Future of palliative medicine

Response to COVID-19 Crisis with Facilitated Community Partnership among a Vulnerable Population in Kerala, India – A Short Report

The unexpected lockdown announced by the Government of India in March 2020 in response to the pandemic left the coastal community in Kerala deprived of not only essential amenities but also healthcare. Some poverty-ridden, over-crowded coastal regions had been declared as critical containment zones with severe restriction of movement, adding to their vulnerability. People with serious health-related suffering (SHS) in this community required urgent relief. A group of educated youth in the community joined hands with a non-governmental organisation specialised in palliative care (PC) services and strived to find the best possible solutions to address the healthcare needs in their community. This paper reports the collaborative activities done during the pandemic in the coastal region and compares the activities with steps proposed by the WHO to develop community-based PC (CBPC). By engaging, empowering, educating, and coordinating a volunteer network and providing the required medical and nursing support, the programme was able to provide needed services to improve the quality of life of 209 patients and their families who would have been left with next-to-no healthcare during the pandemic. We conclude that even in the context of much poverty, delivery of CBPC with the engagement of compassionate people in the community can successfully reduce SHS.

Prioritizing Chinese medicine clinical research questions in cancer palliative care from patient and caregiver perspectives

BACKGROUND

Chinese medicine (CM) modalities, including acupuncture and Chinese herbal medicine (CHM), are popular palliative interventions among patients with cancer, but further clinical research is required to assess their effectiveness and safety.

OBJECTIVE

To prioritize top ten important CM clinical research questions from patients with cancer, cancer survivors and caregivers' perspectives via a face-to-face prioritization workshop in Hong Kong.

METHODS

A list of 25 CM clinical research questions for cancer palliative care, which were identified from existing systematic reviews (SRs) and overview of SRs, was presented to 17 participants (patients with cancer [n = 5], cancer survivors [n = 6] and caregivers [n = 6]). The participants were then invited to establish consensus on prioritizing top ten research questions.

RESULTS

Among the top ten priorities, five (50%) focused on acupuncture and related therapies, while five (50%) were on CHM. The three most important research priorities were (i) manual acupuncture plus opioids for relieving pain; (ii) CHM for improving quality of life among patients receiving chemotherapy; and (iii) concurrent use of CHM plus loperamide for reducing stomatitis.

CONCLUSION

The top ten participant-endorsed CM clinical research priorities for cancer palliative care can guide local researchers on future direction. They can also inform local research funders on patient-centred allocation of limited funding. Under limited research funding, the most important co-prioritized research question from professional and patient perspectives may be addressed first.

PATIENT OR PUBLIC CONTRIBUTION

Patients with cancer, cancer survivors and caregivers participated in conduct of the study to prioritize CM clinical research questions.

Prioritizing Chinese Medicine Clinical Research Questions in Cancer Palliative Care: International Delphi Survey

CONTEXT

Chinese medicine modalities, including acupuncture and Chinese herbal medicine (CHM), have been used as palliative interventions among cancer patients. More research should be conducted to confirm their effectiveness.

OBJECTIVES

The objective of this study was to prioritize Chinese medicine clinical research questions for cancer palliative care.

METHODS

Twelve international experts, including physicians, Chinese medicine practitioners, nurses, and clinical research methodologists (n = 3 from each category), from Asia, North America, Australia, and Europe participated in a two-round Delphi survey for prioritizing 29 research questions identified from existing systematic reviews. The experts were asked to 1) rate clinical importance of answering the questions on a nine-point Likert scale; 2) provide qualitative comments on their ratings; and 3) suggest outcome measurement approaches.

RESULTS

Eight research priorities reached positive consensus after the two-round Delphi survey. Six of the priorities focused on acupuncture and related therapies, of which median ratings on importance ranged from 7.0 to 8.0 (interquartile range: 1.00 to 2.50), and the percentage agreement ranged from 75.0% to 91.7%. The remaining two priorities related to CHM, with median ratings ranged from 7.0 to 8.0 (interquartile range: 1.00 to 1.50) and percentage agreement ranged from 75.0% to 83.3%. Neither positive nor negative consensus was established among the remaining 21 questions.

