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PALLIATIVE & SUPPORTIVE
CARE IN ONCOLOGY
Infections
Diarrhoe/Obstipation
Cardiotoxicity
Neurotoxicity
Bone complications
Pulmonary Tox.
Renal toxicity
Antiemesis
Anaemia
Paravasation
Supportive measures in radiation therapy
Fertility
Fatigue Thrombocytopenia
Pain
Venous Thromboembolism
Tumorlysis
New Toxicities (Targeteddrugs)
Many aspects of supportive care
Nutrition
Lymphedema
Neutropenia
Psychological support
Supportive care improves patient reported outcomes in
cancer patients!
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
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
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
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
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
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
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
Benefits of Early vs Traditional Palliative care
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
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
Indicators of short life expectancy
 Poor performance status [ ECOG >/= 3 ; KPS </= 50 ]
 Persistent hypercalcemia
 Brain/ CSF metastasis
 Delirium
 SVCO
 Spinal cord compression
 Cachexia
 Malignant effusions
 Palliative stenting /venting gastrostomy
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
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
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
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
Symptom management
 Pain
 Dyspnoea
 Anorexia / cachexia
 Nausea / vomiting
 Constipation
 Diarrhoea
 Malignant bowel obstruction
 Fatigue /weakness/ asthenia
 Insomnia / sedation
 Delirium
Psychosocial distress
 Psychological/psychiatric
- depression / anxiety
- distress
 Spiritual/ existential needs
 Social support challenges or concerns
- home
- family
- community
 Resource needs
Educational and informational needs or
cultural factors affecting care
 Patient/family/care-giver values and preferences about information &
communication
 Their perceptions of disease status
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.
Bereavement
 It is the period of mourning after a loss / death.
 The team of palliative care also provides bereavement care
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
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
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
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
Role of complimentary and alternative
medicine in palliative care
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
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
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
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
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
Symptomatic management
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)
Pain
Adapted WHO pain ladder
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
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
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
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
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
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
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.
Thank you
“Supportive & Palliative Care
makes Excellent
Cancer Care possible”

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Role of palliative care in oncology

  • 2. Infections Diarrhoe/Obstipation Cardiotoxicity Neurotoxicity Bone complications Pulmonary Tox. Renal toxicity Antiemesis Anaemia Paravasation Supportive measures in radiation therapy Fertility Fatigue Thrombocytopenia Pain Venous Thromboembolism Tumorlysis New Toxicities (Targeteddrugs) Many aspects of supportive care Nutrition Lymphedema Neutropenia Psychological support
  • 3. Supportive care improves patient reported outcomes in cancer patients!
  • 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
  • 11. Benefits of Early vs Traditional Palliative care
  • 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
  • 14. Indicators of short life expectancy  Poor performance status [ ECOG >/= 3 ; KPS </= 50 ]  Persistent hypercalcemia  Brain/ CSF metastasis  Delirium  SVCO  Spinal cord compression  Cachexia  Malignant effusions  Palliative stenting /venting gastrostomy
  • 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
  • 17.
  • 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
  • 20. Symptom management  Pain  Dyspnoea  Anorexia / cachexia  Nausea / vomiting  Constipation  Diarrhoea  Malignant bowel obstruction  Fatigue /weakness/ asthenia  Insomnia / sedation  Delirium
  • 21. Psychosocial distress  Psychological/psychiatric - depression / anxiety - distress  Spiritual/ existential needs  Social support challenges or concerns - home - family - community  Resource needs
  • 22.
  • 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
  • 30. Role of complimentary and alternative medicine in palliative care
  • 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)
  • 38. Pain
  • 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.
  • 47. Thank you “Supportive & Palliative Care makes Excellent Cancer Care possible”

Editor's Notes

  1. Complementary and alternative based medicine