BRIEF OVERVIEW OF

PALLIATIVE CARE
DR PRADEEP KULKARNI
CONSULTANT IN PALLIATIVE MEDICINE,
BHARATI VIDYAPEETH MEDICAL COLLEGE AND HOSPITAL, PUNE
 ROLE OF PHYSICIAN

TO CURE SOMETIMES

TO RELIEVE OFTEN

TO COMFORT ALWAYS

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 MEDICINE’S SHIFT IN FOCUS . . .
 Explosion in Science, technology, communication
 Potential of medical therapies- “fight aggressively” against illness and
death- Prolong life at all cost

 Improved sanitation, public health, antibiotics, other new therapies-

increasing life expectancy -2006- avg 64 y (F: 65 y; M: 63 y)

 Marked shift in values, focus of society as “death denying”

Value - productivity, youth, independence

3 Devalue - age, family, interdependent caring
 NON COMMUNICABLE
DISEASES
 Affect age group- 35 to 65.

 Require long term psychosocial support.

 Cause economic loss to society.

 Home based, low cost intervention is necessary.

 NCD- cancer, AIDS, organ failures, neurological diseases,

diabetes, hypertension, dementia.
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 NON COMMUNICABLE DISEASES (NCDS)
 58 million people die in the world every year
 38 million of these people die of chronic life limiting illnesses.
 In India out of 98 lacks total deaths, of which 58.69 lack deaths are
due to NCDs.

 Family and carers need help and assistance in caring

 100 million people in need of care

 Majority of pts die in institutions

 Generalized lack of familiarity with dying process, death

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Data from World Palliative Care Alliance 2012 and recent NHSRC data
CURRENT MEDICAL
REALITY
 Focus on curing
disease using
investigative and
treatment-oriented
approach
 Technology in pace
with increasing life
expectancy
 Most money spent in
hospitals
 PALLIATIVE CARE DEFINITION

Palliative care is an approach, that improves the

quality of life of patients and their families, facing
the problems associated with life-limiting illness.

This is achieved through the prevention and relief of

suffering by means of early identification,
impeccable assessment and treatment of pain and
other problems, physical, psychosocial and spiritual.

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..
Disease Trajectory- When?

JPG

8 Palliative Care: Expanding Role and New Approaches  :Academic Internal Medicine Insight | 2010 | 8:3, 609
 PALLIATIVE CARE –
WHEN TO CONSULT
Disease
Early advancement Decompensation Decline and
last days
Experiencing life Death and
limiting illness Dependency and bereavement
symptoms increase

Transitions Transitions Transitions Transitions Transitions

Time of
Diagnosis

Time
McGregor and Porterfield 2009

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CONTINUUM OF PALLIATIVE
CARE

 Health care providers often perceive that palliative care referral is appropriate
only when patient is dying. Palliative care referral is best initiated early, often
at the time of diagnosis.
 Continuum of palliative care supports the patient and family during EOL phase,
process of dying and supports the family during the after death phase and
bereavement period.
FACTS ABOUT PALLIATIVE CARE

 Should be from diagnosis

 It’s not only in end of life
 It’s not only pain management
 Patient and family both are cared
 Physical,social, psychological, spiritual
 Good communication
 Reduces cost of care
PALLIATIVE CARE – HOW IT HELPS

 By reducing pain and suffering

 By improving Quality of life
 By Improving patient-physician communication
Coordinate continuity of care across settings
 By giving support to family during the patient´s
illness and bereavement
WHERE

 HOSPICE
 HOME
 HOSPITAL
 ESSENTIAL COMPONENTS OF
PALLIATIVE CARE

Symptom relief Psychological support

Realistic Hope

Teamwork and partnership

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 PHYSICAL

SUFFERING
PSYCHOSOCIAL EMOTIONAL

SPIRITUAL
PAIN AND
SUFFERING
PHYSI
CAL

TOT
SPIRIT AL
SOCI
UAL PAI
AL
N

PSYCHOLO
GICAL
 Quality of Life

Palliative Care

Team-based Appropriate
Relief from care for at any stage
symptoms, patient & & can help
pain & stress family patients get
better

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 Quality of life
 Very REALITY
subjective
perception
 Reflects gap
between
QoL
expectation EXPECTAT
ION
and reality
 Aspects Of Quality Of Life
 Treatment of pain
 Relief from worry
• Honest
communication
• Support for family

