4. Definition of Supportive Care
Supportive care in cancer is the prevention and management of the
adverse effects of cancer and its treatment
This includes management of physical and psychological symptoms
and side effects across the continuum of the cancer experience from
diagnosis through treatment to post-treatment care
Supportive care aims to improve the quality of rehabilitation,
secondary cancer prevention, survivorship, and end-of-life care
MASCC = Multinational Association of Supportive Care in Cancer
5. Goals of Palliative Care
To anticipate, prevent and reduce suffering
To support the best possible quality of life to the patients, family &
care givers regardless of the stage of the disease or the need for other
therapies
6. Objectives
To give the concept of palliative care in oncology
To discuss the factors involved in palliative care
To give the idea of approach to a patient of palliative care
To discuss the Indian scenario of palliative care
To give the concept of multidisciplinary approach
7. Definition
WHO:
Services designed to prevent & relieve suffering for patients and families facing
life-threatening illness through early management of pain & other physical,
psychosocial & spiritual problems
NCCN:
It is an approach to patient / family / care giver-centred health care that focus on
optimal management of pain and other distressing symptoms, while
incorporating psychosocial & spiritual care according to patient /family needs,
values, beliefs & cultures
8. Palliative care is Palliative care is not
Evidence based medical treatment It is not “giving up” on a patient
Vigorous care of pain and symptoms
throughout illness
Not in place of curative or life prolonging
care
Care that patients want at the same time
as efforts to cure or prolong life
Not the same as Hospice
9. ASCO : Recommendations
• The time to start palliative care is as soon as a patient cancer becomes advanced.
• For newly diagnosed patients with advanced cancer, the panel suggests that early
palliative care involvement within 8 wks after diagnosis
• In-patients and out-patients with advanced cancer should receive dedicated
palliative care services early in the disease course concurrent with active treatment
10. Palliative care should facilitate
a) Patient autonomy
b) Access to information
c) Choice
Palliative care becomes the main focus of care when disease- directed, life
prolonging therapies are no longer
a) Effective
b) Appropriate
c) Desired
12. Who can practice Palliative Care?
Palliative care should be initiated by the primary oncology team & augmented by
collaboration with an inter disciplinary team of palliative care experts
13. When to a start Palliative Care?
Patients having one or more of the following
Uncontrolled symptoms
Moderate – severe distress related to cancer diagnosis and therapy
Serious co-morbid physical and psychosocial conditions
Complex psychosocial needs
Poor prognosis
Potentially life limiting disease
Metastatic solid tumors
Patient/ family/ care giver concerns about course of disease and decision
making
Patient family care giver requests for palliative care
Patient request for a hastened death
15. Criteria for consultation with palliative care specialist
Patient characteristics
Patient with life limiting cancer diagnosis
Limited anticancer treatment options
Need for clarifications of goals of care
Resistance to engage in advance care planning
High risk of poor pain management / resistant pain to conventional interventions
High non-pain symptom burden, especially those resistant to conventional
management
High distress
Need for invasive procedures [i.e. palliative stenting/ venting gastrostomy]
Frequent visits and hospital admissions
Need for ICU level care
Communication barriers [language /literacy /cognitive impairment]
Request for hastened death
16. Assessment
The oncology team assesses the following
Benefits /burdens of anti cancer therapy
Patients / family /caregivers goals /values /expectations /priorities
Symptom management
Psychosocial distress
Educational and informational needs / cultural factors affecting care
18. Benefits/ burdens of anti cancer therapy
Natural history of specific tumor
Potential for response to further treatment
Potential for treatment related toxicities
Patients understanding of disease prognosis
Goals and meaning of anticancer therapy for patient, family, care givers
Impairment of vital organs
Performance status
Serious co-morbid conditions
19. Patients/ family/ care-givers goals/ values/
expectations/ priorities
Shared decision making with patients / family /care-givers
Advance care planning
Goals and meaning of anti cancer therapy
Quality of life
23. Educational and informational needs or
cultural factors affecting care
Patient/family/care-giver values and preferences about information &
communication
Their perceptions of disease status
24. Hospice
Definition : It is defined as the care that is designed to give supportive care to
people in the final phase of a terminal illness and focus on comfort and quality of
life, rather than cure.
Goal : The goal is to enable patients to be comfortable and free of pain so that they
live each day as fully as possible.
Hospice programmes : They are generally home based but they sometimes provide
services away from home [ i.e. In hospitals ].
Philosophy : Is to provide support for the pts emotional, social & spiritual needs as
well as medical symptoms as a part of treating the whole person.
25. Bereavement
It is the period of mourning after a loss / death.
