Fatal Tetanus in a Patient with Carcinoma of the Breast - A Case Report.

Tetanus in patients with malignant wounds can be fatal. We report a case of a patient with carcinoma of the breast, with a malignant wound. She had applied native medication and approached us for pain management. She developed typical features of tetanus which despite prompt detection and management by the palliative care team, turned fatal. We further discuss the need to keep the possibility of the diagnosis in mind, educate the caregivers to be aware of the possibility of a toxic infection like tetanus that can occur in patients with open wounds, ascertain the immunisation status if possible and conclude by reiterating the conclusions of other authors that prophylactic tetanus immunisation for those with malignant wounds could be effective in reducing the resultant morbidity-mortality.

A Typical Perplexing Life-sustaining Therapy Decision at the End of life: A Case Report from Sri Lanka with Attributes Potentially worth Adopting from the UK Legislature.

In many developing parts of the world, evidence on advance care planning (ACP) is either lacking or fragmented. Lack of streamlined means for ACP is known to lead to inconveniences for the clinicians as well as the patients and their families. This case report focuses on a young male diagnosed with metastatic osteosarcoma, who explicitly verbalised his wishes to be managed conservatively without involving invasive life-sustaining measures. However, the patient faced cardiopulmonary resuscitation before his demise against his wishes, which also contradicted with the medical point of view. Sri Lankan doctors face moral, ethical and legal dilemmas as they deal with terminally ill patients at the verge of their death due to the deficiencies in the medical and legislative frameworks in the country.

Correlates of and barriers to ART adherence among adherence-challenged people living with HIV in southern India.

Suboptimal adherence to Antiretroviral Therapy (ART) regimens can lead to the development of drug resistance, virologic and clinical failure, and, on the community level, the spread of drug-resistant HIV. To design effective interventions, it is crucial to understand locally specific barriers to optimal adherence. Self-report data from a cross-sectional sample of 527 adherence-challenged people living with HIV (PLWH) in the South-Indian state of Karnataka showed that they took on average 68% of prescribed doses in the past month. Large majorities of participants encountered individual (95%), social/structural (88%), and clinic/regimen (80%) adherence barriers. Multivariate linear regression analyses of past month adherence showed that disclosure to all adults in the household was positively related to adherence, as was employing a larger number of adherence strategies, perceiving more benefits of ART, and having been on ART for longer. Fears of stigmatization upon disclosure of HIV-status to friends and people at work were negatively related to adherence. These results suggest that some barriers, especially individual-level barriers like forgetfulness are very common and can be targeted with relatively simple individual-level strategies. Other barriers, related to fear of stigma and lack of disclosure may require family- or community-level interventions.

Psychosocial Aspects of COVID-19 in the Context of Palliative Care - A Quick Review.

In a resource-poor country like India, where the health-care systems are difficult to access, overburdened, and unaffordable to many, the impact of the coronavirus disease 2019 (COVID-19) pandemic can be devastating. The increased burden of serious health-related suffering can impact the well-being of health-care workers, patients, and their families alike. The elderly, the frail, the vulnerable, and those with multiple comorbidities are disproportionately affected. Palliative care, with its comprehensive and inclusive approach, has much to offer in terms of alleviating the suffering, particularly those caused by the distressing physical and psycho-socio-spiritual symptoms, the complex medical decision-making, end-of-life care issues, and grief and bereavement, and needs to be integrated into the pathway of care provision in COVID-19. Psychosocial issues contribute to and amplify suffering and are often underestimated and undertreated and not accessible to many. Empowering frontline professionals in the core concepts of psychosocial support and palliative care thus becomes an absolute necessity. This quick review was done by a group of palliative care physicians and mental health experts from India to develop recommendations for physical and psychosocial care in the context of COVID-19. This review was done as part of that process and highlights the role and challenges of the psychosocial domain of palliative care in the context of COVID-19 situation in India.

Responding to Palliative Care Training Needs in the Coronavirus Disease 2019 Era: The Context and Process of Developing and Disseminating Training Resources and Guidance for Low- and Middle-Income Countries from Kerala, South India.