• Care for dignity

• Respect for
personal choice
Palliative Care
Consultation

Diseases
o Cancer
Chronic heart disease – breathlessness at rest
Chronic Kidney failure – after failure of transplant,
multimorbidity
COPD and restrictive lung disease – poor airway reserves
Neurological diseases – deterioration of cognitive function
Dementia – unable to to ADL, unable to communicate
meaningfully
Advantages of Home care
 Often preferred by
patients.
 Familiar surroundings.
 Non medical
environment.
 Maintained family life.
 Close to family and
friends.
 Palliative care isn’t just…
 …Hospice care

 … symptom management that can only be

provided when the curative options are closed

 … Support provided at the end of life to make a

patient comfortable

 … Giving doctors the authority to end curative

treatment or rational care
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 Team Work

 A team is defined as “a group of individuals with a common

purpose of working together.”

 The patient and his/her family are the central members of the team.

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 Models Of Care

 Edmonton- home care, in-patient care, tertiary palliative

care unit and consulting service to support primary care in
community and acute care setting

 Integrated Community based Home Care in South Africa-

draws on hospice and community resources.

 Neighborhood Network in Palliative Care, Kerala -

sustainable
26 community owned service
 Barriers To Palliative Care Services
 At least 100 million people worldwide would benefit from hospice
and palliative care
 Less than 8% of those that need hospice and palliative care access it

Barriers include:
 lack of funding
 lack of trained health professionals
 neglect of hospice and palliative care in policy at the global and
national level
 poor access to medications, particularly opioids.

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 Scope of Palliative Care In India
 Around one million patients with cancer at any point of time need
Palliative Care
 An equal number of patients suffer from other incurable diseases-
cardiac, respiratory, neurological

 Paediatric Thalassemia, HIV, Neurological disorders

 HIV/AIDS- more than 300,000 die per year

 Rapid increase in the number of aged population- The highest

number of patients in need of palliative care in future will be
from amongst the elderly ill

28All these pts can benefit from Palliative Care

 Scarce resources can be utilized better
 Mile Stones

 1987- 1st hospice in India Shanti Avedana

 1994- Pain & Palliative care society

 1994- IAPC

 1997- Establishment of Cipla Palliative Care Centre.

 2008 -Kerala 1st state –palliative policy

 2012 –Palliative Medicine as a specialty

 2013 –Maharashtra 2nd state to have a palliative policy

 MORPHINE AVAILABILITY
1985- NDPS Act & Amendments
India is one of the largest producer of opium gum
1985- Morphine consumption was 540 kg
1997- Morphine consumption was 18 kg
2010- Morphine consumption was 1500 kg
Morphine requirement for pain relief for needy patients is
35000 kg.
Pain and policy group, Wisconsin university, guides the
government.
GLOBAL CONSUMPTION
India
0.08 Tanzania
U.S. (2001) 0.03
45.08

Nepal
PAKISTAN 0.001
Saudi 0.06
Arabia
0.53
WHO ANALGESIC LADDER

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ELDERLY IN INDIA

1.21 billion total, 104million senior citizen,8.6% of total population,
slightly more female.

73 million in rural,31 million urban

60% working, more so in rural,

Average life expectancy after 60 is 17.9years, slightly more in females

www.mospi.gov.in
WHICH PATIENTS ?
ADVANCE CARE PLANNING

 Early communication
 Proxy can be chosen
 Place of care can be chosen
 Unnecessary interventions are reduced
 Autonomy respected
 Legally not binding
THE LEGAL POSITION IN INDIA
Court Judgement on 9 March 2018
 Living will is a valid document
 Legal procedure is tedious
 Hospital committee and The Collector are deciding
 Time consuming
 At least a step forward
 Doctrine of double effect
 Futility is acceptable to law
WHAT IS A GOOD DEATH –
PRINCIPLES AND COMPONENTS

 Components of a Good Death

 Pain and symptom management, clear decision-making,

preparation for death, completion, contributing to others, and
affirmation of the whole person
 Principles of a Good Death
QUALITY OF DEATH INDEX
 Basic end-of-life
health care
environment (20
%weightage)

 Availability of end-of-
life health care (25
%weightage)

 Cost of end-of-life care

(15 %weightage)

 Quality of end-of-life
care (40 %weightage)
 CAREGIVER’S ROLE
 Advocate of patient.

 First to detect the symptoms.

 Needs to be empowered.

 Mediators between Doctor and Family.

 Resolving the collusions.

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IT MATTERS
 Thank You !

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