Indian Journal of Palliative Care
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January-March 2017
Volume 23 | Issue 1
Page Nos. 1-110

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EDITORIAL  

Integrated care plan for the dying: Facilitating effective and compassionate care as an urgent process needed in India p. 1
Stanley C Macaden
DOI:10.4103/0973-1075.197953  
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ORIGINAL ARTICLES Top

Feasibility and acceptability of implementing the integrated care plan for the dying in the Indian setting: Survey of perspectives of indian palliative care providers p. 3
Naveen Salins, Jeremy Johnson, Stanley Macaden
DOI:10.4103/0973-1075.197952  
Introduction: Capacity to provide end-of-life care in India is scored as 0.6/100, and very few people in India have access to palliative and end-of-life care. Lack of end-of-life care provision in India has led to a significant number of people receiving inappropriate medical treatment at the end of life, with no access to pain and symptom control and high treatment costs. The International Collaborative for the Best Care for the Dying Person is an initiative that offers the opportunity to apply international evidence on the key factors required to provide best care for the dying in the Indian context. The aim of this study is to ascertain the perceptions of Indian palliative care providers regarding the feasibility and acceptability of implementing the international program in the Indian setting. Methods: Thirty participants from 16 palliative care centers who had participated in the foundation course of the International Collaborative for Best Care for the Dying Person were purposively chosen for the study. All participants were asked to complete the survey questionnaire that had both open- and close-ended questions. Results: Twenty-three participants completed this survey. The majority of items in the international program were considered relevant, representative of end-of-life care and acceptable in Indian setting. However, participants felt that the concept of the multidisciplinary team (MDT) being responsible for recognizing death may not be possible in the existing Indian setting and a senior doctor may not always be available to document a MDT decision. Some participants felt that in the Indian setting, it was not always possible to communicate about the dying process and make patient aware of the same. A small number of participants felt that using leaflets for communicating end-of-life care process may not be always possible due to logistic reasons and cost. Six participants felt that giving the dying person the opportunity to discuss their wishes, feelings, faith, beliefs, and values may not be possible, representative, and not applicable in Indian setting. The majority of participants felt that using equipment such as a syringe driver for continuous infusion is relevant (n = 16) and representative (n = 13) of end-of-life care, however most thought that it could be challenging to apply in an Indian setting (n = 17), including concerns about lack of familiarity and knowledge and applicability in home care settings. Six participants had reservations regarding the limitation of life-sustaining treatment and felt that discussion and review of cardiopulmonary resuscitation should happen prior to patients entering their end-of-life phase. While most participants thought relevance, representation, and applicability of assessing skin integrity as important, a few participants felt this assessment challenging, especially in home setting, and recommended Braden scale to be used instead of Waterlow for assessing skin integrity. Most participants agreed on the importance of assisted hydration and nutrition; however, again a minority highlighted challenges in this area. Five participants felt that they would sometimes continue hydration under duress from a patient's family. Participants agreed unanimously on the relevance and representation of recording of physical symptoms by MDT–initial and ongoing–with a few participants indicating that frequent observations recommended in the care plan may not be feasible in home care setting. The majority also agreed on the relevance, representation (n = 21), and applicability (n = 18) of providing written information about after-death care, with a small number indicating challenges in the Indian setting, for example, very few unit currently having this information available (n = 2). Notifying general practitioners, primary care physicians, and other appropriate services on patients' death may not be easily applicable in the Indian setting. Conclusions: The survey of palliative care providers about the feasibility and acceptability of integrated care plan at end of life has shown that the international program is relevant, representative of end-of-life care, and acceptable in Indian setting. As would be expected, a number of items need careful consideration and appropriate modification to ensure relevance, representation, and applicability to Indian sociocultural context. The results also suggest that palliative care providers need additional training for the implementation of some of the items in the development of an India-specific document and supporting quality improvement program.
