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Indian Journal of Palliative Care logoLink to Indian Journal of Palliative Care
. 2020 Apr-Jun;26(2):221–236.

Oral Presentations

PMCID: PMC7444564
Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 01: QUALITY OF END OF LIFE CARE IN A CANCER HOSPITAL

Anjna Surath 1

Introduction and Objectives: Patients with advanced cancer, caregivers and palliative care clinicians are often faced with treatment decisions at the end of life. The attention to disease and not the patient delay discussions about EOL. In our country oncology clinicians do not have a plan of care to improve QOL at EOL for patients with advanced cancer. With an aim to improve our skills in EoLC, we noted time of diagnosing EOL like early days/final hours before death, time of discussion with caregivers, and quality of EOL care delivered.

Methods: Information was collected from OP records of patients in last 6 months of this year. They were referred to palliative physician for supportive treatment. Four parameters were chosen: 1) Early/delayed anticipation or prediction of death based on PPS, 2) Caregiver's reaction/concerns about bad news properly addressed, 3) Place of receiving palliative care – hospital, ICU, home/hospice, 4) Caregivers satisfaction to counseling: very satisfied or not satisfied.

Results: Timely assessment of EOL was not possible as patients were referred late, mostly before death. PPS was helpful in identifying EOL status. None died in ICU though some had to stay in hospital. Mostly care givers were satisfied with counseling and many selected homecare.

Conclusion: Early EOL discussions help to improve quality of life of patient and caregivers. Patients must be referred to palliative care at an appropriate time. It is unfair to counsel the care givers hours before death when they are stressed due to social or financial burden.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 02: PALLIATIVE CARE NEEDS ASSESSMENT IN PATIENTS SUFFERING FROM ADVANCED CHRONIC OBSTRUCTIVE PULMONARY DISEASE/INTERSTITIAL LUNG DISEASE

Puneet Rathore 1, Anuja Pandit 1, Vikram Pratap 1, Sushma Bhatnagar 1

Introduction and Objectives: Identifying symptoms is prerequisite for diagnosis and formulating management plans for all patients. Patients with advanced COPD & ILD may experience distressing symptoms and reduced QOL, therefore international COPD guidelines recommend palliative care and advance care planning together with disease-directed care. Our objective is to assess the palliative care need in patients suffering from advanced COPD & ILD attending Pulmonary Clinic in a tertiary care center in India.

Methods: An observational cross-sectional study of 100 patients with advanced COPD & ILD attending Pulmonary Clinic in AIIMS, New Delhi was done. They were assessed using palliative performance scale version 2 (PPSv2) and Needs Assessment Tool: Progressive Disease (NAT: PD).

Results: Out of 100 patients (54 females : 46 males), 24 had COPD and 76 had ILD. All patients had a caregiver readily available for help. 4 patients and their caregivers requested a referral to specialist palliative care, and 33% caregivers needed assistance in managing care of their patient. On assessing wellbeing, 56% experienced some unresolved symptoms, 33% had significant symptoms; 48% faced some psychological symptoms; 48% had some concerns and 4% had significant concerns about their treatment and medicines despite proper explanation; 31% had some concerns of spiritual distress whereas 6% had significant distress. 44% were later found to require specialist palliative care review for their palliative care needs.

Conclusions: A comprehensive care plan for patients of advanced COPD and ILD should be formulated to support and provide them with the best possible supportive and palliative care services to improve their quality of life.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 03: INTERVENTIONAL PAIN MANAGEMENT

Sarita Singh 1, Manish Singh 1, Nasim Akhtar 1

Introduction and Objectives: Pain is the symptom most prevalent and feared in Oncology practice, and has its direct implication upon patients’ quality of life. Neuraxial administration of drugs and spinal cord stimulation to modulate or alter the pain perception are beneficial in intractable cancer pain. It is useful for early introduction of Intervention in select patients of Cancer, simultaneously or before the initiation of strong opioids. Our aim: Experiences of performing sympathetic plexus block in various patients to relieve pain and improve their quality of life.

Methods: In five years experiences we had 350 to 400 patients diagnosed with different cancers, including many with cancer of upper abdomen, lower abdomen, and perineal cancers. In these patients Neurolysis with Alcohol and Radio frequency ablation of related sympathetic Ganglion were done to get the desired results. The observations done retrospectively are shared in this study.

Results: Most patients with cancer had VAS of 8 to 9 and it was decreased up to VAS 3 to 4. Some patients needed risqué analgesics, and some patients were supported with opioids in their advance disease.

Conclusion: In my experience sympathethic block is a good support to relieve intractable cancer pain and also reduce intake of oral analgesics thus reducing the risk of various gastro-intestinal complications.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 04: COLLUSION IN HEALTHCARE CAN Hu PALLIATIVE CARE DELIVERY: A CASE STUDY

Bincy Mathew 1, Saipriya Tewari 1, Bidhu Kalyan Mohanty 1, Vedant Kabra 1, Peush Bajpai 1, Pushpinder Gulia 1, Anusheel Munshi 1, Siddharth Sahai 1

Introduction and Objectives: Collusion is an unharmonious bond between the doctor and a patient or between patient and caregivers. It remains a significant healthcare challenge in the context of the Indian socio-cultural scenario. This case report exemplifies one such experience and highlights the hurdles healthcare faces when dealing with collusion.

Methods: 32 years old lady diagnosed with rectal carcinoma during her pregnancy and underwent diversion colostomy followed by neo-adjuvant chemo-radiation after delivery. Later, she was diagnosed with metastatic disease and treatment was palliative chemo-radiotherapy. Her brothers chose to withhold information regarding the diagnosis and prognosis throughout the treatment trajectory. She had chronic pain (NRS 9/10), severe psychological distress (DT-10/10), and moderate depression (PHQ9-14) during that time. The patient and her family were under a comprehensive oncology team and received multiple sessions from a psycho-oncologist. Analgesics and supportive measures were advised to reduce pain. Additionally, non-pharmacological techniques such as mantra meditation, positive affirmations, and visualization were used.

Results: Patient required multiple hospital admissions. Her condition deteriorated fast despite all medical measures. The collusion between 1) the patient and relatives and 2) patient and healthcare professionals was broken only after the patient's condition further deteriorated. This gave her only a narrow window to decide a caregiver for her 1-year-old son.

Conclusion: Collusion and lack of information can be a factor for persisting total pain. While caregivers desire to protect the patient from the distress of a life-limiting diagnosis, it causes more anguish than comfort. Oncologists need to consider collusion as part of our socio-cultural fabric and develop a strategy to negotiate and improve the care.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 05: PREVALENCE OF RESPIRATORY DISTRESS SYMPTOM CLUSTER AMONG THE LUNG CANCER PATIENTS ATTENDING PALLIATIVE CARE DEPARTMENT AT TATA MEDICAL CENTER, KOLKATA

Chaitanya Patil 1, Shrikant Atreya 1

Introduction and Objective: A frequent observation is that an individual with cancer often experiences multiple concurrent symptoms throughout the course. Lung cancer patients have more symptom distress as compared to any other cancer. This fact accentuates the need to understand the symptom cluster pattern among these patients which will allow the development of improved monitoring methods and facilitate better symptom control.

Methods: We conducted a retrospective review of records (Dec 2018 to Feb 2019) of patients with lung cancer referred to Palliative care department of Tata Medical Center, Kolkata. Along with demographic details, records were reviewed for the presence of cough, breathlessness, fatigue, pain and histological type. Associated history like presence of psychiatric disorder, diabetes mellitus, hypertension/IHD, and any medical intervention in the past were also noted.

Results: The most common histological type was adenocarcinoma followed by small cell and squamous cell carcinoma. The prevalence of Cough with fatigue, Fatigue with breathlessness, cough with breathlessness and cough, fatigue and breathlessness were 20.24%, 25%, 20.24%, and 13.10% respectively. Fatigue only, and Cough with fatigue cluster were found to be significantly higher proportion in small cell carcinoma when compared to other types of lung carcinoma.

Conclusion: The most common respiratory distress cluster was found to be fatigue with breathlessness in the present study. A higher proportion of fatigue, and fatigue with cough cluster in small cell carcinomas can be attributed to the aggressiveness and neuroendocrine origin of the tumor. More prospective studies are required to substantiate its clinical implications in a palliative care setting.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 06: EXAMINING PREVALENCE OF ANXIETY AND DEPRESSION IN CANCER PATIENTS PRESENTING TO A CANCER HOSPITAL IN ASSAM

HM Iqbal Bahar 1

Introduction and Objectives: Anxiety and depression are common in patients with cancer. Underdiagnosed and under-treated, they have profound consequences on the patient and caregivers.

We aimed to examine the prevalence of anxiety and depression in patients with cancer at Cachar Cancer Hospital and Research Centre, Assam.

Methods: A prospective observational study was conducted on 79 patients over a period of six months. Patients were first assessed for anxiety and depression using the ‘Patient Health Questionnaire-4’ (PHQ-4). Patients who scored 3 on anxiety subscale of PHQ-4 were considered positive for further screening using the Generalized Anxiety Disorder scale (GAD-7). Patients who scored ≥3 on depression subscale (PHQ-4) were considered positive for further screening using the ‘Patient Health Questionnaire’ (PHQ-9) for confirmation.

Results: The mean age was 51 years (+13SD); male/female ratio (1:1.2), 41.7% in stage IV; 48% in ECOG 2; mean duration of stay 5.32 days; most common cancer was Head and Neck (56.25%). Out of 79 patients assessed by PHQ-4, 17 patients (21%) needed screening for anxiety by GAD-7, 16 patients (20.25%) needed screening for depression by PHQ-9 and 10 patients (12.5%) needed screening both for anxiety and depression. About 40% of the patients screened were found to have severe anxiety/depression which needed medical intervention.

