 66% in 2016 (P < .001). During 2014 to 2016, outpatient visits increased 26% (from 8,524 to 10,732), inpatient days increased 49% (from 1,763 to 2,625), inpatient visits at other hospitals increased 41% (from 248 to 417), and home visits increased 57% (from 3,951 to 6,186). Total clinical expenditures in 2016 were $288,489 (PPP corrected, $5.1 million). Between 2014 and 2016, the cost of delivering care increased by 74%. The mean cost per clinical encounter in 2016 was $15 (PPP corrected, $263).

Conclusion

Demand for palliative care services has increased substantially, with an increasing proportion related to cancer. The organization of clinical services by TIPS may serve as a model for the development of other palliative care programs in low- and middle-income countries.

Effectiveness of different methods of health education on knowledge and attitude regarding palliative care among college students in urban Puducherry: a pre-post intervention study

Background The World Health Organization estimates that around 6 million people need palliative care in India but not even 1% of the patients have access to it. Objective To find the prevalence of knowledge on palliative care and compare the effectiveness of different methods of health education on attitude regarding palliative care among urban college students in southern India. Subjects A pre-post intervention study was conducted in three different arts, science and commerce colleges in urban Pondicherry in August 2017. Methods Data regarding attitude change towards palliative care by three different modes of intervention in the three colleges: health talk (Group A), health talk with video (Group B) and health talk and interaction with a patient's caregiver (Group C) - before and after intervention - were collected using a predesigned pretested structured questionnaire. Results Among the 65, 75 and 67 participants in Groups A, B and C, respectively - the majority belonged to urban nuclear families; the mean age was 19.5 (0.9) years and Group C had only female students. The prevalence of knowledge about palliative care was found to be 9.2%. There was a difference in attitude scores among the three groups (p = 0.02) with Group C having the highest change of a score with a median of 2 (-1,5). Conclusion Awareness about palliative care is very low among non-medical undergraduate college students of urban Pondicherry. The best method of health education in changing the attitude towards palliative care was interaction with patient's caregiver.