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Body image and sexuality in women survivors of breast cancer in India: Qualitative findings p. 13
Michelle S Barthakur, Mahendra P Sharma, Santosh K Chaturvedi, Suraj K Manjunath
DOI:10.4103/0973-1075.197954  
Objectives: With increasing rates of breast cancer survivors, psychosocial issues surrounding cancer survivorship have been gaining prominence. The following article reports on body image and sexuality-related issues in aftermath of the diagnosis and its treatment in the Indian context. Materials and Methods: Research design was mixed method, cross–sectional, and exploratory in nature. Quantitative sample consisted of fifty survivors while the qualitative sample size included 15 out of the 50 total breast cancer survivors who were recruited from hospitals, nongovernmental organization, and through word-of-mouth. Data was collected using quantitative measures, and in-depth interviews were done using semi-structured interview schedule that was developed for the study. Qualitative data were analyzed using descriptive phenomenological approach. Results: In body image, emerging themes were about identity (womanhood, motherhood, and attractiveness), impact of surgery, hair loss, clothes, and uncomfortable situations. In sexuality, barriers were faced due to difficulty in disclosure and themes were about adjustments made by spouses, role of age, and sexual difficulties due to treatment. Conclusions: Findings imply need to address the issues of body image and sexuality as it impacts quality of life of survivors.
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Impact of scrambler therapy on pain management and quality of life in cancer patients: A study of twenty cases p. 18
Komal Kashyap, Saurabh Joshi, Saurabh Vig, Vishwajeet Singh, Sushma Bhatnagar
DOI:10.4103/0973-1075.197948  
Aim of the Study: To study the effect of scrambler therapy on patients with chronic cancer pain. Materials and Methods: This is a prospective, observational study conducted on patients with chronic pain due to malignancy which is not responding to oral analgesics. A total of twenty patients were included in the study (ten males, ten females) with a visual analog scale score of >4 on oral analgesics. Patients aged 18–70 years with a life expectancy of >3 months having bony, neuropathic, or mixed type of pain were included in the study. A total of 12 sessions of scrambler therapy were planned, ten sessions on consecutive days and one session each on two follow-up visits after 1 week each. Each session lasted for 40 min. Pain relief and quality of life according to the World Health Organization Quality of Life were recorded as primary outcome variables. Results: All patients had good pain relief and improvement in all four domains of quality of life. Pain scores decreased significantly (P < 0.01) after each session and at each follow-up. Patients showed significant improvement in physical, psychological, social, and environmental health (P < 0.01) after the therapy. Conclusion: Scrambler therapy offers a promising role in the pain physician's armamentarium as an adjunct to pharmacological therapy for the treatment of chronic drug-resistant cancer pain; it may bring down analgesic drug requirements significantly and improve quality of life in cancer patients. Larger prospective, randomized multicenter studies are needed to validate the findings of the small pilot studies published in literature so far.
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Prevalence of phantom limb pain, stump pain, and phantom limb sensation among the amputated cancer patients in India: A prospective, observational study p. 24
Arif Ahmed, Sushma Bhatnagar, Seema Mishra, Deepa Khurana, Saurabh Joshi, Syed Mehmood Ahmad
DOI:10.4103/0973-1075.197944  
Introduction: The phantom limb pain (PLP) and phantom limb sensation (PLS) are very common among amputated cancer patients, and they lead to considerable morbidity. In spite of this, there is a lack of epidemiological data of this phenomenon among the Asian population. This study was done to provide the data from Indian population. Methods: The prevalence of PLP, stump pain (SP), and PLS was prospectively analyzed from the amputated cancer patients over a period of 2 years in Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi. The risk factors and the impact of phantom phenomenon on patients were also noted. Results: The prevalence of PLP was 41% at 3 and 12 months and 45.3% at 6 months, whereas that of SP and PLS was 14.4% and 71.2% at 3 months, 18.75% and 37.1% at 6 months, 15.8% and 32.4% at 12 months, respectively. There was higher prevalence of PLP and PLS among the patients with history of preamputation pain, smoking with proximal level of amputation, receiving general anesthesia, receiving intravenous (IV) opioid postoperative analgesia, and developing neuroma or infection. Conclusion: The prevalence of PLP and PLS was higher among the cancer amputees as compared to SP, and a few risk factors responsible for their higher prevalence were found in our study. The PLP and PLS lead to considerable morbidity in terms of sleep disturbance and depression.
