Palliative Care Beyond Oncology!

The World Health Organization (WHO) defines ‘Palliative care’ 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. This broad definition does not distinguish between cancer and non-cancer patients. Over a period of time, the term ‘palliative care’ has become synonymous with cancer-related patients. Most of the research publications on palliative care are related to the issues involving patients suffering from cancer in some form or the other, involving one system or more. A broad PubMed search with terms ‘palliative care’ produces 42,649 hits; articles mostly related to cancer patients. There is another subgroup of non-cancer or non-malignancy patients; PubMed search reveals only 90 articles in relation to them.

Several non-cancer conditions were identified in our search. Non-malignant lung conditions such as chronic obstructive lung diseases, asbestosis, cystic fibrosis, and other parenchymal lung diseases require palliative services for management of symptoms such as pain, breathlessness, inability to maintain oxygenation, cough, anxiety, and even depression. Conditions relating to the gastrointestinal system requiring palliative services have also been identified. Chronic abdominal pain, chronic pancreatitis, and malignant bowel obstruction are some of them. Patients with life-threatening cardiac problems and others with abnormal spine conditions, such as osteoarthritis, kyphoscoliosis, and spinal cord malformations requiring orthopedic interventions may at times be bed-ridden for prolonged periods and so cannot be devoid of palliative care. Patients having undergone colostomy form a very special “stoma group” who may require repeated counseling and care to improve their day-to-day lining and quality of life. Patients with end-stage renal disease require special care and monitoring. One cannot neglect the needs and requirements of patients with AIDS or the HIV positive individuals. Apart from symptomatic care, they also require psychological and emotional support to help them adjust in the society. Neurological patients form an important group utilizing palliative care services, but have received less attention in this field. Unlike the short life-span in terminally-ill cancer patients, neurologically-impaired patients have a more variable duration of life, and some may even respond to various medical therapies. Care of the neurological patients poses greater challenges as they may have other disabilities such as cognitive dysfunctions, communication problems, altered sensorium, physical and other behavioral problems. Patients with stroke, epilepsy, dementia, and spinal problems also require palliative care. Neuropathic pain syndromes are debilitating conditions that require active interventions. Trigeminal neuralgia is one of the commonest causes of facial pain that can affect the daily activity and quality of life of the individuals. A recent study by Holloway[1] revealed that patients with stroke are a common diagnosis seen on an inpatients palliative care consult service; accounting for nearly 6.3% of all palliative care consultations alone. Another retrospective data shows that neurologic patients formed the second largest group who were seen in the palliative care service centers. ‘Comfort measures’ and ‘hospice candidancy’ were the main reasons for their consultation, and Chahine and colleagues[2] emphasized on understanding the need of these neurologic patients to tailor their palliative care services. Pain appears to be the commonest symptom requiring treatment. However, complaints such as anxiety, depression, dysphagia, and breathlessness also require palliative services. In general, it may be expected that the needs for palliative care are similar for both cancer and non-cancer patients. But, there still remains dissimilarity in the two groups of patients. Non-cancer patients have a gradual decline in functional activity compared to sudden functional decline in cancer patients. Symptoms such as nausea, vomiting, and pain are more likely to occur in cancer patients. It is, therefore, important to understand the needs for palliation in the non-cancer patients.

With the ever increasing complexities of day–to-day life and advances in medical science, more and more people with neurological problems are likely to live longer. Palliative care in India is no longer in an infancy stage. Appropriate timely management of symptoms improves the quality of life in these patients. Pain, by far, appears to be the most common presenting symptom requiring palliative intervention in most of the cancer and non-cancer conditions. Literature is scarce on these issues although the need to have palliative services for non-cancer patients was realized nearly two decades ago.[3] A lot of work has been performed, but more needs to be done in terms of creating awareness and producing data. This emphasizes the need for well-planned and effective palliative care facilities and more research in these areas.