Conclusion: Findings suggest that anxiety/depression is common in cancer patients in our region. There is a need for routine screening for anxiety and depression in cancer patients in palliative care settings, including questions about past, personal and family history, and the need for a range of interventions and support services.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 07: COMPARISON OF SYMPTOM PROFILE AND SURVIVAL IN PATIENTS WITH ADVANCED HEAD AND NECK CANCER WITH OR WITHOUT HYPERCALCEMIA REFERRED FOR SPECIALIST PALLIATIVE CARE

Jayaseelan Prarthana 1, Jayeeta Deodhar 1

Introduction and Objectives: Hypercalcemia in advanced head and neck cancer (HNC) patients predicts a poor prognosis. Few studies on patients referred for palliative care have reported the same. Our objective was comparison of symptom profile and survival in patients with advanced HNC with/without hypercalcemia referred for palliative care.

Methods: A retrospective analysis of electronic and paper medical records of adult advanced HNC patients referred to SPC service in a 4-month period was done. Records with missing data were excluded. Serum calcium levels, patient characteristics, documented symptoms/symptom burden using ESAS were recorded. Survival noted from the date of referral to death in patients with hypercalcemia and with normal serum calcium levels. Statistical analysis was done using SPSS v23.

Results: Of 200 HNC patients assessed, 90 had documented corrected serum-Ca level. 51 patients (26%) had HCM and 40 patients (20%) had normal Ca levels (NCa). Most patients referred were males (86%) and mean age was 46 ±10 years. Patients were referred for BSC>EPC (29vs 22) in HCM, while in NCa patients were referred for EPC>BSC (31 vs 9). Distressing symptoms frequently reported in both groups were same but statistically significant in HCM, median ESAS being 23, while NCa patients was 16. Number of patients reporting pain was 42 and 30, halitosis 36 and 21, and trismus 14 and 19 in hypercalcemia and with NCa levels, respectively. Median Survival was 36 days in HCM and 50 days in NCa.

Conclusion: HCM was present in 26% in advanced HNC patients in our study, with a higher symptom burden and reduced survival. It is therefore important to promptly identify HCM in advanced HN malignancies to initiate early hypercalcemia correction and improve the quality of life of patients.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 08: END OF LIFE CARE PRACTICE AT A TERTIARY CANCER CENTRE IN INDIA: AN OBSERVATIONAL STUDY

Bhanu Pratap Maurya 1, Sushma Bhatnagar 1, Seema Mishra 1, Rakesh Garg 1, Sachidanand Jee Bharti 1, Nishkarsh Gupta 1, Vinod Kumar 1, Varnika Minhas 1, Nandan Choudhary 1, Puneet Rathore 1

Introduction and Objectives: 80% of advanced cancer patients in India require end of life care (EOLC). Improving quality of life of these patients is challenging because of lack of understanding of palliative care and various barriers. Our aim: to assess the current EOLC practices and magnitude of futile care in a tertiary cancer center and evaluate barriers in the provision of good EOLC in cancer patients.

Methods: A cross-sectional study was done on 90 patients. Patients diagnosed to be ‘end of life’ by using palliative prognostic index (PPI) were enrolled. Socio-demographic and clinical details were recorded using hospital record. Information regarding counseling by treating or PC physician were recorded. Various barriers encountered for EOLC was explored from the PC physician.

Results: In 90 patients analyzed, PPI score was >6 (survival shorter than 3 weeks) in 57 patients, 26 patients had score >4 (survival shorter than 6 weeks) and 8 patients had score <=4 (survival more than 6 weeks). 56 patients preferred home as place for EOLC, 27 preferred hospital and 7 preferred hospice. Family member related barrier was most common in provision of EOLC, suggesting lack of understanding, communication and decision making. Physician related barrier was the next showing lack of confidence of physicians to send EoLC patients home or not comfortable for DNR. The most common symptom was refractory pain (46 out of 90), dyspnea(n-38), and unconsciousness (n-14).

Conclusion: EOLC is the least studied part of patient care with various barriers. With proper communication and palliative care, futile treatment can be avoided, and family members and patients can be prepared for good death.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 09: TREATMENT OF SEVERE MUCOSITIS PAIN WITH KETAMINE HYDROCHLORIDE MOUTHWASH IN CANCER PATIENTS

Kikato Chishi 1

Introduction and Objectives: Mucositis is a common complication of high dose oropharyngeal radiation therapy in head & neck cancer patients. It is also an adverse effect of some chemotherapeutic agents. Intense mucositis pain can affect nutritional status, speech, comfort and thus reduces treatment compliance and affect quality of life. Primary objective of this study was to determine the effectiveness of ketamine Hydrochloride used as mouthwash in relieving pain and other distressing symptom of severe mucositis. Secondary objective is to study its safety prole.

Methods: Thirty-two patients suffering from radiation induced mucositis grade III or IV according to WHO mucositis grading scale were treated with Ketamine Hydrochloride 20mg/5ml used as mouthwash once daily for five consecutive days. Other pain medication like NSAIDS, Opioids and adjuvants were continued.

Results: A statistically significant reduction in pain score was achieved after treatment (from 7.8±1.2 to 3.2±1.3; p<0.0001). Also found significant improvement of other distressing symptom like swallowing (5.7±1.2 to 2.8±1, p<0.0001), anxiety (4.8±2 to 1.8±1.3, p<0.0001), appetite (5±1.8 to 2.5±1.8, p<0.0001), mouth opening (1.8±0.7 to 2.4±0.7, p<0.0001) etc. Five patients developed giddiness which was transient and relieved with rest after few minutes. Two patients on anti-hypertensive medication were excluded due to further increase in blood pressure.

Conclusion: Mucositis treatment with ketamine Hydrochloride as mouth wash show favourable outcome with acceptable safety prole, and therefore can be a viable treatment option in severe mucositis under close observation.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 10: ADDRESSING SPIRITUAL AND PSYCHO-SOCIAL NEEDS OF PATIENTS WITH ADVANCED NON-COMMUNICABLE DISEASES ADMITTED TO GENERAL HOSPITAL IN NEPAL

BK Manju 1

Introduction and Objectives: Previous work at a general hospital in western Nepal showed that patients with advanced NCDs have psychosocial, spiritual, and physical needs. Involvement of hospital counsellors improved holistic care of such patients. However, few patients were referred. This audit was undertaken to assess the proportion of patient with advanced NCDs referred to counsellors by hospital doctors and nurses, and whether this improved following two-day holistic training in palliative care for these staff.

Methods: Patients with advanced NCDs appropriate for palliative care admitted to the medical ward were identified by the PC nurse using SPICT-LIS, and number of counsellor referrals recorded for one month before training. Participants were taught to use SPICT-LIS as part of the training. Three months after training, referrals were re-audited over one month and participants were questioned about their level of confidence in delivering palliative care.

Results: Pre-intervention audit identified 58/115 (50%) patients with advanced NCD appropriate for palliative care; 18/58 (31%) were referred to a counsellor. In the post-intervention audit 49/155 (32%) were identified with palliative care needs and 47/49 (96%) were referred. In the survey doctors, nurses and counsellors indicated that they found SPICT-LIS useful for assessing palliative care needs and increase in confidence level in taking a team approach to palliative care.

Conclusion: This audit showed that training in palliative care including using SPICT-LIS was useful for enabling medical, nursing and counselling teams to identify patients and refer them to the hospital counsellor. Training also enhanced participants’ confidence in taking a team approach to palliative care.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 11: SYMPTOM BURDEN AND QUALITY OF LIFE ASSESSMENT IN PATIENTS OF GASTROINTESTINAL MALIGNANCIES ATTENDING THE PALLIATIVE CARE CLINIC OF A TERTIARY CARE CENTER, INDIA

Vikram Pratap Singh 1, Seema Mishra 1, Sushma Bhatnagar 1, Atul Sharma 1, Nishkarsh Gupta 1, Sacidanand Jee Bharti 1, Rakesh Garg 1, Vinod Kumar 1

Introduction and Objectives: To assess symptom burden and quality of life of patient suffering from gastrointestinal malignancies attending the palliative care clinic of a tertiary care center in India.

Methods: A prospective observational study was done on 307 patients of GI malignancy attending the PC clinic. Demographic data was recorded in a predesigned proforma. Pain assessment was done by BPI, symptom burden assessed using ESAS-R, and quality of life with the EORTC QOL-C30 questionnaires at the time of presentation, at one month, and at three months.

Results: Mean age was 48.9 ± 14.1 years. BPI score – Mean score of PSS and PIS at 1st visit were 6.3±0.9 and 6.1±0.7; followed by 3.3±0.3 (PSS) and 4.1±0.4 (PIS) at 1-month. At 3-months (n=275), PSS was 2.3±0.2, PIS was 2.8±0.3 and found statistically significant (p<0.0001). As per ESAS-R, the most burdensome symptom is fatigue (7.4 ±1.1), followed by pain (7.3±1.7), lack of appetite (6.4±1.3), depression (6.4±0.8), anxiety (6.2±1.6). Significant difference seen in symptom burden between baseline and 1-month, and baseline and 3-months (p<0.0001). Mean score of Global health according to EORTC scale was 40.5±2.9. Most burdensome symptom was insomnia (70.9±21.2) followed by loss of appetite (68.2±15.2), pain (66.4±18.4), fatigue (65.5±15.8); least prevalent symptom was diarrhoea (1.5±6.9). In functional scales (EORTC QLQ C30), most burdensome function impaired was emotional functioning (56.2±4.3) followed by cognitive functioning (55.3±6.3); least function reported by patients was role functioning (41.3±9.9).

Conclusion: Symptom burden is very high in patients with gastrointestinal malignancies and they have poor quality of life. Hence it is very necessary to have good assessment of symptom burden to provide good quality of life in such group of patients.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 12: IMPROVING QUALITY OF LIFE THROUGH PRANAYAMA DURING CANCER TREATMENT

Mili Baruah 1, Raghavendra Ramanjulu 1, Anthony Pais 1, CU Poovamma 1, Revathi Rajagopal 1

Introduction and Objectives: Cancer treatment is usually long term that can cause physical and psychological distress thereby negatively impacting the quality of life (QOL) of patients. Research suggests pranayama to be an effective intervention for managing cancer related symptoms and having positive outcomes. This study aims to evaluate the effects of pranayama on QOL among patients during cancer treatment.