BACKGROUND: Palliative care has an important role to play in the global coronavirus disease 2019 (COVID-19) pandemic. It is integrated and is a key component in the governmental and community structures and services in Kerala, in India. Palliative care in the state has grown to be a viable model recognized in global palliative care and public health scene. The community network of palliative care, especially the volunteers linking with clinical teams, is a strong force for advocacy, relief support including provision of emergency medications, and clinical care. OBJECTIVE: To develop a palliative care resource tool kit for holistic care of patients affected with COVID-19 and to support the health-care workers looking after them to enable palliative care integration with COVID-I9 management. METHODS: The Kerala State government included senior palliative care advisors in the COVID-19 task force and 22 palliative care professionals formed a virtual task force named Palli COVID Kerala as an immediate response to develop recommendations. Results: Developed a palliative care in COVID-19 resource toolkit which includes an e-book with palliative care recommendations, online training opportunities, short webinars and voice over power point presentations. CONCLUSION: Integrated Palliative care should be an essential part of any response to a humanitarian crisis. The e resource tool kit can be adapted for use in other low- and middle-income countries.

A Behavioral Adherence Intervention Improves Rates of Viral Suppression Among Adherence-Challenged People Living with HIV in South India.

The success of antiretroviral therapy (ART) has led to both extended life expectancy and improved quality of life among people living with HIV (PLWH). To maximize the efficacy of first line ART regimens in low- and middle-income countries (LMIC), we need culturally-relevant interventions that empower participants to reduce barriers to long-term uninterrupted adherence. The Chetana adherence intervention trial was designed in collaboration with local community groups as a comprehensive wellness program for adherence-challenged PLWH and included peer-led adherence support, yoga, nutrition, information about local resources, and individual counseling using motivational interviewing techniques. Intervention arm participants were almost twice as likely to be virally suppressed at their 12-month follow-up visit (AOR = 1.98; 95% CI [1.2, 3.23]) as were participants in the active control arm. They were also about twice as likely as control arm participants to self-report ≥ 95% adherence (AOR = 1.86, 95% CI [1.09, 3.15]), and as having eliminated individual adherence barriers (AOR = 2.33, 95% CI [1.51, 3.62]) and clinic attendance barriers (AOR = 2.01, 95% CI [1.20, 3.38]) These low-cost strategies can be implemented by local NGOs, making it both scalable and sustainable in this and similar settings.

Multilevel model of stigma and barriers to cancer palliative care in India: a qualitative study.

INTRODUCTION: Palliative care coverage and opioid consumption in India are relatively low compared with global data. The literature suggests commonplace concealment and collusion in withholding information, but these hypotheses lack evidence. OBJECTIVES: This study aimed to develop an explanatory evidence-based model of stigma, communication and access to cancer palliative care in India that can be used to develop, test and implement future interventions. DESIGN: This cross-sectional qualitative study sampled advanced cancer patients (n=10), their family caregivers (n=10) and oncologists (n=10). Grounded theory procedures were utilised to analyse transcripts, and a theoretical model generated. SETTING: A tertiary teaching hospital in South India. RESULTS: The model explains how stigma associated with communicating a diagnosis of advanced cancer is enacted by treating oncologists, family members and community. This leads to patient expectations of cure and futile treatment uptake. Patients commonly only present needs with respect to pain, not within psychological, social or spiritual domains, likely due to the lack of patients' insight into their diagnosis and prognosis. As a result of oncologists' and families' unwillingness to disclose the prognosis, and patient focus on pain due to their lack of insight, palliative care clinicians view their services as under-utilised, and patients perceive palliative care as a pain management service that is not 'different' from other clinical services. Advanced care needs and purchase of futile treatments lead to lost employment among families, increased family debt and high care costs, which are rarely disclosed due to their unwillingness to discuss their needs. CONCLUSION: Our novel theoretical model is an essential first step to ensure that complex interventions are plausible, with mechanisms of action that address the needs of relevant stakeholders. A family-centred approach with an oncology workforce skilled in communication and an enabled patient population could increase access to palliative care, and improved outcomes may be attainable.

A Qualitative Study on Palliative Needs of Stroke Patients in an Indian Tertiary Care Setting - Doctors' Perspective.