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A comparison of the effects of pilates and mckenzie training on pain and general health in men with chronic low back pain: A randomized trial p. 36
Ali Hasanpour-Dehkordi, Arman Dehghani, Kamal Solati
DOI:10.4103/0973-1075.197945  
Background: Today, chronic low back pain is one of the special challenges in healthcare. There is no unique approach to treat chronic low back pain. A variety of methods are used for the treatment of low back pain, but the effects of these methods have not yet been investigated adequately. Aim: The aim of this study was to compare the effects of Pilates and McKenzie training on pain and general health of men with chronic low back pain. Materials and Methods: Thirty-six patients with chronic low back pain were chosen voluntarily and assigned to three groups of 12 each: McKenzie group, Pilates group, and control group. The Pilates group participated in 1-h exercise sessions, three sessions a week for 6 weeks. McKenzie group performed workouts 1 h a day for 20 days. The control group underwent no treatment. The general health of all participants was measured by the General Health Questionnaire 28 and pain by the McGill Pain Questionnaire. Results: After therapeutic exercises, there was no significant difference between Pilates and McKenzie groups in pain relief (P = 0.327). Neither of the two methods was superior over the other for pain relief. However, there was a significant difference in general health indexes between Pilates and McKenzie groups. Conclusion: Pilates and McKenzie training reduced pain in patients with chronic low back pain, but the Pilates training was more effective to improve general health.
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Poverty reduction in India through palliative care: A pilot project p. 41
Cathy Ratcliff, Ann Thyle, Savita Duomai, Manju Manak
DOI:10.4103/0973-1075.197943  
Introduction: EMMS International and Emmanuel Hospital Association (EHA) implemented a pilot project, poverty reduction in India through palliative care (PRIPCare). A total of 129 interviews with patients and family enrolled in palliative care at three EHA hospitals (in Fatehpur, Lalitpur and Utraula) and staff discussions established that 66% of palliative care patients had lost livelihoods due to illness, 26% of patients' families had members who had lost livelihoods due to the illness, 98% of enrolled households had debts, 59% had loans for which they had sold assets, 69% of households took out debt after their family member fell ill, many patients do not know about government benefits and lack necessary documents, many village headmen require bribes to give people access to benefits, and many bereaved women and children lose everything. Palliative care enabled 85% of patients and families to spend less on medicines, 31% of patients received free medicines, all patients reduced use of out-patient departments (OPDs), 20% reduced use of inpatient departments (IPDs), and therefore spent less on travel, 8% of patients had started earning again due to improved health, members of 10% of families started earning again, and one hospital educated 171 village headmen and increased by 5% the number of patients and their families receiving government benefits. If only 0.7% of needy adults are receiving palliative care, these benefits could be delivered to 143 times more families, targeted effectively at poverty reduction. Palliative care has great scope to reduce that most desperate poverty in India caused by chronic illness. Context: This article concerns a study by the UK NGO EMMS International and Indian NGO EHA, to assess whether palliative care reduces household poverty. Aims: EHA staff had noticed that many patients spend a lot on ineffective treatment before joining palliative care, many families do not know their entitlement to government healthcare subsidies or government pensions, and many bereaved widows and children are disinherited. Convinced that palliative care can address these, EMMS and EHA implemented PRIPCare – a pilot project. Settings and Design: EHA began training staff for rural palliative care in north India in 2009, and started its first palliative care service at Harriet Benson Memorial Hospital, Lalitpur, Uttar Pradesh, in 2010, with home-based care backed by hospital out- and in-patient care. With EMMS support since 2012, EHA's palliative care service functions in eight hospitals in six states and Delhi. Subjects and Methods: EMMS International provided the concept, commissioned the study and reviewed the report. EHA hired and guided a consultant, who piloted a questionnaire in EHA's Delhi Shalom Centre, and conducted 129 in-depth, one-to-one interviews in July and August 2015 with patients or close family members enrolled in the palliative care of three EHA rural hospitals, in Fatehpur, Lalitpur and Utraula. This represents 83% of patients in these hospitals, which in July 2015 was 79 patients in Lalitpur, 39 in Utraula, and 38 in Fatehpur. The questionnaire concerned illness, cost of treatment, use of government benefits, and family economic status. The consultant held focus group discussions with palliative care staff in these three hospitals. Statistical Analysis: An intern in EHA's Shalom Centre in Delhi entered data into Excel. The consultant analysed it using Excel. Results: Poverty of palliative care patients