Methods: A pre and post study design was used. Patients (n=40) were approached, out of which (n=30) patients met the inclusion criteria and were selected for the study. Firstly, a pre assessment of patients undergoing treatment in the out-patient and in-patient department was conducted using the EORTC-C30 QOL tool. Following which an intervention that consisted of five Pranayama's and few relaxation techniques were administered to be practiced at home on a daily basis. A mid evaluation assessment of QOL was conducted after one month and a post assessment at the end of three months. Data was analysed using descriptive and inferential statistics.

Results: Patients (40.2%) who had received Pranayama at the end of one month reported a satisfactory QOL. At the end of 3 months, the same set of patients reported a good QOL.

Conclusion: Pranayama is found to be a holistic approach among cancer patients to improve their quality of life. Mind body medicine is a much needed service for cancer treatment along with conventional treatment which will in turn help improve overall clinical and psychological outcomes.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 13: TO STUDY THE EFFECTS OF INTERACTION OF PALLIATIVE CARE PATIENTS WITH THERAPY DOGS

Minal Kashivar 1, KS Sundari 1

Introduction and Objectives: In Animal Assisted Interventions (AAI) trained therapy animals are incorporated in an intervention process. There is a growing body of global research supporting the benefits of AAI. Research on benefits of AAI for palliative care patients is less, with this being the first quantitative research in the Indian setting. AAI aims to improve the QOL of the patient by helping patients focus away from pain bringing spontaneous joy. Our aim: to observe interaction between the palliative patients and a trained therapy dog and determine the benefits of this interaction.

Methods: AAI was provided in a group therapy format, with session being of 45 mins. The therapy dogs and handlers were trained and certified from Animal Angels Foundation. The intervention was directed by a psychologist, also a trained animal therapist. All patients were evaluated on the distress scale pre and post session with a therapy dog. The patients were also evaluated post interaction on the Human-Animal Interaction scale. The data was collected with a new group of patients every session due to patient's death or due to patients being discharged.

Results: A reduced post-session score as compared to a pre-session score by all patients indicate that interaction with therapy dogs helps deal with distress in a better way. High scores on Human-Animal Interaction scales indicate that the patient bonded with the animal resulting in the patient experiencing change in their perception of distress.

Conclusion: With more research in this area, AAI can prove to be an effective alternative therapy.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 14: END-OF-LIFE CONVERSATION VERSUS WAREHOUSE OBLIVION – WHAT SHOULD I CHOOSE?

Rita Mukhopadhyay 1, Hiranmoy Bhattacharjee 1, Mita Mukhopadhyay 1, Nita Mukhopadhyay 1, Sangeeta Paul 1, Soumyadeep Chakraborty 1, Ajit Kumar Mukherjee 1

Introduction and Objectives: “Disease may invade bodies of patients, but the experience of illness devastates all those around them. Suffering demands that others bear witness, and family members are assigned front-row seats.” We have super-specialty hospitals everywhere with technologies to keep a human being alive until s/he breath their last. And yet, we cannot alleviate the suffering, frustration and helplessness of the terminally ill patients and their family members. Is lying on an ICU bed during the end-of-life, attached to myriads of tubes a “quality of life”-the “warehouse oblivion” we wish for ourselves? If not, why would we do that to our patients? Modern medicine is about “doing” and not “talking”. So, let us start the “End-of-Life Conversation” at the very beginning of a terminal diagnosis.

Our objectives are: 1) Educating and counseling patients and their families during the end-of-life care of a terminally ill patient by starting the EOL conversation at the time of diagnosis to help them beat the “Warehouse Oblivion.” 2) Identify and remove barriers (financial, emotional, social, and communicational).

Methods: One-on-one counseling leading to peace and tranquility.

Results: Ilajit Memorial Trust has been navigating more than 100 patients since its inception in March 2017. We lost eleven of them. Individual cases will be discussed.

Conclusions: In our experience, the terminally ill patient and the primary caregiver together or independently often need a non-judgmental entity outside the family to hold onto and talk about their challenges and fears in a non-clinical set up.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 15: CLINICAL AND SOCIO-DEMOGRAPHIC CORRELATES OF DYSPNEA IN ADVANCED CANCER PATIENTS PRESENTING IN PALLIATIVE CARE UNIT AT A TERTIARY CANCER CENTRE IN INDIA

PA Ajisha 1, Sushma Bhatnagar 1, Seema Mishra 1, Vinod Kumar 1, Sachidanand Jee Bharti 1, Nishkarsh Gupta 1, Rakesh Garg 1

Introduction and Objectives: Dyspnea has significant correlation with psychological status like anxiety in cancer, anxiety and depression in non-cancer, and with demographic factors like sex/age in non-cancer populations. Indian studies focused on correlating factors, including medico-psycho-social with perception of dyspnea, have rarely reported this. Our objective is: to identify factors correlated with dyspnea in advanced cancer patients hospitalized in PC unit of a tertiary cancer hospital in India within a broad range of medico-psycho-sociodemographic factors.

Methods: A prospective observational study done over 12 months (Nov'17 to Oct'18) in Department of Palliative Medicine, AIIMS, Delhi. All admitted patients screened, assessed on admission, and details of socio-demographic information, diagnosis, ECOG score, dyspnea (NRS) noted. All potential causes of dyspnea including Self-reported symptoms were noted.

Results: Of 883 patients (mean age 49 years) studied, 138 patients had shortness of breath, females 62.32% (n=87). Of 138 patients, 43 patients had Lung Cancer (31.16%), 30 patients (n-21.74) had gynaecological cancers. Lung metastasis present in 34.78% (n=48). Most common symptom other than dyspnea was pain (n=100, 72.46%). Other symptoms were fatigue (n=66,47.83%), lack of sleep (n=51,36.96%), decreased appetite (n=60,43.48%), cough (n=32,23.19%), nausea (n=39,28.26%), abdominal distention (n=37,26.81%), anxiousness (29,21.01%). Significant univariate association seen between intensity of dyspnea and primary site of malignancy (p=0.02), anxiety and dyspnea (p=0.02), presence of lung metastasis and severity of dyspnea (p=0.02). No association between pain and intensity of dyspnea was seen.

Conclusion: Intensity of dyspnea as perceived by advanced cancer patients is not only affected by organic causes but also psychological causes like anxiety. It is important to alleviate other medical and psychological symptoms for better management of dyspnea for a better QOL.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 16: A CASE STUDY OF PALLIATIVE TREATMENT ON SQUAMOUS CELL CARCINOMA OF MOUTH

Prem Kumar Sachan 1

Introduction and Objectives: To study the effect of homeopathic treatment in a case of Squamous Cell Carcinoma of Mouth.

Methods: A 35 years female, with a growth in the left cheek, diagnosed as well-differentiated Squamous Cell Carcinoma on biopsy. CT scan on June 9, 2018 reported the size as 24.0 X 16.0 X 16.0 mm. Homeopathic treatment was started on January 7, 2019. At initiation of treatment, the growth crossed out to left Cheek and spread like a cabbage of 3.5 inches diameter. There was excruciating pain. CT imaging dated January 11, 2019 reported ‘Malignancy in left buccal space and alveolus involving lower bucco-gingival sulcus from left canine to molar space with erosion of the alveolar margin of mandible, involvement of the cutaneous and subcutaneous planes and regional and contralateral carotid space deposits'. In response to treatment, growth process was observed to stop; and pain intensity reduced markedly. Within next 3 months, patient reported no pain. The growth decayed and fell off exposing a funnel like aperture in cheek. With continued treatment, surrounding tissue of aperture regenerated and slowly sealed the aperture within next 15 days. In the next 60 days normal skin growth was seen.

Results: CT imaging dated December 17, 2019 reported as “No obvious mass lesion or abnormal enhancement; however minimal fat stranding is noted at left cheek area. No obvious underlying erosive bony changes.

Conclusion: Squamous Cell Carcinoma of the cheek is shown to heal and respond to the treatment without any apparent sign or symptoms of the disease.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 17: BURDEN OF CARE AMONG PRIMARY CAREGIVER OF SPINAL CORD INJURY PATIENT ATTENDING AT BP KOIRALA INSTITUTE OF HEALTH SCIENCE

Ram Mehta 1, Pramila Singha 1, Pushpa Parajuli 1, Pashupati Chaudhury 1

Introduction and Objectives: Spinal cord injury (SCI) patients need special care, attention and treatment. Primary caregiver of such patients experience physical, psychosocial, emotional, and financial burden. Identification and reduction of caregiver burden are crucially important to improve overall well-being of primary caregivers. The objectives of this study are to assess the burden of care among primary caregivers and evaluate the association between selected demographic variables and burden of care.

Methods: A descriptive cross-sectional study was conducted among 71 primary caregivers of Spinal Cord Injury patients in OPD, ward and rehabilitation center of the Orthopedic Department. Data was collected by using the Zarit Burden Interview Scale. Association of burden scores with selected demographic variables analyzed by using one-way ANOVA and independent sample t-test.

Results: 67.6% of the primary caregivers were female with mean age 36.63±10.50. 64.8% (n=46) experienced moderate to severe burden, whereas 16.9% (n=12) experienced severe burden. Mild to moderate burden was experienced by 18.3% (n=13) of primary caregivers. A statistically significant association was found between burden scores and the number of children (P=0.017), whereas the other demographic variables were not significantly associated with burden score.

Conclusion: About two-third primary caregivers of SCI patients were experienced moderate to severe burden. The sociodemographic variables were not associated with the burden score, whereas the number of children was associated with the caregiver's burden score.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 18: DEATH ANXIETY AND ITS CORRELATES AMONG PATIENTS WITH ADVANCED CANCER: FINDINGS FROM A TERTIARY CANCER CENTRE

Revathi Rajagopal 1, Raghavendra Ramanjulu 1, Michelle Normen 1

Introduction and Objectives: Anticipation of death is often exhibited in patients with advanced cancer. Being an existential concern, it may have a negative impact on outcomes. The purpose of this study is to examine and identify disease-related and psycho-social factors associated with death anxiety among patients with advanced cancer.

