This presentation is about the 'end of life care' in terminally ill patients, and its why and how.

1. END OF LIFE CARE
Dr. Sharat Kolke MD, DNB.
KOHINOOR HOSPITAL
An Introduction

2. “It kills me sometimes, how people die.” …... Markus Zusak
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3. Some Statistics
More than 1 million new cases of cancer occur each year in India
with over 80% presenting at stage III and stage IV.
Two-thirds of patients with cancer are incurable at presentation and
need palliative care.
Only 0.4% of the patient population has access to oral morphine.
In 2008, India used an amount of morphine that was sufficient to
treat pain adequately in only about 40,000 patients suffering
from moderate to severe pain due to advanced cancer which is
approximately 4% of the population needing the same.
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4. 83% of people in India would prefer to die at home.
Palliative care at home is the most cost effective, relevant
and practical option in the Indian setting.
Prolonged and futile life support has undoubtedly
imposed enormous economic and human cost on
patients and their families that is avoidable.
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7. That is why there is an overwhelming
need for a national palliative care
initiative to bridge these gaps
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8. What is end of life care?
"Death is not extinguishing the light; it is putting out the lamp because the dawn has come." -
Rabindranath Tagore
①Achieve a ‘Good Death’ for any person who is dying,
irrespective of the diagnosis, duration of illness and
place of death
②Emphasis on quality of life and quality of death.
①Acknowledgement that palliative care is a human
right, and every individual has a right to good, peaceful
and dignified death.
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9. What does a ‘Good Death’ mean?
It involves the ability to know
①When the death is approaching,
②Have physical symptoms well–controlled,
③Patient centered needs met,
④Right to die in a dignified manner at a place of choice
&
⑤Without life needlessly prolonged with artificial
means.
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10. Recognizing the dying process
①Failing vital parameters,
②Decreased movements,
③Decreased spontaneous verbalization,
④Decreased solid and liquid intake,
⑤Skin changes such as greyish mottling and
⑥Cold extremities
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11. Decision making
Open honest communication,
Shared decision-making
Smooth transition of the care process
The decision makers should always be the primary care givers, in
consultation with the palliative care team.
Primary care givers are the ones who have longer patient/family
contact and therapeutic bonding so that better communication can
be facilitated.
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12. Communication
The key EOLC communication
 Prognostication,
 Discussion on resuscitation,
 Advance care planning and
 End of life symptoms
The process of EOLC is founded on good
communication and ethical principles
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13. Process of end of life care
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14. Scope of Palliation in end of life care
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15. European physicians were reported to have had no
difficulty in making end-of-life decisions in 81–93% of
cases.
But extremely challenging in India due to a number of
barriers:
①Unawareness of ethical issues,
②culture of heroic “fighting till the end,”
③lack of palliative care orientation and
④legal and administrative prejudices
Impediments to EOLC in India
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16. Impediments to EOLC in India
There are no legal framework or policies guiding the clinicians on
EOLC or dignified death.
The culture of medical practice in India is generally ‘paternalistic’
with little consideration for the patient’s autonomy and the respect
for the patient’s choices.
Medical education in India is founded strongly on the ‘acute model
of care’, which is assessment and treatment leading to cure.
Lack of knowledge of ‘chronic care and palliative care’ leading to
the treatment of EOL patients acutely and inappropriately.
“I'm not afraid of death; I just don't want to be there when it happens.”01-10-2017 sharatkolkeppt 17

17. Legal pitfalls in India
Euthanasia v/s EOLC
Good EOLC involve respecting patient choices,
consideration of futility, deliberated consensus decision-
making, and a humane touch.
Futility as defined by the American Thoracic Society is
“A life-sustaining intervention is futile if reasoning and
experience indicate that the intervention would be highly
unlikely to result in a meaningful survival for that
patient”
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18. Components of EOLC
"Despise not death, but welcome it, for nature wills it like all else." - Marcus Aurelius
 Autonomy – offering the patient a choice & respecting it
 Beneficience – acting in the best interests of the patient
 Non-maleficience – do no harm or do any futile
interventions.
 Justice – treat everyone on equal terms
 Honesty – be open with the patient and the relatives
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19. “I'm the one that's got to die when it's time for me to die, so let me live my life the way I want to.”
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20. “Dying can be a peaceful event or a great agony
when it is inappropriately sustained by life
support” …Roger Bone
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21. Cure sometimes,
Treat often,
Comfort always
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22. Thank You
sharatkolke@hotmail.com
9820059062
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