  • 18% of households enrolled for palliative care earn Rs 5000/month
  • In 63% of households, the highest wage earner earns Rs 5000/month
  • 66% of palliative care patients had lost their livelihoods due to illness
  • 26% of patients' families had members who had lost livelihoods due to the illness
  • Before palliative care, 80% of households paid for medicine, treatment, laboratory tests and travel to healthcare
  • 98% of enrolled households have debts; 59% had sold assets to gain 0-interest loans
  • 69% of households took out their debt after their family member fell ill
  • 11% of enrolled households receive government benefits
  • 49% of households have food cards or below poverty line cards
  • Many patients do not know their rights to government benefits
  • Many patients lack documents to enroll for government benefits
  • Many village headmen demand bribes to list people as eligible for benefits
  • Patients do not plan inheritance; many bereaved women and children lose everything.
Poverty reduction through palliative care
  • 85% of patients and families spent less monthly on medicine and travel after joining palliative care than before, due to symptom management, cheaper medicine, and home-based care
  • 31% of patients received free medicines on the palliative care programme
  • All patients reduced the use of OPDs after joining palliative care. 20% reduced use of IPDs. Both contributed to lower travel expenditure
  • 8% of palliative care patients started earning again due to improved health
  • Members of 10% of families started work again through palliative care respite
  • Staff tell families of benefits to which they are entitled and how to get them
  • One hospital palliative care team educated 171 Pradhans and increased by 5% the proportion of palliative care patients and families who receive government benefits
  • Early diagnosis plus immediate enrollment on palliative care contributes to greater household poverty prevention and reduction, and greater dignity
  • Palliative care's awareness-raising has increased the number of patients enrolling on palliative care. Expanded services could enroll people earlier in their illness, since 59% of patients were diagnosed over 2 years ago, but only 19% of patients had been on the palliative care programme for 2 years
  • Reduced use of OPD and IPD free up regular hospital services for others.
  • In India, approximately 645,441 children on any 1 day need palliative care, but only 0.7% of them receive it (ICPCN, EMMS, 2015). If only 0.7% of needy adults are receiving palliative care, then the benefits above could be delivered to 143 times more families, if targeted effectively at poverty reduction.
Conclusions: Holistic palliative care can reduce the desperate poverty driven by life-limiting illness, and can do so systematically, on a large-scale, in-depth, especially if started early in the illness. Home-based care also frees up hospitals to serve more patients with treatable conditions.
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Concordance in the assessment of effectiveness of palliative care between patients and palliative care nurses in Malaysia: A study with the palliative care outcome scale p. 46
Kwee Choy Koh, Esha Das Gupta, Sangeetha Poovaneswaran, Siaw Ling Then, Michelle Jia Jui Teo, Teik Yiap Gan, Joanne Hwei Yean Thing
DOI:10.4103/0973-1075.197961  
Context: The Palliative Care Outcome Scale (POS) is an easy-to-use assessment tool to evaluate the effectiveness of palliative care. There is no published literature on the use of POS as an assessment tool in Malaysia. Aim: To define the concordance in the assessment of quality of life between patients with advanced cancers and their palliative care nurses using a Malay version of the POS. Settings and Design: This study was conducted in the palliative care unit of the Hospital Tuanku Ja'afar Seremban, Malaysia, from February 2014 to June 2014. Subjects and Methods: We adapted and validated the English version of the 3-day recall POS into Malay and used it to define the concordance in the assessment of quality of life between patients and palliative care nurses. Forty patients with advanced stage cancers and forty palliative care nurses completed the Malay POS questionnaire. Statistical Analysis Used: The kappa statistical test was used to assess the agreement between patients and their palliative care nurses. Results: Slight to fair concordance was found in all items, except for one item (family anxiety) where there was no agreement. Conclusions: The Malay version of the POS was well accepted and reliable as an assessment tool for evaluation of the effectiveness of palliative care in Malaysia. Slight to fair concordance was shown between the patients and their palliative care nurses, suggesting the needs for more training of the nurses.