Methods: A cross sectional study was designed with a sample of 300 patients, > 18 years with advanced (Stage III or IV) cancer in the out-patient and in-patient department. They were assessed using Templer's Death Anxiety Scale, Memorial Symptom Assessment, Hospital Anxiety (A) & Depression (D) Scale, and EORTC QLQ C-15-PAL questionnaire. Data was analyzed using descriptive and inferential statistics.

Results: Patients (50.8%) reported moderate levels of death anxiety predicting poor QOL. Female patients had lower QOL and higher death anxiety. The most distressing concern involved fears about impact of one's death on others, and dying alone or suddenly. Physical symptoms like changes in physical appearance and pain were most strongly associated with death anxiety (r =0.760, p=0.000). Multiple regression analysis showed depression HADS-D (β =.40, p =.002) and anxiety HADS-A (β =.39, p =.002) as strong predictors of death anxiety.

Conclusion: Death anxiety can be understood as an outcome of having cancer. It is common in patients with advanced cancer and determined by interaction of psychological factors and physical suffering. Clinical and research implications highlight the need for an interdisciplinary approach to identify patients who could have death anxiety that is cardinal to tailor-make psychological interventions for better clinical outcomes.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 19: PALLIATION IN ORAL CANCER PATIENTS BY LASER: A NEW HOPE

Rusy Bhalla 1

Introduction and Objectives: Palliation implies relief of symptoms. In oral cancer symptoms in unresectable tumors comprise of pain, swelling, feeding problems, trismus and bleeding. Laser ablation is a USFDA approved procedure for destruction of soft tissue tumours. Laser ablation was studied as adjunct in palliation for oral cancer patients.

Methods: 20 patients of Buccal cancer were included in the study over a 4-year period: 10 patients of non-operated, unresectable tumour, and 10 patients who underwent surgery & chemo-radiation.

Results: All patients had ≥90% dissolution of the tumour in a single session by laser. 90% of patients had a good pain relief within 48 hours of laser. 70% of patients were able to return to work, and 30% could continue with their daily activities. 2 patients had a remission period where they went back to their work for a period of 8 months. Virgin patients had a better outcome in all parameters and their average remission period was 8 months. 2 patients lived for 2 years and 1 is still alive. The OS survival was 7 months in post op patients and OS in non-operated patients was 1-yr.

Conclusion: Laser ablation surgery offers an excellent way to palliate patients starting with pain, reduction of swelling and restitution of oral intake. Many of these patients can be mistaken to be in remission. It can be used for virgin cases as well as post-surgery patients. This is a form of palliation which is more acceptable to patients.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 20: NOVEL INTERVENTION OF LOW-DOSE MENTHOL APPLICATION FOR NEUROPATHIC PAIN: 79 CASE STUDIES FROM A NEPAL HOSPITAL

Ruth Powys 1, Purna Maya Thapa 1, Sunita Bhandari 1

Introduction and Objectives: A novel intervention of cold-induced analgesia elicited by low-dose menthol application is being explored for management of Neuropathic Pain (NP). At Green Pastures Hospital, Pokhara, previous clinical audits of leprosy and spinal cord injury patients have highlighted significant burden of NP. Case studies were undertaken on the effectiveness of 2% menthol in mustard oil for people suffering NP from various conditions referred to PC service.

Methods: Pain data of patients experiencing NP was collected using Brief Pain Inventory (BPI) and Leeds Assessment Neuropathic Symptoms and Signs (LANSS) pain scale. Twice-daily application of 2% menthol in mustard oil over 6-weeks was assessed: pre-application, 2-hours post-application, at 2-week, and at 6-week intervals. Confounding effects due to underlying improvement (e. g. of leprosy reaction), was checked by 2% menthol initially applied to only one affected limb, and data at 2-weeks confirming a positive difference.

Results: 79 episodes from 64 (27M, 37F) patients included 47 leprosy-affected (LAP). 70/79 (89%) showed improvement; 47/79 (59%) demonstrated 30% reduction in pain, and 5/79 (6%) had total relief. Medians of overall BPI improvement was 38%; overall worst pain improvement was 33% and total LANSS improvement was 35%. Response increased over 6-weeks, and LAP response was higher than non-LAP: at 6-weeks, 14/16 (88%) LAP compared to 4/7 (57%) non-LAP demonstrated clinical response and 16/16 (100%) LAP compared with 5/7 (71%) non-LAP showed improvement.

Conclusions: 2% menthol as a novel intervention for neuropathic pain in our case studies has elicited very encouraging results, particularly for LAP. For non-LAP, increasing to 5% menthol in sunflower oil is being explored.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 21: EMPOWER THE CAREGIVERS ON CHRONIC, MALIGNANT NON-HEALING WOUND MANAGEMENT IN HOMECARE SETTINGS BY TARGETED EDUCATION

N Sangeetha 1, Seena Xavier 1

Introduction and Objectives: Non-healing wounds require a systematic approach and dedicated involvement of different medical specialties. However, achieving this remains a universal challenge. This creates increased pressure on caregivers to manage chronic malignant wounds at home. This study aims to support caregivers, through education and training, help them attain good practice in wound management in homecare setup. Our objective is to determine the impact on education, regarding the chronic wound care management with proper dressing techniques by caregivers.

Methods: Focused group were educated on concern areas and topics:

1) How to take care of patients with chronic-malignant non-healing wound at home settings. 2) Dressing techniques and methods. 3) Sterile techniques. 4) Preparation of Normal Saline, Gauze and dressing pad at the home. 5) Importance of non-adhesive dressings. 6) Prevention of Infection and maggots 7) Comfort and quality of life to patient. Pre & Post-education assessments were done with 20 caregivers based on: Knowledge on dressing techniques, Fear & Anxiety, Self-Confidence, QOL and care, Comfort, & Challenges.

Results: Building a partnership with caregivers and active participation through wound management education reduced fear and anxiety in 85%, raises self-confidence in 90%, improves QOL and comfort.

Conclusion: Patient caregivers are willing to perform wound dressings. This education helped them to ensure their ability and confidence to look after their loved ones at home.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 22: USE OF ANTIBIOTICS IN END OF LIFE CARE FOR ADVANCED CANCER PATIENTS IN A TERTIARY CARE CANCER CENTER

Shamali Poojary 1, Jayita Deodhar 1, Anuja Damani 1, Arunangshu Ghoshal 1, MA Muckaden 1

Introduction and Objectives: Advanced cancer patients at their end of life (EOL) have complex symptoms including fever and infection. However, evidence for use of antibiotics in EOL for these patients is unclear in low resource settings. Our aim is to examine patient profile and reasons, types and routes of antibiotic usage, and symptom control in advanced cancer patients in the last 2 weeks of life.

Methods: This is an observational retrospective analysis of medical records of patients enrolled in the home-based palliative care services in a 5-month period. Patients admitted in general hospitals for EOL care and/or records with missing data were excluded. Sociodemographic variables, cancer diagnoses, symptoms, type, route and reasons for antibiotic administration were noted. Relevant statistical analysis was done using IBM SPSSv21.

Results: 175 patient records were analyzed. 56 (35.6%) were >60 years. Most frequent cancer diagnoses were lung (17%) and breast (11%). Common symptoms were respiratory and gastrointestinal, in 15 (8.6%) and 9 (5.1%) respectively. 3% had fever; 33 (18.9 %) received antibiotics in last 2 weeks prior to death. Mainly cephalosporins and beta-lactams were used. 54.5% received IV antibiotics. 69% patients who died in emergency department (ED) received antibiotics, as compared to 14% who died at home. 63.6% who received antibiotics had no symptom relief.

Conclusions: Use of antibiotics was less in patients who died at home, compared to those in ED. Appropriate and judicious use of antibiotics should be considered for advanced cancer patients at their EOL.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 23: INFORMING DESIGN OF A SMART PHONE MOBILE APPLICATION TO IMPROVE PAIN MANAGEMENT: A SURVEY OF CANCER CARE INSTITUTIONS IN NEPAL

Daniel Munday 1, Virginia LeBaron 1, Bishnu Paudel 2, Sandhya Chapagain 2

Introduction and Objectives: Providing effective cancer pain management is essential for palliative care, and mobile technology can help with this effort. The Nepalese Association of Palliative Care (NAPCare) developed Pain Management Guidelines (PMG) but are currently paper-based limiting up-take and ability to track implementation. This research aims to design a mobile health application ('app') to facilitate broader implementation of the NAPCare PMG.

Methods: A cross-sectional survey of healthcare providers was conducted to inform design of the mobile app. Questions focused on: participant demographics; knowledge, attitudes and confidence in managing cancer pain; perceived barriers to cancer pain management at individual, institutional and country levels; awareness and use of the NAPCare PMG; and barriers to smartphone use and desired features of a mobile app. Surveys were administered by pencil-and-paper and analyzed in SPSS (IBM v. 26.1).

Results: 97 healthcare providers from 4 institutions in Nepal completed the survey: public general hospital (n=30); public cancer hospital (n=30); private cancer hospital (n=30); and hospice (n=7). 48 (49.5%) had training in palliative care/cancer pain management and majority (n=62; 63.9%) reported high confidence levels (scores of 8 or higher/10) in managing cancer pain. Most respondents (80.4%; n=78) use an Android smartphone and 95.9% (n=93) had heard of the NAPCare PMG. Participants report high frequency app use for patient care (n= 46; 47.4%) and personal reasons (n=67; 69.1%). Key barriers to smart phone use included cost of data access (n=60; 61.8%) and concern about using a mobile phone in front of patients (n=41; 42.2%).