INTRODUCTION: Stroke is the development of a focal neurological disturbance lasting >24 h, of vascular origin. In India, stroke is one of the leading causes of morbidity and mortality. Most stroke patients, during their duration of treatment and posthospitalization, want relief of suffering, a sense of control and minimized burden on the family. AIM: The aim of this study is to describe treating doctors' perspectives on the palliative needs of stroke patients in India. METHODOLOGY: This qualitative study was conducted at a tertiary care hospital in South India. A total of 17 doctors involved in the care of stroke patients were interviewed, using an interview guide. The interviews were audio recorded simultaneously. The audio recording was transcribed verbatim, and the data were coded using a grounded theory approach. An inductive approach using thematic analysis was used to manually analyze the data. RESULTS: Eight themes emerged. (1) Functional disability: loss of independence due to immobility, speech deficits, visual disturbances, feeding difficulties, and incontinence cause immense distress. (2) Physical burden: pain in the form of central poststroke pain, periarthritic shoulder, psychogenic pain, and various sequela of chronic bed bound state like bed sores and pneumonia add to the burden. (3) Psychological needs: depression is common in stroke patients along with other psychological issues such as anxiety, agitation, apathetic state, and behavioral disturbances (4) Social issues: Cost of treatment of stroke patients coupled with their loss of employment leads to huge economic burden. They also face abandonment by children or spouse, in all sections of socioeconomic strata. (5) Caregiver burden: caregiver has a major role in a setting of stroke and in the long-term affects all domains of their lives, compromising their psychological and physical health. (6) Counseling-an unmet need: counseling is particularly important in a setting of stroke for the patient as well as the caregivers and results in a better patient outcome. However, clinicians expressed that it was inadequate due to the huge patient load, time constraints, and lack of effective counseling skills. (7) Spiritual needs: few clinicians stated that existential distress and spiritual struggle are seen in debilitated stroke victims and are often unaddressed. (8) Issues at the end of life care: patients with massive stroke, multiple comorbidities, and poor rehabilitative potential requires end of life care. CONCLUSIONS: From the interviews of the clinicians, we can conclude that care of a stroke patient is more than medical management and rehabilitation, as several other aspects of the patient's life are affected by the condition. The quality of life aspect has to be looked upon as an area that requires active intervention in a setting of stroke. Physical disabilities were viewed as the most significant factor in reducing the quality of life. Spiritual needs have a low priority in comparison to other physical needs. Due to high patient load and time constraints, many of the needs are unaddressed. Two important areas where palliative medicine has a major role in a setting of stroke are counseling and alleviating caregiver burden. However, referral of stroke patients to palliative medicine is low and further research to identify barriers to specialist palliative care of stroke patients will help in promoting the referrals to palliative medicine.

Perspective of Orthopedists on Pain Management in Osteoarthritis: A Qualitative Study.

CONTEXT: Osteoarthritis (OA) is a degenerative disorder characterized by pain, stiffness, and loss of mobility of the joint. As the most prevalent form of arthritis and a leading cause of impairment, it is imperative to understand the treating doctor's perception of pain relief among these patients. OBJECTIVES: To assess orthopedists' perspectives on pain management in OA. MATERIALS AND METHODS: In this qualitative study, a guide-based interview was conducted on 15 orthopedists of a tertiary care hospital and audio-recorded simultaneously. A grounded theory approach was adopted for data transcription with an inductive approach for thematic manual analysis. RESULTS: Five themes emerged - (1) quality of life: OA produces significant disease burden causing severe impairment; (2) pain management: although patients usually demand immediate pain relief, a multipronged approach to treatment emphasizing on physiotherapy and surgery rather than analgesics is needed. Most participants preferred individual discretion while others felt the need for systematizing pain management; (3) precautions/side effects of treatment: paracetamol is often prescribed due to its better benefit - adversity profile as compared to nonsteroidal anti-inflammatory drugs and weak opioids; (4) barriers: participants expressed several barriers to optimal pain management; (5) counseling: Participants concurred that counseling would improve patients' quality of life. CONCLUSIONS: Participants agreed that OA being associated with debilitating pain and impairment requires optimal pain management for improving patients' quality of life. As crucial as counseling is, it is often compromised due to the large outpatient load. The doctors concurred that a multi-disciplinary team approach is needed to integrate and optimize pain management in OA.