The team of palliative care also provides bereavement care
26. Hospice & palliative care development in India
Palliative care has been developing in India since mid 1980s
Now in India there are > 150 palliative and hospice centres in 16 states
Mostly concentrated in large cities [but in Kerala it is more wide spread]
Non governmental organizations, public and private hospitals
But in rest of the states of India it is totally absent
Barriers to the development of palliative care are:
Poverty
Population density
Opioid availability
Work force development &
Limited National palliative care policy
27. Developing palliative care in India
Based on the western models of palliative & hospice care for implementation in
Indian cultural context, successful models are being developed for
Affordable
Sustainable
Community based palliative care services
28. Role of counselling in palliative care
Most of the patients in palliative care suffer from depression therefore
counselling plays a very important role in palliative care
for the better cooperation of the patient and care takers
accepting the facts
to understand the treatment, its benefits and side effects
The counsellor provides emotional & psychological support to patients
Therefore it is a part of palliative care rather than considering it as separate
entity
29. Role of family physicians in palliative care
Attending to palliative care needs is a responsibility of primary care doctors
They are in a unique position to provide comprehensive care to the patient
To make it possible for terminally ill patients to remain at home for the
remaining period of life , they should have an access to a doctor who is
Easily approachable
Skilled in palliative care
Prepared to come for a home visit
Provide round the clock care
Therefore family physicians of palliative care patients should be trained for
the basic interventions and care to be offered
Improving the skills of doctors in palliative care principles have to be
initiated in the profession so that they could meet the needs of challenging
society
31. Alternative therapy
It is the term used to describe any medical treatment or intervention that has not
been sufficiently scientifically documented or identified as safe and effective for a
specific condition
All the following are alternative therapies :
Acupuncture
Guided imagery
Chiropractic treatment
Yoga & meditation
Hypnosis
Bio feedback therapy
Aromatherapy
Herbal remedies
Massage
32. Integrative medicine
Integrative medicine : Medical care + Evidence based CAM
Evidence based CAM should be added to medical care:
Patient dissatisfaction with conventional medical care alone
A need for personal control
Traditional and superstitious thoughts
33. Few benefits
Some of the CAM have evidence in acting as adjuvants along with
medical treatment, therefore can be used
Acupuncture and massage therapy may provide pain relief in cancer pain
/ in end stage patients
Relaxation by imagery can improve oral mucositis pain
Patients with severe COPD and dyspnoea may benefit from the use of
relaxation with breathing retraining
34. Metronomic chemotherapy
To avoid the problems caused by traditional chemotherapeutic regimens a
new modality called Metronomic chemotherapy has been proposed
It refers to the chronic equally spaced administration of low doses of
various chemotherapeutic drugs without extended rest periods
The novelty of this modality lies not only in its anti tumor efficacy with
very low toxicity but also in a cell target switch, now aiming at tumor
endothelial cells
This new concept includes the possibility of treating tumors that no longer
respond to traditional chemotherapy
35. Role of metronomic chemotherapy in palliative care
Studies show that use of metronomic chemotherapy in palliative care in
various sites like
Head & neck ca
Breast ca
Ovarian ca
Advanced GI ca
Refractory haematological malignancies
Showed cost effectiveness, well tolerated with minimal toxicity and
improved quality of life
37. Pain
• “Pain is whatever the experiencing person says it is, existing
whenever he/she says it does.”
- Margo McCaffery, 1968
• An unpleasant sensory and emotional experience associated
with actual or potential tissue damage, or described in terms of
such damage.
- International Association for the Study of Pain (IASP)
40. End stage of life – peaceful death
Peaceful death is one that is free from avoidable distress and suffering of patients,
families and caregivers; in general accord with patients and family's wishes and
consistent with clinical cultural and ethical standards i.e.
Freedom from pain
Being at spiritual peace
Being with family
41. Benefits of palliative care
Kavalieratos et al
Systematic review and meta analysis of 43 RCTs in palliative care vs usual care : both in
IP & OP settings
Improved QOL & symptom burden
No change in survival
Improvements in advance care planning, patient and care-giver satisfaction and
lower health care utilization
42. Benefits of palliative care
Davis et al
A review of 62 studies on palliative care in ambulatory and home care [ 28 RCTs ]
Improvements in depression, patient / cae-giver QOL,patient and family
satisfaction,care-giver burden
Reduced aggressiveness at EOL, increased advanced directives
Reduced hospital length of stay and hospitalizations,reduction in overall cost of
care
43. Benefits of palliative care
Temel et al
Patients with newly diagnosed stage IV NSCLC with standard monthly out patient
palliative care
Improved QOL
2.7 months medial benefit
Less aggressive curative care [ 4th line chemo ]
Hospice referral earlier and longer duration
Improved prognostic awareness – less chemo at EOL
44. Take home message
• Palliative care is a part cancer therapy
• It should be started as early as possible
• The treating physician along with caregivers, patient and his family
should work as a team in palliative care
• Palliative care in India is still developing – therefore palliative care
policy and specific guidelines according to the Indian conditions should
be developed
45. Take home message
• All patients of cancer should be given good QOL till the end of life
• Hospice & bereavement should be a part of your palliation
• Counselling the patient and his family about the disease, options of
treatment and prognosis should be done for better decision making
46. Take home message
• Patient autonomy, willingness and preferences should be respected
• Emotional, spiritual & psychological support to be provided to the
patient and his family
• Finally the patient should have a pain free life till the last breath and a
peaceful death.