Conclusion: A smart phone application has potential to implement PMG and track barriers to cancer pain management in Nepal. It must be designed to be culturally and contextually congruent and address perceived barriers.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 24: PREVALENCE OF POLYPHARMACY AND POTENTIALLY INAPPROPRIATE MEDICATIONS IN GERIATRIC ONCOLOGICAL PATIENTS

Neha Singh 1, Seema Mishra 1, Sushma Bhatnagar 1, Rakesh Garg 1, Nishkarsh Gupta 1, Sachidanand Jee Bharti 1, Vinod Kumar 1

Introduction and Objectives: Elderly (>65 years) constitute 8% of Indian population. In patients with advanced cancer nearing end-of-life, medications are added to control symptoms, while few for co-morbid conditions are stopped. Polypharmacy and PIM (Potentially Inappropriate Medications) use contribute to pill burden, cost, nonadherence and drug interactions. Our Primary objective: to assess prevalence of polypharmacy and PIMs in geriatric cancer patients in a tertiary care hospital in India; Secondary objective: to explore possible factors leading to PIM use.

Methods: Geriatric patients attending cancer clinics in IRCH, AIIMS, New Delhi with cancer, meeting inclusion criteria and informed consent were recruited. Their demographic data, stage, performance status, treatment history (including alternative/complementary therapy), multimorbidity status, name and dosing of medications recorded in a predesigned proforma. Beers criteria used to assess PIM use. For the purpose of study, we defined polypharmacy as intake of >5 medication per day on a regular basis, including prescription, non-prescription; and multi-morbidity as >2 co-morbidities.

Results: Preliminary findings (till date n=30) of this ongoing study are: Prevalence of polypharmacy is 53.3%, PIM use in total is 16.6 %, and PIM use in polypharmacy was 31.2%. 98.7% of those with polypharmacy have metastasis (stage IV). 66% patients with poor PS had polypharmacy. 26.7% of patients were multi-morbid-88% had polypharmacy and 25% had PIM use.

Conclusion: Elderly patients with metastatic illness, poor performance status and presence of multi-morbidity are more likely to have polypharmacy and PIM use. Though PIM use is not seen in majority of patients with polypharmacy, patients with polypharmacy are more likely to have PIM use.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 25: PILOT SCALE STUDY TO ASSES AND IDENTIFY TRAINING NEEDS OF VOLUNTEERS IN PALLIATIVE CARE

Pratima Mehta 1, Prajakta Dhavale 1

Introduction and Objectives: Volunteers play critical role in palliative care and contribute in practical, emotional & spiritual support to patient, caregiver and family members. A pilot study is conducted to identify potential gaps in understanding emotional and/or practical needs of volunteers and present solutions to address such needs through better training programs.

Methods: A comprehensive questionnaire (in English & vernacular language) was compiled for the volunteers to answer. The data collected was analyzed for emerging themes.

Results: Volunteers participating in the study (n = 20), found satisfaction in serving the society and spending valuable time with patients & relatives and intrinsic motivation from other volunteers at the center. Self-experience in patient care as part of profession or as caregiver is a motivating factor. With training, better knowledge of palliative care and cancer was reported. Volunteers were able to face patients and caregivers with more confidence and provide better emotional support. They overcame challenges by frequent interactions with professionals and other volunteers. 30% said training helped in overcoming few challenges. 70% said they are emotionally and mentally impacted by their work. A need to improvise the frequency of training programs was felt.

Conclusion: The study identified training needs of volunteers w. r. t motivation, knowledge, coping mechanism, stress factors and self-confidence for better engagement in volunteering. The study lays a good foundation for training programs for volunteers to empower them to provide holistic support/service.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 26: ASSESSMENT OF SYMPTOM BURDEN IN PAEDIATRIC CANCER PATIENTS IN A TERTIARY CARE CENTRE IN INDIA

Bhawesh Pangaria 1, Seema Mishra 1, Sushma Bhatnagar 1, Sameer Bakshi 1, Sachidanand Jee Bharti 1, Deepam Pushpam 1, Rakesh Garg 1, Nishkarsh Gupta 1, Vinod Kumar 1

Introduction and Objectives: Even though the data for need of integration of Paediatric Palliative Care as a holistic approach in cancer is increasing, assessment of symptom burden is still very inconsistent in children. In this study, we try to analyze the symptom burden and quality of life in malignancies in paediatric age group of 8-18 years. Our objective is to assess the symptom burden in pediatric cancer patients attending palliative care clinic at a tertiary care center in India.

Methods: De novo patients presented to the OPD, were included in the study based on inclusion and exclusion criteria. The patients’ demographic profile, disease and treatment status was recorded. Baseline functional status assessment of patient using Lansky Play Performance Scale, symptom burden assessment using SSPedi.

Results: 20 patients were assessed for symptoms. Pain was the most common symptom present in 80% patients. In psychological symptoms, sadness was seen in 75%, anger 65%, fear 35%. 60% children complained of tiredness, 25% nausea, constipation in 10%, loose motions in 10%, mouth ulcers in 15%.

Conclusion: It was seen that pediatric patients have wide range of symptoms, both physical and psychological, from early on in the disease. There is a need of palliative management of these patients early in the disease for better quality of life.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 27: ROLE OF COMMUNITY MEDICINE DEPARTMENT IN PALLIATIVE CARE-GUJARAT EXPERIENCE

Dinesh Kumar 1, Uday Shankar Singh 1

Introduction and Objectives: Palliative Care education is currently limited to NGOs and few specialized centers. Separate Palliative Care departments are non-existent in most teaching hospitals. Given the current status, an existing department needs to take up the task of starting services and training in Palliative Care. Community Medicine Departments, given their available manpower, involvement in training activities, presence in communities and relation with government are rightly placed to take up this role.

Methods: We share the activities related to Palliative Care carried out by Department of Community Medicine at our institute over last 3 years.

Results: The department is involved in: 1) Palliative Care outpatient services with 1200 new visits and 6000 revisits since July 2016 (Collaboration with Department of Anaesthesiology). 2) Training for nursing [BSc and GNM] students (3 years). 3) Sensitization workshops for medical students, Interns and post-graduate students. 4) Training of Community Health Officers – 60 as part of Certificate Course in Community Health [Govt. Initiative]. 5) Training of Village Level Health Workers-150 in Gujarati language with focus on identifying patients and providing non-medical home care. 6) Participation as trainer and Expert in National Programme for Palliative Care in association with Government of Gujarat at state and district levels. 7) Advocacy with Government of Gujarat & IAPSM_GC. 7) Translating Palliative Care Handbook for Volunteers into Gujarati Language. 8) We also publish articles in local press related to Palliative Care.

Conclusion: Departments of Community Medicine of medical colleges can play a very important role in delivery and training of Palliative Care.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 28: SIBLING INVOLVEMENT IN PEDIATRIC PALLIATIVE CARE – A SINGLE CENTRE EXPERIENCE

Smriti Khanna 1, Joanna Pinto 1, Veronique Dinand 1

Introduction and Objectives: The experiences of siblings of children with life-limiting illnesses are often neglected by family members as well as professionals. Some siblings are primary carers of the sick child; some, while not in caregiving roles, are still greatly affected by their sibling's illness. Many siblings are excluded by the family with the intention of protecting them. We aim to explore the needs of siblings and acknowledge the importance of including them in care of paediatric patients.

Methods: We reviewed counselling session notes of eight cases wherein we involved siblings of sick children.

Results: In our patients’ families, the roles performed by siblings were: actively assuming function of caregivers, participation in end-of-life care, bereavement support to the family. Some of the siblings we spoke to willingly talked about death, and in one case they facilitated a bereavement discussion with the rest of the family. We also observed the effects on mental health of the sibling such as loss of a sense of self and guilt.

Conclusion: Even though in palliative care we work with the entire family, siblings may be left out. As palliative care practitioners, it is important to explore the needs and concerns of siblings. In a cultural context where resources are limited, it often falls on the older sibling to assume the role of caregiver. Their mental health needs to be addressed. Promoting attachment and contact between siblings (especially in children with chronic stable ill ness) is a motivation to adhere to treatment.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 29: COMPLETE DECONGESTIVE THERAPY IN BREAST CANCER RELATED LYMPHEDEMA - STAGE III: NURSE-LED MANAGEMENT - A CASE STUDY

Malarvizhi K Natrajan 1, SJ Nalini 1, Jaya Mohan Raj 1, Usha Vishwanath 1

Introduction and Objectives: Breast Cancer related lymphedema is a progressive and chronic syndrome resulting from cancer treatment. The optimal management of lymphedema involves complex decongestive therapy where patient's engagement, adherence and motivation are pivotal factors in management success. Failure to engage in management is often attributed to patient noncompliance rather than understanding of other contributing factors or challenges faced by patients that can impact outcomes. This case study is presented to illustrate the health care professionals’ evidence-based clinical practice guidelines to help implement a safe treatment plan to overcome the multifactorial challenges.

Methods: 54-year-old overweight woman with dominant arm lymphedema, volume difference of 417 ml from the affected arm, unable to perform daily activities over two years’ duration. Treatment protocol was planned and carried by a certified nurse-lymphedema-therapist. CDT was followed daily for five days a week and lysis of fibrotic tissue on alternate days. Circumferential measurements and volumetric analysis were done on a weekly basis in phase 1. In phase 2, the analysis was done on 1st, 15th, and 30th day of treatment commencement.

Results: A decrease of 240 ml of edema volume was noted in the affected arm with complete treatment of fibrosis. Treatment was weaned to compression garment including day-arm sleeve with gauntlet and a night-wrap.

Conclusion: CDT significantly reduced the mean volume and circumference of the affected limb and significantly increased the upper limb shoulder joint movement as evidenced by decreased Quick Dash score and improved self-care assessment score thereby improving the health-related quality of life.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 30: EDUCATION IN PALLIATIVE CARE: A HOLISTIC PERSPECTIVE

K Eswaranna 1

Introduction and Objectives: Care for the terminally ill continue to remain poor in our society. Their needs are not understood completely either by the family or by society. Person-centric treatment and concept of total pain need improvement. More sensitization is needed in issues related to end-of-life care. The objective of this paper is to improve awareness about palliative care from multi-dimensional perspective, educate patients and family about their right to quality of life, sensitize medical professionals to integrate palliative care with mainstream treatment.

