Pain and Palliative Care

Why should it matter to us?

Dr. Sushma Bhatnagar

Professor & Head
Department of Onco-Anaesthesia, Pain & Palliative Medicine
All India Institute of Medical Sciences,
New Delhi, India
 Progress in Medicine : Some
milestones
• 10000 BC: Witch doctors  1892: Discovery of viruses

• 6500 BC: Trepanation  1928: Penicillin

• 3000 BC: Sutures  1943: Dialysis

• 1284: Eyeglasses  1948: RCT

• 1798: Smallpox vaccination  1955: Polio vaccine

• 1842: GA  1977: MRI

Medical Science in relation to cancer:
Present Scenario

Molecular
Immunology Biology

Nanotechnology Robotics
 Progress of therapeutics
The positive side
• Cancers going incurable to curable
• Less invasive surgeries
• Increased life expectancy and five year
survival rates
• Emerging pain management modalities
• Better drug profiles
 Progress of therapeutics
Negative aspects
Increased Life Emergence of new
expectancy complications
Ventilation associated
? Growing complications
problems
?Recurrence rates New drug resistant flora

Worsened Quality of
Better drug ? life?
Growing End of life care
costs? issues?
Progress of therapeutics :Major loss

• Loss of Confidence
1

2
• Increased cost burden to families

• Loss of trust in health care system

3
Various other condition needs rethinking
Cancer
Chronic Cardiac disease
Chronic pulmonary disease
Kidney failure,
Alzheimer's,
HIV/AIDS
Amyotrophic Lateral Sclerosis (ALS)
Post COVID syndrome
Possible answer – Palliative care
 Philosophy of palliative care

“The task of medicine is to care

even when it cannot cure.”

Palliate – “To reduce the violence of (a disease)"

and “To ease (symptoms) without curing the
underlying disease.”
 Idea of Medical Futility

The famous Hippocratic corpus included

a promise

not to treat patients who were

“overmastered by their disease.”
 Dame Cicely Mary Saunders
(22 June 1918 – 14 July 2005) was an English Anglican
nurse, social worker, physician and writer, involved
with many international universities.
She is best known for her role in the birth of the
hospice movement, emphasizing the importance of
palliative care in modern medicine
 Prof Balfour Mount
The term ‘palliative care’ was coined first in 1975
Mount developed a comprehensive hospital-based service at the
Royal Victoria Hospital, Montreal that included an in-patient ward,
consultation service, home care programme, and bereavement
support service under the name Palliative Care service by which he
meant non-curative therapy aimed at improving the quality of life.
 Dr Robert Twycross

“Hospice palliative care was initially a protest

movement against medical neglect in the
post-war years when doctors had more they
could do to cure, then the dying presumably
got more and more neglected”.
Palliative care in India is deep rooted

King Ashoka (273-232 B.C)

We have ancient traditions in India of looking after those
who are dying with special care and attention

18 institutions built very similar to modern hospices.

He had even established a refuge for the dying in
Varanasi near the sacred river Ganges.
 Few milestones of development ofd
Palliative care in India
1993- Pain and Palliative Care Society (PPCS) was
established in Kerala
1994- IAPC was registered as Public Trust and Society
at Ahmedabad
1994- 1st International Conference of IAPC at Varanasi
2012-MCI recognized Palliative Medicine
2014- Amendment of NDPS Act
2021- DNB, Palliative Medicine
 WHO Definition 1990
• Palliative care is the active, total care of
patients with progressive, far advanced
disease and limited life expectancy whose
disease is not responsive to curative
treatment. It refers to the control of pain and
of other symptoms as well as the treatment of
social, psychological, and spiritual problems.
 WHO Definition 2002

PC is an approach that improves the quality of life of

patients and their families facing the problem
associated with life-threatening illness, through the
prevention and relief of suffering by means of early
identification and impeccable assessment and
treatment of pain and other problems, physical,
psychosocial, and spiritual.
 IAHPC- Definition

Palliative care is the active holistic care of

individuals across all ages with serious health-
related suffering due to severe illness, and
especially of those near the end of life. It aims to
improve the quality of life of patients, their families
and their caregivers.
Goals Of Palliative Care
 Palliative care : Positive outcomes

Better Better
Family understanding Informed patient-
of diagnosis
meetings choices physician
and prognosis
relationship
Palliative Care is often misunderstood to be
End-of-Life Care
 Traditional Model
Palliative
Anticancer Treatment
Care

Diagnosis Death
 Two ends of the
continuum of care of a patient
“Diagnostic and Therapeutic Strategies” “Comfort Care”

Not end of life care

Jennifer S. Temel et all: Early Palliative Care for Patients with Metastatic Non–
Small-Cell Lung Cancer, N Engl J Med 2010;363:733-42.
There is now robust evidence
that specialist palliative care
services make a difference
Randomised controlled trial of early vs late referral
to palliative care for people with metastatic
non-small cell lung cancer.
Palliative care group had significantly:
- better quality of life (FACT–L)
- less depression
- fewer people getting aggressive therapy
- better survival (11.6 vs 8.9 months)

Temel J et al. N Eng J Med 2010

What extra we need to learn in medicine
• Maintenance of vital functions
• Reduce mortality
• Prevent morbidity
• Realistic Hope
• Honest information
• Maintain QOL as much as possible till the end
Need to teach HOLISTIC CARE
(Dame Cicely Saunders -1960)
 You are already on the track
• Realised the need
• Started working
• Create System with available resources
• Shared knowledge, motivate and inspire
• Create manpower
• Follow up on time to time
To improve awareness and knowledge
IRCH,AIIMS
• DMG
• Ambulatory palliative care team/pager team.
• DIRC discussions
• Rotation posting
• Academic activities & joint teaching sessions
• Regular audit of palliative care activities
• Coordination with home care teams
 Palliative care in ICU
14– 20% of ICU patients meet the
typical “triggers” for palliative
care consultation

Significant barriers to implementing transitions to PC

1- Recognition of the transition point to palliative care
2- A lack of effective communication between physician and with patients
 Transition to Palliative Care

A transition to Palliative Care is defined as a shift

from ‘curative treatment’ with a focus on cure
or chronic diseases management to ‘Palliative
Care’ with a focus on maximizing quality of life.
 Need to learn three triggers
The Surprise Question: ‘Would you be surprised if
this patient were to die in the next few months,
weeks, days’?
General indicators of decline - deterioration,
increasing need or choice for no further active care.
Specific clinical indicators related to certain
conditions.
Yes- Identify, Assess and Plan
 Models of Palliative care
• Integrative Model
• Consultative Model
• Mixed model
 Barrier at Physician Level

• End of life discussions rarely happens at early

• Perception of need of Palliative care varies

• No formal training and practice of Communication issues.

• Complexity of various stages of the disease

• Dealing with conflicts in intensive care and in OT

 At Patients Level

• Do not leave hope on technological

advancement.
• Remain in denial
• Conflicts of interest
• Poor understanding of health care system
• Ignorance
• Poverty
Benefits of Integration of Palliative
Care in Continuum of care

Patient &
Family

Integration
is
beneficial
for
Staff Organization
Create a system where you want to die

The reality is that most of us end our lives in an ICU

which we never desire!!!!
 Take Home
• Medical science is incomplete without Integration of PC

• Extension of services beyond cancer patients.

• Increasing awareness- patients, physicians and public

• Distinguish: Palliative care from end-of-life care.

• Need to learn teamwork and interdisciplinary approach.

The power of healing does not lie in just prescribing drugs.
What it essentially requires is caring for the patients