CONCLUSION

The findings will inform rational allocation of scarce research funding for evaluating the effectiveness of Chinese medicine for cancer palliative care, especially on acupuncture and related therapies. Further research on herb safety and herb-drug interaction should be performed before conducting international trials on CHM.

End-of-Life Practices in Rural South India: SocioCultural Determinants

Introduction:

End of life care of terminally ill is a sensitive topic in our socio cultural ethos. In a country where Euthanasia policies are widely debated, dignified death is a desired form of death. Euthanasia literally means “good death”. In India the debate still continues on practices related to euthanasia and its legalization until recently when the verdict on the passive euthanasia has been passed by the supreme court. In addition, lack of an effective palliative care system has led to complex situations towards the end of life. Globally, it is estimated that palliative care is needed in 40-60% of all deaths. However there is no training or facility to meet this demand.

Methodology:

A focus group discussion (FGD) was carried out among 22 residents in a rural area of Tamilnadu to identify the social and cultural determinants of end of life care practices. A FGD guide was prepared and after an informed consent the study was undertaken. An in depth interview was carried out among a sub group of participants.

Results:

The FGD and the IDI revealed several end of life practices in the rural areas such as Thalaikoothal, Feeding the ill with holy water and sand etc. The study also revealed the major determinants leading to such practices such as the social, and cultural beliefs in addition to economical and emotional factors.

Conclusion:

Several factors determine the end of life decisions in a family ranging from economical to social and cultural factors. While we are examining these factors, it is important to strengthen the palliative care provision in the country by building capacity and integrating it in primary care.

Evaluation of Community-based Palliative Care Services: Perspectives from Various Stakeholders

Background

As a part of Memorandum of Understanding with Tamil Nadu Institute of Palliative Medicine, community-based palliative care services have been initiated 2 years back in our urban field practice areas.

Aim

The aim of this study was to evaluate the home care service, a major component of our community-based palliative care, with a view to identify the unmet needs of the services rendered for decision-making about the program.

Materials and Methods

It was a descriptive qualitative design carried out by the authors trained in qualitative research methods. In-depth interviews were done among four patients, seven caregivers, two social workers, six nursing staffs, and six medical interns for a minimum of 20 min. Interviews were audiorecorded, transcribed verbatim, and content analysis was done manually. Ethical principles were adhered throughout the study.

Results

Descriptive coding of the text information was done; later, similar codes were merged together to form the categories. Five categories under the theme of strengths and five codes under the theme of challenges of the home care services emerged out. Categories under strengths were physical management, psychological care, social support, efficient teamwork, and acceptance by the community. Codes for felt challenges were interdisciplinary collaboration, volunteer involvement, training enhancement, widening the services, and enhancing the community support.

Conclusions

This review revealed the concerns of various stakeholders. There is a need for more interprofessional collaborations, where team members understand each other's roles for effective teamwork, as evident from the framework analysis.

Integration of Specialized Pain Control Services in Palliative Care: A Nationwide Web-based Survey

Introduction:

Pain control is an important part of palliative care (PC), and conventional analgesics do not provide adequate pain relief to all patients. Many patients present with complex pain syndromes that require interventional pain control measures usually deployed by pain specialists. There is adequate integration of specialized pain control services with PC elsewhere, but information about the same in our country is lacking.

Materials and Methods:

An internet survey was conducted among palliative specialists regarding the need and availability of pain specialists for their patients suffering from complex pain syndromes. Their attitude toward integrating specialized pain control services in their practice was also explored.

Results:

Majority of palliative physicians came across situations where specialists in pain would control the patients’ pain better. There was a poor availability of such services, and when available, the cost was significant. It is heartening to note that though there is poor integration of specialized pain control services with palliation, palliative physicians acknowledge the need for pain specialists and their techniques for providing pain relief for their patients.

Conclusions:

Effective pain control is needed in palliation, barriers however exist, and there is a need to make pain specialists and interventional techniques more freely available.