Methods: Questionnaire and tools to assess the requirement of patients and families along with the moral attitude of the medical personnel was devised. Options for patients to choose their end-of-life care plan was included. Few forms were also designed to evaluate the level of PC education in students and other professionals.

Results: The questionnaires and forms helped tremendously in evaluating the PC educational status of patients, caregivers, students, and others contributing to patient care.

Conclusion: Education in Palliative care should be seen as a holistic perspective to improve care and quality of PC service provided to the beneficiary which is the patient.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 31: IMPACT OF THE MEASURES TAKEN TO EMPOWER PALLIATIVE CARE TEAM IN A TEACHING TERTIARY CARE HOSPITAL – A QUALITATIVE STUDY

Shoba Nair 1

Introduction and Objectives: Palliative care provision can only be possible with a multidisciplinary team (MDT) approach. A PC team consists of nurses, doctors, physiotherapists, pharmacists, psychologists and/or chaplains. Empowering each member of the team is important to maintain quality of care. This could comprise of improving knowledge or skills. It is important for team members to be familiar with standard protocols of management of different medical conditions. This can be achieved by good communication within team, regular academic sessions, supervising and facilitating activities like procedures, care provisions, communication skills etc. The quality of these measures will determine the outcome which is excellent patient care. Objective is to describe the impact of measures taken to empower a PC team.

Methods: Design-Qualitative Study; Setting-Palliative Medicine Department in a teaching tertiary care hospital; Sampling-Purposive sampling; Method-Individual interviews with team members with interview guide. Interviews were audio recorded and transcribed verbatim. Thematic analysis was done.

Results: Main themes identified were: 1) Multidisciplinary patient management activities enhancement 2) Initiating multidisciplinary academics and 3) Initiating multidisciplinary research. Sub themes were a) MDT meetings b) MDT ward rounds c) Nurses-only ward rounds d) Regular academics e) Interdepartmental seminars f) Inclusion and administration of IPOS routinely g) Nurses’ presence during OPD consultation h) Telephonic follow-up by nurses I) Research projects.

Conclusions-The measures taken have empowered the team members by improving their knowledge and skills in the management of PC patients. It has improved the team members’ confidence and ensured that every step is taken to provide quality care to patients.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 32: FACTORS ASSOCIATED WITH ACCEPTANCE OF PROGNOSIS AMONG ADVANCED CANCER PATIENTS AND THEIR CAREGIVERS REFERRED FOR PALLIATIVE CARE IN INDIAN SOCIO-CULTURAL CONTEXT

GG Chinchalkar 1, D Dharkar 1

Introduction and Objectives: Communicating disease prognosis is an integral part of palliative care (PC). Concept of PC is still unknown and unacceptable to the Indian Population in Central India. They continue searching for curative options and spend more, with poor quality of life. There is a gap in evidence regarding factors influencing acceptance of prognosis for advanced cancer patients and their caregivers in India and this was the objective of our study.

Methods: Study design was retrospective-observational. Patients with advanced cancer, referred for PC at the Palliative Care dept of Indian Institute of Head and Neck Oncology, Indore, between 7th Oct'19 and 31st Dec'19 were included. Data collected for demographic, socio-economic, clinical details, disclosure/acceptance of prognosis, number of PC consults, symptom control, ongoing treatment, etc. Descriptive statistics were used for overall data and Chi square/Fisher's exact test was applied to interpret association between categorical variables.

Results: 47% (n= 45) of 96 patients did not accept prognosis at first PC visit. Of these, 60% followed up (n=27), 49% took further curative treatment and 29% accepted prognosis with subsequent PC consults till end of study period. Disclosure of prognosis by treating oncologist (p<0.001), early referral for PC (p<0.001), good symptom control (p=0.02) and more than one PC consults (p=0.04), were significant factors associated with acceptance of prognosis.

Conclusion: Early PC referral/disclosure of prognosis by treating oncologist and good symptom control are important modifiable factors which decide the acceptance of prognosis by patients/caregivers. Spreading awareness of PC may help prevent unnecessary treatment and thus improve the quality of life of patients and caregivers.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 33: PALLIATIVE CARE NEEDS AND OUTCOMES OF PATIENTS WITH HEPATOCELLULAR CARCINOMA IN THE UGANDA CANCER INSTITUTE AND MULAGO NATIONAL REFERRAL HOSPITAL

Florence Nalutaya1 1, Liz Gwyther 2, Elizabeth Namukwaya 1,3, Emmanuel Seremba 4, Nixon Niyonzima 5, Julia Downing 2, Mhoira Leng 2,6

Introduction and Objectives: HCC is a leading cause of morbidity and mortality in Uganda. A previous qualitative study showed multidimensional needs. It was important to ascertain these needs and patient outcomes. This study aims to determine the PC needs and outcomes of patients with HCC at Uganda Cancer Institute (UCI) and Mulago National Referral Hospital (MNRH).

Methods: A longitudinal, quantitative, descriptive study was conducted from in-patients using convenience sampling with HCC and aged >18. Structured questionnaire using validated tools was administered by face-to-face interview at baseline, then telephone follow-up at 1, 2 and 3 months. This tool includes socio-demographic and disease information, APCA POS and symptom assessment.

Results: Of 50 participants, 74% were male (70% <45yrs). 80% had <6-months’ duration of illness. All were stage 3/4 with 56% ECOG and performance status 0-2. 35% were undergoing chemotherapy. 80% had moderate to severe pain, with 48% on morphine and 30% accessing a SPC care. 50% had abdominal fullness. Degree of insight-10% ‘full', 60% ‘some’ and 30% ‘none'. 68% expected a cure while 30% felt hopeless. 42% reported insufficient spiritual support.

Conclusions: Majority of patients are young men presenting with late stage disease. Late presentations indicate the need for strong public education about prevention and early identification of HCC. There are significant unmet needs requiring further strengthening of PC within medical and oncology services. Excellent communication and clear referral pathways are needed to ensure early PC and multidisciplinary support.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 34: AN ASSESSMENT OF CHRONIC ILLNESS AND PALLIATIVE CARE NEED IN A SOUTH SUDANESE REFUGEE POPULATION WITHIN UGANDA

Mhoira Leng 1,42,43, Natalie Webber 1, Vicky Opia 3, Peace Bagasha 2, Rebecca Noble 1, Jackson Amone 4, Nasur Buyinza 5, Chitra Venkateswaran 6, Liz Grant 7, Julia Downing 8

Introduction and Objectives: Palliative care (PC) is recognized an essential component of healthcare provision in humanitarian settings including WHO & SPHERE guidelines. Evidence is needed from field settings to inform service development & health systems integration. Uganda hosts 3rd highest refugee population worldwide. We aim to determine chronic illness burden & PC need amongst refugees in Adjumani District and explore experiences of refugees living with chronic illness.

Methods: Following a Rapid Participatory Appraisal & training interventions, 24 Village Health Teams identified 331 potential participants with chronic disease. Ethical approval obtained for research team to screen & seek consent from individuals > 17, parents > 8 with assent from children >10. 110 completed survey by interview including the APCA-POS, POS-S, ECOG & sociodemographic variables. Participants with unmet clinical needs were signposted for support.

Results: 29% of participants were in South Sudan. Musculoskeletal conditions including chronic pain & trauma were most prevalent 39%, HIV 19%, neurological conditions 13% & liver disease 12%. 89% lived with their condition >1 year. Significant symptom burden; median number of symptoms 5, 67% reporting pain scores 4-5/5. Only 7% had access to oral morphine & 14% received PC. Median total APCA-POS score was 18/35 for adults & 14.5 for children; reflecting unmet PC needs. Social demographics revealed challenges including access to running water, sufficient food & paid employment.

Conclusions: There is a significant burden of chronic disease & unmet PC care need amongst refugees living in Adjumani district. Stakeholder engagement & health systems strengthening needs to guide implementation of PC services through governmental & NGO sector planning. This innovative research has wider implications for the provision of UHC for chronic disease & PC in humanitarian settings.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 35: CHANGING REFERRAL PATHWAYS: EARLY INTERVENTION A SUCCESS STORY

Sonali Kulkarni 1

Introduction and Objectives: As per WHO, Cancer is the second leading cause of death globally, and is responsible for an estimated 9.6 million deaths in 2018. Effective public health strategies, comprising of community and home-based care are essential to provide pain relief and palliative care for patients and their families in low-resource settings. We follow a Family-care model that believes in empowering the family as well as patients with a focus to improve QOL. The OPD service serves as a point of contact for patients to seek PC. We build on the approach of Early Assessment, Palliative Care Advocacy, Issue identification, Timely support care and counseling from a Multi-Disciplinary team.

Methods: The two cases outlined were of oral cancers with Ulcero-proliferative fungating growth in poor condition. Identified by volunteers and referred to PC before confirmation of diagnosis. Networking with hospital on timely basis led to early identification of disease. They were referred to Palliative Care for IPD care. The goals of care included – Pain management, Wound Management and hygiene. The patients and family members were counseled and encouraged to seek curative treatment.

Results: With help of timely interventions, networking and follow up, we were able to facilitate continued care for the patient and their family.

Conclusion: These two cases benefitted from the Multi-disciplinary approach which helped improve their Quality of Life and facilitate their transfer to a home-based care setup.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 36: SYMPTOM PREVALENCE IN ADVANCED CANCER PATIENTS IN PALLIATIVE HOMECARE SETTING IN NORTH INDIA

Reena Sharma 1

Introduction and Objectives: There is a lack of affordable, high quality PC services in most parts of India for people with advanced cancer. Information on prevalence of symptoms in this patient group would help in development of these services. The objective of this study was to determine the prevalence of symptoms in advanced cancer patients registered with a palliative homecare service.