Effect of Music Therapy on Pain and Anxiety Levels of Cancer Patients: A Pilot Study.

BACKGROUND: The pain associated with cancer is highly detrimental to the quality of life of the affected individuals. It also contributes to the anxiety of the patient. There is a need for a nonpharmacological approach in addition to the pharmacological therapy for the management of the pain for a more holistic improvement in the individual. With this study, we wish to achieve this through music. OBJECTIVE: To assess the effect of music therapy on pain scores and anxiety levels of cancer patients with pain. STUDY DESIGN: In this quantitative study, a comparative study was done on fourteen cancer patients admitted for pain relief under the Department of Pain and Palliative Medicine, of a tertiary care hospital, having moderate to severe pain (numerical pain rating scale [NRS] - of 4 to 10). SUBJECTS AND METHODS: Convenience sampling was used. Patients were allocated to test group or control group nonrandomly. The test group patients were subjected to music therapy for 20 min while the control group patients were kept occupied by talking to them for 20 min. The NRS scale was used to assess the pre- and post-interventional pain scores and the Hamilton anxiety rating scale was used to assess the pre- and post-interventional anxiety scores in the two groups. STATISTICS: Student's t-test was used for comparing the pre- and post-interventional data. Two sample t-test was used to compare the data obtained from the control and study groups. RESULTS: Statistically significant reduction seen in the pain scores in the test group after music therapy (P = 0.003). No statistically significant reduction seen in the pain score in the control group (P = 0.356). There was a statistically significant reduction in the postintervention pain scores in the test group compared to the control group (P = 0.034). The reduction in anxiety levels in both groups after intervention was not statistically significant. CONCLUSION: Music therapy was found to lower the pain score of a patient who had received standard palliative care for pain reduction. It was also more effective than the act of talking in reducing the pain score. A study with a larger sample size should be undertaken to conclude that, music therapy can be used in addition to morphine and other painkillers to reduce pain as a part of a more holistic approach to palliative care strategies.

Experience in Strategic Networking to Promote Palliative Care in a Clinical Academic Setting in India.

BACKGROUND: Palliative care in low and middle-income countries is a new discipline, responding to a greater patient need, than in high-income countries. By its very nature, palliative as a specialty has to network with other specialties to provide quality care to patients. For any medical discipline to grow as a specialty, it should be well established in the teaching medical institutions of that country. Data show that palliative care is more likely to establish and grow in an academic health care institution. It is a necessity that multiple networking strategies are adopted to reach this goal. OBJECTIVES: (1) To describe a strategic approach to palliative care service development and integration into clinical academic setting. (2) To present the change in metrics to evaluate progress. DESIGN AND SETTING: This is a descriptive study wherein, the different strategies that are adopted by the Department of Palliative Medicine for networking in an academic health care institution and outside the institution are scrutinized. MEASUREMENT: The impact of this networking was assessed, one, at the level of academics and the other, at the level of service. The number of people who attended various training programs conducted by the department and the number of patients who availed palliative care service over the years were assessed. RESULTS: Ten different strategies were identified that helped with networking of palliative care in the institution. During this time, the referrals to the department increased both for malignant diseases (52-395) and nonmalignant diseases (5-353) from 2000 to 2013. The academic sessions conducted by the department for undergraduates also saw an increase in the number of hours from 6 to 12, apart from the increase in a number of courses conducted by the department for doctors and nurses. CONCLUSION: Networking is an essential strategy for the establishment of a relatively new medical discipline like palliative care in a developing and populous country like India, where the service is disproportionate to the demands.

Prevalence of Hyponatremia in Palliative Care Patients.

