Palliative Medicine and People

SYNCHRONIZING THE SUPPLY AND THE DEMAND

Palliative medicine is a relatively new medical specialty with its complete potential not been harnessed till date. Palliative medicine which aims to reducing suffering and improving people's quality of life (QoL) is still a virgin as far as its acknowledgment and outreach is concerned.[1] Lack of acknowledgment of people's suffering, lack of acceptance of a separate medical specialty and apathy are largely responsible for the unheard agony and preventable suffering thriving even five decades after the big bang origin of the modern hospice and palliative care movement. The Indian palliative medicine scenario is a lot worser compared to its western contemporaries. Despite two decades of tiresome and diligent efforts, we are still plagued by lack of acknowledgment both among professionals and laymen and limited outreach, and it lags light years behind other broad specialties. Population explosion, raising incidence of cancer and other chronic ailments, absence of licensing facilities, fragmented scarce efforts, lack of certified training institutions and universally adhered education curriculum, limited access to opioids and other essential drugs, corporate indifference and last but not the least the government palliative care policy going into oblivion are some of the factors launching a multi-pronged attack by increasing the demand and halting the supply. A plethora of independent organizations dedicated and devoted to the palliative medicine have been set up in the country in the past few years. An organized, coordinated and consolidated instead of fragmented effort is necessary to ensure maximum coverage and avoid duplication. Formulating and implementing a ‘Core curriculum for basic and advanced palliative care’ will ensure a uniform, standard and strategic training of all the amateurs pursuing fellowship, postdoctoral certificate and degree courses from these varied institutions. Developing and training in comprehensive palliative care catering to the multidimensional nature of suffering will go a long way in strengthening the roots of holistic approach to patient care. A single certifying board for developing, implementing standards and accreditation should be established for all the courses offered by different institutions. The institutes applying for the accreditation from the certifying board should receive the same upon satisfying uniform set standards comprising requisite number of experienced and qualified faculty, the patient load and an infrastructure for exposure to different models of palliative care that is, hospital, nursing home, community, hospice, home-based, government as well as corporate to empower them with both theoretical as well as practical training. A proportionate number of certifying institutions and certified professionals from different regions of the country will ensure a widespread and equitable access. The applying candidates should preferably be allocated to the certified institutes within their geographical location with an optional clinical posting in the same or different geographical location to acquaint them with the prevailing needs, unmet needs, challenges and the time-tested troubleshooters as well as with the diversities prevailing elsewhere that is, uniformity in diversity. Palliative care requirements differ with geographical, religious and economic background of the target population. Therefore, adopting a model successful in one might turn out to be unacceptable and unsuccessful in a different location. What is necessary to ensure continued success is adopting what is feasible and modifying what is inappropriate that is, need-based palliative care. A bi-annual enrolment would ensure some degree of flexibility thereby avoiding loss of opportunity and potential talent due to personal or professional commitments. An obligatory community project in an area of need as an indispensable component of the certifying process would serve the multipurpose of imparting clinical acumen, sensitizing the fellows toward and reducing the prevailing suffering as well as conducting various community-oriented palliative care feasibility studies. The certified fellows need to be encouraged to spread awareness, increase acknowledgment, identify professional colleagues interested and/or already working in palliative care and recommending them for the certification program to ensure an exponential and sustained increment in willing hands at work. A paradigm shift in attitude as well as approach consisting of the following is required to curtail the unheard agony:

• Developing palliative care as a part of primary health care that is, essential and practical, and scientifically sound and socially acceptable health care made universally accessible to those in need

• Increasing the spectrum beyond cancer to include all life-threatening ailments hampering the QoL. Cancer, organ failure and frailty being the top scorers follow different trajectories necessitating varied approaches that is, ‘diagnosis-specific palliative care’[2]

• Resetting the trigger from ‘prognosis’ to ‘need’ as the requirement of palliative care

• Introducing palliative care early in the disease spectrum rather than at the end and priming the patients and carer regarding the concept of advanced directives and planning to ensure continued QoL in the end

• Embodiment of a national palliative care center with proportionate representation from its regional subcenters with a common goal of Universal provision of palliative care to each and every one in need

• Utilizing statistics and achievements to foster acknowledgment, setting benchmarks and moving toward a unified goal rather than an ego booster or to prove superiority. Everyone should work to strengthen the credibility of the specialty as a whole rather than the specialists practicing it

• Raising the standard of national and regional palliative care conferences, ensuring multi-professional, multi-cultural and multinational delegates as well as faculty. The same should be utilized to propose national policies inclusive of end-of-life care policy and generating funds. These should also act as an open, easily accessible forum for the patient or carers in need to listen, empathize and professionally resolve their issues

• Designing an online palliative care portal promptly providing an expert as well as practically feasible answers to patient or professional's queries.

With the recent amendment of National Drug and Psychotropic Act and with a slow but steady rise of acknowledgment, manpower, pain and palliative care clinics at major regional cancer hospitals and hospices, the situation is improving but still under the mark. It is high time for the torchbearers to understand the rising urgency due to population explosion, health care standards and hence elderly population, cancer and other chronic life-threatening diseases and join their hands to develop state-of-the-art palliative care services available to each and every homo sapiens in need. Only by acknowledging the ancient idiom of “Unity is strength,” can a massive conjoint blow be targeted against the unheard agony as bring back life to death.