Methods: Data was collected retrospectively from the record files of 180 advanced cancer patients enrolled in CanSupport's homecare program from Nov'18 to Oct'19. Patients included were aged ≥18 years. The doctors in the teams complete a symptom checklist of 24 symptoms on the first visit including Pain score.

Results: Of 180 patients, 97 males and 83 females. The most common cancers were head & neck (28%), gastrointestinal tract (19%), breast (14%), genitourinary (11%) and lung (6%). The eight most common symptoms were pain (70%), loss of appetite (68%), fatigue (63%), loss of weight (48%), taste alteration (35%), constipation (31%), sore mouth (23%) and nausea/vomiting (20%). The average number of physical symptoms reported was 5 of range 0-14. Most patients with pain were on medication but 52% had moderate to severe pain as strong opioids had not been prescribed.

Conclusions: Patients with advanced cancer have a large burden of symptoms. PC services need to be integrated into primary health care to relieve suffering during last days of life. Availability of strong opioids is essential and trained health professionals to prescribe them.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 37: PALLIATIVE PHYSICIAN IN THE EMERGENCY DEPARTMENT: A NOVEL YET PERTINENT CONCEPT FOR INDIA

Ruparna Khurana 1, Sushma Bhatnagar 1

Introduction and Objectives: The emergency department (ED) is a hostile ground for patients suffering from critical illness, nearing end-of-life within fast-paced and chaotic environment. Physicians and staff are overworked, under pressure to save lives, make place for new patients, fraught with need of prompt decision-making, and sending patients to appropriate places. Palliative patients suffer inadvertent intubation and spend the last few hours of their lives away from their loved ones in seclusion. Introduction of a PC physician attending the ED is a novel concept that shall go a long way in bridging the gaps in care.

Methods: Observational analysis to evaluate patient-related outcomes of PC consultation, before an impending intubation of advanced malignancy patient in the ED. During a 30 days ED posting period, all PC referrals for ‘end-of-life care’ were attended to, detailed interviews with patient, family and ED physician were undertaken; emphasizing ‘futile care, judicious use of medical resources'; and a decision was reached keeping the patients’ wishes central.

Results: 10 calls were received of EOLC, patients of advanced metastatic cancer who presented to ED in view of acute event: sudden worsening of dyspnoea (5), altered sensorium (3), and seizures (2). 8 patients were on PC follow up. After detailed interviews, counselling and discussions with all stakeholders, 8 patients refused invasive interventions, and allocated to homecare teams. 2 patients decided on invasive treatments due to other issues.

Conclusion: Palliative physician in an emergency department can be an asset to support the ED physicians. End-of-life care is central to the ideology of PC; and this pilot observation confirms that timely intervention by a palliative physician prevents inadvertent intubation in palliative patients.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 38: AAROHAN: A PROJECT ON EMPOWERING BENEFICIARIES OF PALLIATIVE CARE

Shriya 1

Introduction and Objectives: Patient and family involvement in shared decision-making is recognized as the key propeller of healthcare redesign. This trend should be rightly reflected in PC, a medical specialty that champions patient-centered care. The objective of Project Aarohan is to train and empower patients with serious health-related suffering and their caregivers to network and collaborate with people from their community to develop a network of palliative care advocates.

Methods: Aarohan is a patient and caregiver empowerment project run by Pallium India. Trainings were delivered via video-conferencing in partnership with Project Echo, 1.5 hours a day. 20 participants were selected through application and online interview.

Results: There were 16 online training sessions. Of the 20 participants selected, 3 were patients, 13 caregivers, 1 transwoman doctor and 3 cancer survivors. 4 out of 20 participants dropped out after first 2 training sessions. 12 participants are now engaged in advocacy activities: public awareness programmes, collaborating with other organizations. Pre-training and post-training evaluation analysis found an increase in the participants’ awareness of PC and the need to network.

Conclusion: While PC has made significant strides in human resource, infrastructure, training and capacity building, there is a stark paucity of initiatives to empower patients and caregivers. Evidence from around the world suggest that empowering patients and caregivers improve quality of care. There is a need for more such projects and research into patient and caregiver advocacy so that it becomes an inevitable chapter of the PC discourse.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 39: PALLIATIVE CARE IN HUMANITARIAN CRISIS-KERALA FLOODS

VK Vyshnavi 1

Introduction and Objectives: While flood affects a whole geographic area, certain people are particularly vulnerable, such as those with pre-existing serious illness, disabilities, the elderly, and children. Their plight in the aftermath of a natural calamity could be much worse than others. The objectives of the study are: To Identify palliative care needs in flood affected area of Pandanad panchayath-Alappuzha district (Kerala), & devise palliative care strategy for future disasters.

Methods: We surveyed the population of one panchayath in one district, including 13 wards of Pandanad panchayath-Alappuzha district. The survey tool included questions about the physical, emotional and medical aspects of the individuals.

Results: Out of 6077 people surveyed in one panchayath, Pallium India team supported 310 PC patients in the flood affected areas of the panchayat, and formalized the work as “Punarjani-Rebuilding lives”. The issues of people affected were physical, social, psychological and financial. Analysis identified that, people with long term diseases were aged 60-79. Rehabilitation of PC patients and families were the major challenges we faced during the period. Strategized plan of action to have special focus on PC patients-was one of the awareness slogans.

Conclusion: Inclusion of PC in state disaster management policy is one of the long-term goals of Punarjani project. The Kerala state disaster management authority is keen to have future collaborations for a multifaceted approach to disasters. Since disaster specific policies are essential in each state, there is a future opportunity to create a strategy for palliative care involvement in humanitarian crisis.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 40: A CASE STUDY ON CHALLENGES AND OBSTACLES FACED DURING ESTABLISHMENT OF PALLIATIVE CARE UNIT, JMCH JORHAT AND STRATEGIES FOLLOWED TO OVERCOME DIFFICULTIES

Pranjal Protim Gogoi 1

Introduction and Objectives: Increasing number of malignancy cases cause huge physical/psychological/social/spiritual burden on patients, families and the society, creating an urgent need of intervention for a holistic management. There is no existing Oncology facilities in Jorhat and almost no knowledge or sensitivity for Palliative Care. This is true for the medical fraternity also. Establishment of a PCU to provide comprehensive PC service poses a huge challenge and resistance to improving patient's quality of life. The objective is to take a different approach to provide PC service which is termed as ‘Jorhat model of palliative care'.

Methods: Establishment of an OPD reflecting holistic PC, sanitization of district administration & health authorities, sensitization within JMCH, sensitization of peripheral govt health institutions & health workers; community sensitization, tracking of under-treatment/follow-up cases; thus, creating a concrete route of patient movement from community till the tertiary care center; along with sensitization of private health institutions and practitioners. Two strategies were followed: BOTTOM UP: activities initiated from ground level health workers towards superior authorities, & TOP DOWN: activities initiated from Superior Authorities towards ground level workers.

Results: Total patients: 652 in 5 Months (Monthly average: 130.4); Total morphine consumption: 25,905 mg (Monthly average: 5181 mg)

Conclusion: Establishment of Palliative Care Unit without existing Oncology facilities and where PC is a less pronounced phrase, is a challenging task to perform. But the ultimate establishment and overall smooth functioning of Jorhat PCU proves that we can provide Holistic PC even without Oncology department.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 41: CAN RESILIENCE AFFECT ONE'S GENERAL HEALTH: A STUDY ON 99 ONCOLOGY NURSES

Arati Hota 1, Anjum S Khan Joad 1

Introduction and Objectives: Health care personnel working in cancer units are exposed to high levels of physical, emotional and psychological strain. Resilience is viewed as a vital attribute which can enable a nurse to cope with their work environment and to maintain healthy psychological functioning. We aimed to examine the relationship between resilience, years of work experience and general health.

Methods: This study was conducted with 99 nurses working at BMCH&RC, Jaipur. GHQ-28 (Goldberg, 1978) measured emotional distress and Resilience Scale (Dr. Vijaya Lakshmi) measured resilience. Statistical analysis was done to find an association between these variables.

Results: There were more males (60:39) and 80.8% are young adults. 44.45 % had average, 55.55% had high resilience, none of the nurses had low resilience score. Among average resilience score 27.2 % had high GHQ score which signifies emotional distress and 12.7% shows high GHQ score with high resilience. Resilience was high in those who were working more than 5 years (30.9%) in oncology. 67% (6 months to two years’ experience in oncology) had average resilience and high GHQ score. Those who had high GHQ score had a high score in Somatic symptoms, Anxiety & Insomnia and Social dysfunction subscale. Inference: Cancer Centres need to implement interventions to enhance resilience and impact the health of nurses.

Conclusion: Nurses with less experience in a cancer centre had lower resilience and general health scores.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 42: SOCIAL PROBLEMS IN CANCER PATIENTS: A STUDY IN A PALLIATIVE CARE SET UP IN A TERTIARY CANCER CENTRE

Linotto Assumi 1, Kabindra Bhagabati 1, Poonam Doley 1, Bidisha Sarma 1

Introduction and Objectives: Following the diagnosis of Cancer and its treatment, patients and their families not only experience physical and emotional difficulties but are impacted in varied social aspects. The social problems thus need to be elucidated in a deeper manner. The objective of the study is to identify the social problems in cancer patients and how each issue impacts their lives.

Methods: The study was carried out by interview and face-to-face group discussion. 40 patients were interviewed: OPD and IPD patients in the Palliative Medicine Department. 10 group discussions were organized within the ward in which 80 patients and caregivers participated.

Results: Different social problems identified in the study are: Financial constrains which includes treatment expenditures, resource management, children's education and marriage expenditures; Community issues which includes disease stigma, social isolation, adapting with the health care environment, legal issues, and experiences of insufficient collaboration between health care and social services; Responsibilities which include household duties, change of roles in the family, official duties, and other organizational and administrative roles; Family issues which includes problems with spouses, children, grandparents and other relatives.