INTRODUCTION: Hyponatremia is an undertreated finding in clinical practice. It is the most common electrolyte abnormality. Hyponatremia can be asymptomatic or can cause symptoms ranging from nausea and lethargy to convulsions and coma. Palliative care patients have a multitude of symptoms and there are several contributing factors towards this. Hyponatremia could be one of the contributing factors. Looking at the prevalence of hyponatremia would highlight the magnitude of the problem and would prompt healthcare professionals to investigate and treat hyponatremia in palliative care patients, which in turn might reduce symptoms such as fatigue and nausea. This could improve the quality of life in palliative care patients. AIM: To assess the prevalence of hyponatremia among patients referred for palliative care in a tertiary care hospital. METHODOLOGY: This is a descriptive study, with retrospective analysis of consecutive patient charts for 5 years. The sodium levels at the time of referral for palliative care, was reviewed. Inferential statistics for the result was calculated using the Z-test. RESULTS: Of the 2666 consecutive patient charts that were reviewed, sodium values were recorded in 796 charts. Among the recorded charts, 28.8 % of patients showed hyponatremia at the time of referral which was significant with a P value of 0.000 (<0.05). Of these, 61.1 % had malignancy as their diagnosis and the rest had nonmalignant diseases, ranging from trauma to chronic obstructive pulmonary disease. CONCLUSIONS: Prevalence of hyponatremia is significant in palliative care patients. A prospective study looking at the causes and clinical outcomes associated with hyponatremia in palliative care patients is needed.

Prescription Pattern of Analgesic Drugs for Patients Receiving Palliative Care in a Teaching Hospital in India.

BACKGROUND: Drugs used in the palliative care unit for managing symptoms are major contributors toward the expenditure occurring in palliative care. This study was conducted to understand the prescription pattern of analgesic drugs in the patients who are receiving palliative care in a teaching hospital in India by a retrospective study of case records. METHODS: Case record based, retrospective, descriptive study was conducted at the Pain and Palliative Care Department of St. John's Medical College Hospital, Bengaluru. Case record files of all patients referred to Pain and Palliative Care Department for the treatment of pain in the year of 2012 were studied. Patients' age, gender, diagnoses, numerical pain rating scale (0-10), drugs prescribed, dosage, frequency, route of administration were recorded. The difference in drug utilization between the genders was done using Chi-square test. Data were collected from 502 patients of which 280 (56%) were males and 222 (44%) were females. Twelve percent of patients had mild pain (1-3), 34% had moderate pain (4-6), and 54% had severe pain (7-10). The most commonly used analgesic drugs were opioids (47%), followed by nonsteroidal anti-inflammatory drugs (36%). The opioids used were tramadol (56%), and morphine (38%). Ninety percent of patients with numerical pain scale more than 6 received morphine. There was no difference in analgesic drug utilization with regards to gender. Prescription pattern differed depending on the severity of pain. Opioids were the most commonly used drugs for pain management. CONCLUSION: The study shows that prescription pattern in palliative care unit of this hospital was in accordance with WHO pain management guidelines. The study showed the current trend in prescription of analgesic drugs in the teaching hospital where the study was conducted.

Prevalence of Pain in Patients with HIV/AIDS: A Cross-sectional Survey in a South Indian State.

OBJECTIVES: Primary - To measure the prevalence of pain in HIV/AIDS with patients. Secondary - To assess the type, site, severity, management of pain and impact of pain on quality of life in these patients. DESIGN: Multicentre cross-sectional survey (This paper is a pilot study). SETTINGS: ART centre at St. John's Medical College Hospital, Bangalore and Snehadan, A supportive and care centre for HIV/ AIDS patients at Bangalore. MATERIALS AND METHODS: Data sheet, Brief pain inventory and Short - Form McGill pain questionnaire. SUBJECTS: This is an ongoing study and the pilot study includes 140 HIV/AIDS patients in different stages of the disease. RESULTS: About 66.7% (28/42) in-patients and 24.5% (24/98) out-patients complained of pain. Of the 52 patients who reported pain, 32% (14/52) reported neuropathic pain and 68% (38/52) reported noci-ceptive pain. Headache was most common followed by pain in the soles of feet and low back. Only 26.9% (17/52) received any form of analgesic. Pain severity significantly affects the quality of life. CONCLUSIONS: Pain is a common and debilitating symptom of HIV/AIDS. It is however, under-estimated and under treated.