This document discusses end-of-life care and palliative care. It notes that the majority of deaths in India occur in misery, and quality of death in India ranks poorly compared to other countries. Palliative care aims to improve quality of life for patients through effective pain and symptom management as well as psychosocial support. It discusses principles of palliative care including open communication, addressing total pain, use of opioids and other adjuvants for pain management, and withdrawal symptoms from opioids. The document also covers advance directives, best interest decisions, double effect, and when to stop life-prolonging treatment for terminally ill patients.

1. Dr Anil Gupta
MBBS| MD| DNB| MNAMS
MD PGIMER Chandigarh
SR AIIMS, New Delhi
Consultant Oncology

2. Are we in ??
 Healthcare industry
 Sick care Industry

3. EOLC- End of Life care
GSF- Gold standard
framework
Identify Assess  Plan
ICP- Integrated care
pathway
Sick care
Health care

4.  Crude death rate - 9.45/1000 (2021)
 Life expectancy 67.2 yr (2021)
 The total number of people dying every year ~ 7 million
 Majority of them die in misery
 “no one of us is getting out of here alive”
 In the UK, a world-wide survey was done for Quality of Death in 2015 and India
was ranked 67th amongst 80 countries

5. Good quality palliative care can be defined as the care, which I would
be happy to have given to a member of my own family if he or she was
dying, or to receive myself when my time comes
Psychosocial Care
- Open questions
- Encourage talking
- Tolerate silence
- Avoid unnecessary interruption
- Breaking bad news
Principles to improve quality of life, well-being, comfort and human dignity for individuals,
being an effective person-centred health service that values patients

6. “The physical pain caused by the malignant tumour is only one aspect; there is also
financial, social and emotional suffering associated with cancer. There are momentous
decisions involved in fighting against cancer, probabilities to be balanced, cost-benefit
analyses to be conducted”
“Palliative care was originally considered to constitute only end-of-life care, when
doctors would feel no more active therapy was possible”

7. Kubler-Ross Extended Grief Cycle
• Warning shots

8.  “Pain is what the patient says hurts”
 “Total Pain”– the term used when psycho social, physical, and spiritual distress combine to
affect the patient
 “Pain is experienced by people and families and not merely by nerve endings”
 Types
 Nociceptive Pain/Neuropathic Pain/Sympathetically maintained pain
 Acute/ Chronic
 Social/Physical/Emotional/Spiritual

9. Adjuvants
- Gabapentin
- Amitriptyline
- Pregabalin
- Steroids
- Radiotherapy

10.  Strong opioids exist to be given; not merely to be withheld. Their use
is dictated by therapeutic need and response NOT by the brevity of prognosis.
 Choose according to intensity and type of pain and not according to the stage of
disease
 Use Immediate release preparations first, aimed at achieving sustained pain
relief
 Change to slow release preparations only after stable pain relief
 Cover common side effects prophylactically
 Continue step I drugs
 Breakthrough pain- daily dose/6
 Review, Review, Review

12.  Morphine
- Oral Regular- Starting dose 10 mg 4 hourly
- Oral Modified Sustained Release (MST)- 12 hourly
- Injectable Diamorphine- twice potent as oral form
 Fentanyl
- In the form of patches 12.5/25/50 mcg for 72 hours
- 25 mcg is equivalent to 60 mg of daily morphine
- Oxycodone- Dose morphine divided by 2
- Oxynorm liquid
- Oxycontin – slow release BD preparation

13.  Early symptoms of withdrawal include:
 Agitation
 Anxiety
 Muscle aches
 Increased tearing
 Insomnia
 Runny nose
 Sweating
 Yawning
Late symptoms of withdrawal include:
 Abdominal cramping
 Diarrhea
 Dilated pupils
 Goose bumps
 Nausea
 Vomiting
These symptoms are very uncomfortable but are not life threatening. Symptoms usually start
within 12 hours of last heroin usage and within 30 hours of last exposure.

14.  When it is almost certain that we have exhausted all line of
treatment and death is imminent-
 Step 1: Recognition of “Futility of Further Management” by primary
clinician.
 Step 2: Clinicians Consensus on futility of further management.
 Step 3: Early and detailed explanation of prognosis with proper
communication and documentation of disclosure by patients and
or family members for withholding life support.
 Step 4: Assessments before initiation of end of life care
 Step 5: Continuous assessment of daily supportive care plan
 Step 6: Documentation of daily progress note
 Step 7: Feedback

15.  Directions given in advance by patient for the treatment and management in case
of any grave event
 Overrules best interests decisions, lasting power of attorney appointed prior to
AD, court appointed deputy
 It only applies if the person lacks capacity to take decision

16. ”A single act having two possible foreseeable effects, one good and one harmful, is
not always morally prohibited if the harmful effect is not intended”
Mrs. Y is having far advanced carcinoma cervix and is in renal
failure. The patient presents in a state of terminal panic. She
was given parenteral midazolam to relieve the panic. In a few
minutes she dies

17.  Where a patient lacks capacity to make a decision the treating clinician can decide
to proceed with the treatment in their best interests.
If
 No advance directive
 No time to pursue independent advice
 Not trial therapy
 The decision can’t be deferred until capacity is regained
 Decision should involve patient as far as possible (including previously expressed
views, culture, religion etc) and must avoid discrimination.

18.  Is it morally justified to stop life prolonging or life sustaining treatment in Terminally ill
patient
 Good death- A death in comfort
 Article 21 enshrines the fundamental right for protection of life and liberty. Legal
interpretation of this article can be used to ensure right to life and right to die with dignity.
 Section 88 of IPC protects physicians when death occurs as a result of limiting life support
when it is no more warranted.

19. “Death, done well, can be a beautiful
and liberating experience, a chance for
families to come together and to heal, to
share memories and hope, to embrace
both the past and the future and to
complete the great circle of life”