Conclusion: Health care providers constituting the PC team should be vigilant as much as possible to identify these social problems experienced by the cancer patients and their families. Addressing these issues in time will enable them to get a clear picture of their state and acquire adequate service to ease elevating social problems.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 43: COUNSELLOR'S INTERVENTIONS TO EMPOWER ADVANCED CANCER PATIENTS WHO DESIRE FOR EUTHANASIA IN PALLIATIVE CARE

Vasudha Kothapalli 1

Introduction and Objectives: Terminal illness can be extremely distressing and unbearable. Due to which at times euthanasia would seem to be an option in handling with the unbearable suffering. It is very important to give patients time and space to have their voices heard with respect to these issues and help allay their fears. Our objective is to highlight various aspects of “desire for euthanasia” described by our patients and highlight the interventions done to help them overcome their desire.

Methods: Examples were taken from a review of recent case-note records of in-depth counselling sessions to illustrate different areas that may lead to feelings of desire for euthanasia and interventions which also included beyond textbook approach were used to help the patients overcome the desire.

Results: Results were observed in 4 domains Psychological, physical, social and economical. Common themes observed are: 1) Psychological-Giving up on hope, Helplessness, Existential 2) Physical-Medical (Pain), Physical Appearance 3) Social-Social isolation, burden on the family 4) Economical-Financial crisis. These themes have emerged from the sense of “unbearable suffering”.

Conclusion: Addressing such desires would require an in-depth understanding of the meaning, in order to ensure that the patients’ needs are being addressed to lessen their sense of suffering which could also reduce their desire for euthanasia.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 44: THE ROLE OF PROFESSIONAL SOCIAL WORKERS AND How THEY ARE INVOLVING IN PALLIATIVE CARE ACTIVITIES IN INDIAN SCENARIO – A MODEL BY PALLIUM INDIA

Babu Abraham 1

Introduction and Objectives: Social workers (SW) are a core service in hospice and PC teams. Their professional values and skills are a perfect match with PC services, which are designed to treat the whole person in an interdisciplinary manner to enhance quality of life during challenging time. The objective is to highlight the role of professional SW in PC patients and families.

Methods: MSW at Pallium India contribute to the following: Psychosocial and spiritual stress management, giving support in ethical dilemmas, Financial stress management, Advance care planning, rehabilitations, Grief and bereavement support, Care Coordination that includes special consultation, Counselling and Psychotherapy, Crisis Intervention, Patient Education and Resource Navigation Services, Patients advocacy, Community mobilization that includes volunteer mobilization and formation of future generation with social responsibility, liaison between patients and care providers, Helping them in unemployment and job related issues, Interpersonal issues other than related to family etc.

Results: Outcomes improves QOL of patients and family members in all aspects. Awareness about government schemes and support, PC awareness, optimal utilization of community resource.

Conclusion: Professional social workers are an integral part of Palliative Care, who can contribute to the holistic care of patients and family.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 45: SEXUAL DYSFUNCTION IN WOMEN WITH GYNECOLOGICAL MALIGNANCIES TREATED AT A TERTIARY CANCER CENTRE IN INDIA-A PROSPECTIVE CROSS-SECTIONAL STUDY

MS Biji 1

Introduction and Objectives: Early detection combined with scientific advances in the treatment of gynecological cancers has contributed to better survival of patients. However, treatment can lead to significant adverse effects, one of them being sexual dysfunction. The objective of this paper is to assess severity of sexual dysfunction in women treated for gynecological malignancies using Sexual Function-Vaginal changes Questionnaire (SVQ), and find out the association between sexual dysfunction with various treatment modalities and comorbid conditions.

Methods: Eligible women with gynecological malignancies treated with curative intent were enrolled into this prospective study after getting informed consent. They were administered the Malayalam translated version of SVQ. All demographic and treatment details were taken from their case records.

Results: Total 73 patients with median age 52(24-66) years participated in the study. Majority (n=55,75.3%) of them were Stage 1 or 2. Carcinoma Cervix (60.3%) was the commonest malignancy. Almost 54(74%) survivors expressed low or no sexual interest and 33 (45.2%) were dissatisfied with their sexual life. About 38 (49.3%) survivors did not have any sexual activity since completion of treatment. 64 (87.7%) survivors reported that their physician never discussed the effects of treatment on sexual life during their initial consultations. 68 (93.2%) survivors felt their treating physician should discuss about this prior to starting treatment, and 67 (91.8%) survivors wanted it to be discussed with their spouses also. There was no significant association of sexual dysfunction with different treatment modalities or comorbidity status.

Conclusion: A significant proportion of women treated for gynecological malignancies had sexual dysfunction and dissatisfaction with their sexual life. Sexual aspect of patients is an area totally neglected by medical team. Physicians should counsel patients and their partners on potential sexual problems which may occur after treatment for gynecological malignancies.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 46: PROJECT ECHO FOR PALLIATIVE CARE TRAINING IN SOUTH EAST ASIA-THE TRIVANDRUM EXPERIENCE OF RUNNING A VIRTUAL ONLINE TELE-MENTORING PLATFORM

Rajalekshmi Balu 1, Deepak Varughese 1

Introduction and Objectives: Project ECHO is a unique health education platform that uses teleconferencing technology to increase access to healthcare. It has been used for Palliative Care training at various centers around the world. This paper describes the experience of the Trivandrum Institute of Palliative Sciences (TIPS) in being a part of Project ECHO.

Methods: The process of conducting the ECHO sessions have been described. Completion rates and Certification rates were calculated. A cross-sectional study was done to identify barriers in practicing Palliative Care after the course was completed.

Results: The average completion rate was 65.1%. The average certification rate was 55.2%. After the course, 6% of respondents were involved in full time palliative care, 44% were involved on a part-time basis and 6% were involved in administrative roles in palliative care. 90% of participants were able to bring a palliative care approach in their regular practice. 42% of respondents were able to access morphine.

Conclusion: The completion rate for the ECHO Programme is higher than that of regular distance education courses. Morphine access continues to remain a challenge to the delivery of palliative care services. Other challenges include lack of community awareness, lack of volunteers and lack of support from the respondent's current organization.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 47: PREFERENCE OF ADULT FAMILY MEMBERS ON HOSPITAL-BASED BEREAVEMENT SUPPORT IN TERTIARY CANCER CENTRE

Amelia Michael 1, R Raghavendra 1

Introduction and Objectives: Bereavement following the loss of a loved one to life-limiting illnesses such as cancer is a traumatic experience. Bereavement and grief are unique to each individual. Understanding the factors that influence coping in bereavement, specific to our community will provide evidence-based research that will guide policymaking. The objective is to explore hospital-based bereavement support in India from the perspectives of bereaved adult family members through in-depth interviewing using a semi-structured interview topic guide.

Methods: A qualitative study using thematic analysis to explore the phenomenon of bereavement support in India, its social and psychological processes. 8 bereaved family members were interviewed using open-ended questions as per interview guide, with use of appropriate probes. The responses recorded using a digital voice recorder, transcribed and analyzed to arrive at major themes and subthemes.

Results: All participants preferred bereavement support. Acceptance of a formal bereavement support is influenced by factors such as, acknowledging caregiver needs throughout trajectory of illness, trust in palliative team, support at time of death, contact from hospital after demise of patient, information regarding bereavement support prior to demise of patient. The expectation from support is a listening ear, place to understand end-of-life experience, seeking advice and motivation regarding care for family and interaction with other bereaved caregivers.

Conclusion: There is preference for hospital-based bereavement support. Family meetings, identification of caregiver needs prior to demise of patient, facilitate acceptance of bereavement support. The right environment for a constructive interaction facilitated by the palliative team, will help individualize bereavement care for each family member.

Indian J Palliat Care. 2020 Apr-Jun;26(2):221–236.

OP – 48: COMPARISON OF PAIN INTERVENTION WITH ANALGESICS AND PULSED RADIOFREQUENCY ABLATION OF NERVES VERSUS ANALGESICS ALONE IN PATIENTS WITH HEAD AND NECK MALIGNANCY IN TERMS OF PAIN RELIEF AND QUALITY OF LIFE AT 3 MONTHS FOLLOW UP: A PROSPECTIVE RANDOMIZED STUDY

Manisha Pandey 1, Sushma Bhatnagar 1, Seema Mishra 1, Nishkarsh Gupta 1, Sachidanand Jee Bharti 1, Rakesh Garg 1, Vinod Kumar 1

Introduction and Objectives: Head and neck cancer (HNC) is the 6th most common cancer in the world and persistent pain associated with it leads to deterioration in QOL. Pulsed Radiofrequency Ablation (RFA) is claimed to be an effective method in controlling pain for HNC.

Methods: This prospective randomized control trial was conducted at Department of Palliative Medicine, IRCH AIIMS, New Delhi overs 18 months. Patients were randomly allocated in one of the two groups (30 each). Pain was assessed using NRS Scale. Breakthrough pain and Morphine equivalent daily dose were calculated. QOL was assessed using EORTC QLQ C-30 and EORTC QLQ H, and N 35. Group 1: Pain management using oral opioids and adjuvants; Group2: Pain management using Pulsed RFA (Maxillary/Mandibular/Glossopharyngeal nerves) in addition to oral opioids and adjuvants.

Results: Percentage median change of morphine equivalent daily dose between Group 1 and Group 2 was done (at baseline and then at 3 months). It was-500% and-50% respectively showing more requirement of morphine in group 1 than in group 2 at 3 months follow up. For NRS, breakthrough pain and satisfaction score, the p-value was statistically insignificant at baseline but was found to be statistically significant just after intervention (p<0.05). However, insignificant at 3 months follow-up. Role functioning and constipation were found to be statistically significant at 3 months follow-up which was initially statistically insignificant.

Conclusion: This study shows the role of Pulsed RFA of nerves in the management of pain in head and neck cancer patients and may help in decreasing the opioid requirements.

Articles from Indian Journal of Palliative Care are provided here courtesy of Scientific Scholar

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