PALLIATIVE CARE ONCOVISION PPT for students

palliative care

1. PALLIATIVE CARE : NEED OF THE HOUR !! Dr (Col) R Ranga Rao, VSM MD, DM Senior Director Oncology services, Max Superspeciality Hospital, Shalimar Bagh, New Delhi, India [email protected] [email protected]

2. नमस्ते!!

3. CA: Cancer J Clin . 2018;68:394-424. © 2018 American Cancer Society HEADLINES : CANCER There will be an estimated 18.1 million new cancer cases (17.0 million excluding nonmelanoma skin cancer) and 9.6 million cancer deaths (9.5 million excluding nonmelanoma skin cancer) in 2018. In both sexes combined, lung cancer is the most commonly diagnosed cancer (11.6% of the total cases) and the leading cause of cancer death (18.4% of the total cancer deaths) breast cancer (11.6%), prostate cancer (7.1%), colorectal cancer (6.1%) Palliative care of 30-50 % of cancer patients required !!

4. Requirement of palliative care Despite modern treatment advances, approximately 50% of all cancer patients die from their disease, suggesting that for every second patient, the focus eventually has to shift from cure or life prolongation to palliation. World Each year, an estimated 40 million people are in need of PC, 78% of them live in low- and middle-income countries, for children, 98% of those needing PC live in low- and middle-income countries. India : 14 lakh new patients are diagnosed each year 4 lakh new cases require PC 6 lakh old patients require PC Currently they are being done mostly by medical oncologists & radiation oncologists

5. Palliative care : Definition “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” ‘Palliative Care’ is considered under the human right to health.

6. Goals of palliative therapy : Concrete symptom control or relief from suffering, suffering” is a holistic one that adequately addresses all the elements of chronic illness and pain management. treatment complications, pain and other distressing symptoms, a support system Communications Decision making Coordinated care Psychological and spiritual care, to help the individual live as actively as possible, rehabilitate the individual’s family. Improve quality and comfort

7. When is PC required ? CANCER cardiovascular diseases, chronic respiratory diseases, HIV/AIDS, diabetes, including kidney failure, chronic liver disease, multiple sclerosis, Parkinson’s disease, rheumatoid arthritis, neurological diseases, dementia, congenital anomalies, chronic mental illness, spinal cord injuries, and drug-resistant tuberculosis.

8. Palliative care : The Concept Today, supportive and palliative care has been recognized as an important component of quality of life care for patients, particularly those with advanced or incurable cancer. Require considerable care, time, compassion Clinicians are too busy for these tasks with curative efforts Less time for counselling, symptomatic care & coordination, Less attention for these patients NEED for palliative care team /specialist !

9. Palliative therapy vs Palliative care vs Care of Dying Palliative therapy Any Anti cancer therapy for an advanced cancer patient Requires oncologists to carefully plan, select and offer Cancer a chronic disease –years can pass by !! Palliative care Minimal or no oncological care Symptom control Best Supportive care Care of dying A patient with terminal illness Pain specialist a palliative specialist ?

10. Palliative Care Team: for Cancer Palliative care specialist Pain specialist Specialized in understanding the types of pain, Can manage opioids, Palliative nurse Counselor Social nurse/worker Spiritual person/Volunteer Religious Coordinator/navigator Oncologist Guides/Leads the team Understands the basic disease Treatment, Prognosis Anti cancer therapy if any Can refer to other members as necessary Oncology Nurse practitioner Discuss the holistic care with the entire team

11. Who is a palliative care specialist ? Oncology background Understand the intricacies of anti cancer treatment Differentiate the “lines” between curative and palliative therapy Palliative therapy and palliative care Cancer a chronic disease Side effects of therapy and management Prognosis assessment Comprehensive Physician Manage pain and symptomatic treatment Manage Complications Psychologist & Social Specialist End of Life care specialist

12. What makes him a palliative care specialist ? Physician/ Oncologist of any discipline Understanding of Concepts of oncology Trained in palliative care Fellowship in oncology Centre (1-3 YEARS) Advanced cancer patients Training Symptom control Pain management incl opioids, nerve blocks Understanding of cancer Counselling Communication skills Social, Spirituality, religion

13. PC spl Oncologist Pain & Sympto Rx Psycho social E of Life care

14. Continuum of cancer care Curative therapy Palliative Therapy Palliative care Dying Anticancer therapy ‘Comforting’ therapy oncologist oncologist Palliative care spl Palliative care spl Family Nurse Family Nurse Spiritual Religious

15. Benefits of integration of Palliative care Team/Centre Patients Serious and terminally ill patients can get better quality of holistic care covering social, spiritual and psychological aspects Bridge acute care and palliative care  Continuum of cancer care Cure to EOL care  Care under one roof Reduction of cost Staff on-the-job training in end-of-life care and critical communications. Hospital enhanced positive image in the community for providing better care that encompasses not only the patient, but also the relatives. provide greater care to a larger number of people. Physicians Less burn out & Better well being

16. Barriers to Palliative care Physicians/Oncologists Lack of concept in society ALL DISEASES MUST BE CURED!! LOSING NOT acceptable !! Patient Denial Less acceptance Ignorance of palliative care Hopes for ‘cure’ Wants to fight and get treated Family Less acceptance Curative therapy Comprehensive training Lack of trained PC specialists National commitment to cancer and PC care

17. Case study 1 40 year old smoker presented with backache Diagnosed to have metastatic lung cancer Non mutant Squamous cell: mets to spine, few bones, nodes Symptoms Pain Weakness Inability to walk Very eager to fight and live well Palliative chemotherapy and RT given to bone, lung and md Excellent response and relief of pain, Good QoL for 18 months Recurrence of cancer with spinal pain, weakness, resp distress Palliative care : When, how, what

18. Case study 2 45 year old lady with breast lump and mild hip bone pain Metastatic breast cancer Luminal A type : Oophorectomy + Tamoxifen  AI Lump regressed, pain disappeared Asymptomatic, excellent quality of life PET CT  very good PR SBRT to hip bone Surgery to breast was offered after one year 3 years  Asymptomatic Recurrence  Palbo + Another AI  Good PR X 1.5 years Progression on PET CT: Pt is well  Next line of therapy Constant denial mode of problem : HOPE !!

19. Palliative care in India Started in Kerala about 30 years ago Dr Rajagopal : ‘Father of palliative care’ Currently Director ‘WHO palliative care division’ Padmashree Nobel prize Nominee Founder of “Pallium India” Formulated Palliative Care policy in Kerala Founded a chain of PC centers in every district OF KERALA Helped streamlining for opioids for pain relief Govt and NGO efforts in the world and India

20. How to overcome the shortage of PC teams? Palliative care units to be established Under oncology teams Proper planning: short term & long term Training : short and long Work experience in Cancer Centre Train the oncologists in PC Nurses, coordinators, social workers Navigators, Hospice Community awareness programs

21. Palliative care in India Over 60 centers in India PC and Hospice Kerala and Karnataka leaders National program of palliative care State programs exist Very few PC spl exist

22. Conclusions Palliative care should be an INTEGRAL PART of any Comprehensive Cancer Centre Completes the continuum of care Cure  Care Bereavement  rehabilitation Formal Training of PC fellowship : Curriculum Develop teams of PC across the country in private and Public sectors Oncologists can devote more time to curable situations Need of the hour !!