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Efficacy and safety of povidone-iodine pleurodesis in malignant pleural effusions p. 53
Hadi Kahrom, Manouchehr Aghajanzadeh, Mohammad Reza Asgari, Mahdi Kahrom
DOI:10.4103/0973-1075.197958  
Introduction: Malignant pleural effusion (MPE) is determined by the detection of malignant cells in pleural fluid or pleural tissue. Neoplasm of lung, breast, ovary and lymphoma are the causes of more than 75% of MPE. Pleurodesis is a usual technique in the management of MPE to achieve a symphysis between two layers of the pleura, and various chemical agents have been used in an attempt to produce pleurodesis. With regard to complications and limitations of these sclerosing agents, efficacy and safety of povidone-iodine have been investigated in this study. Materials and Methods: Between June 2014 and June 2016, 63 consecutive patients were admitted to the Department of Thoracic Surgery because of symptomatic MPE. After insertion of a chest tube, pleurodesis with instillation of povidone-iodine was performed. Thyroid and renal function tests were checked, and success rate as well as recurrence of MPE was monitored in the next follow-up visits. Results: The complete response to this procedure was about 53.57%, and failure of treatment was 10.71% with efficacy of 82.2%. The most common complication was pain during instillation (26.9%). Changes in thyroid and renal function tests were not significant. Conclusion: Povidone-iodine is a safe and effective agent with minor side effects in pleurodesis of patients with MPEs and can be used as an accessible and low-cost alternative than other sclerosing agents.
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Health care providers' perception of their competence in providing spiritual care for patients p. 57
Hossein Ebrahimi, Hossein Namdar Areshtanab, Mohammad Asghari Jafarabadi, Soraya Golipoor Khanmiri
DOI:10.4103/0973-1075.197957  
Background: Spiritual care is an important part of health-care provision. Spiritual care can improve patients' health. One of the requirements for providing appropriate spiritual care for patients is having the required competence. Aim: This study was conducted to investigate the perception of health-care providers of their own competence in providing spiritual cares for patients hospitalized in medical-educational centers of Iran. Subjects and Methods: This study is a cross-sectional, analytical research conducted on 555 nurses of medical-educational centers in Tabriz, Iran, in 2014. Data were collected using a two-part questionnaire including demographic information and the spiritual care competence scale. Data analysis was performed using descriptive (frequency, percentage, mean, and standard deviation) and inferential (independent t-test, Pearson, Spearman, ANOVA with Tukey test) statistics in SPSS software version 13. Results: Results showed that the mean score for nurses' perception of their competence in providing spiritual care for patients was average, that is, 95.2 ± 14.4. Mean score of nurses' perception of their competence in providing spiritual care in each aspect was significantly higher than average (P < 0.05). The highest score was related to individual support and consulting with patients, that is, 21.1 (4.0), and the lowest score was related to reference to experts, that is, 9.5 (2.3). The type of employment and participation in workshops had significant relationships with nurses' perception of their competence for providing spiritual care (P < 0.05). Conclusion: The findings indicate that authorities and policymakers should take steps in planning for nurses' training for promoting their competence in providing spiritual care for patients; therefore, holding workshops is necessary.
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Behaviors are deceptive in pain estimation: A comparison between nurses and psychiatrists p. 62
Suresh Yadav, Geetha Desai, Santosh K Chaturvedi
DOI:10.4103/0973-1075.197955  
Aim: This study assessed the influence of pain behaviors on pain estimation by nurses and psychiatrists. Materials and Methods: Pain ratings performed by nurses and psychiatrists who observed the case scenarios using role plays were assessed. The data were computed and frequencies were derived. t-test was used to compare the ratings between the groups. Results: There was significant difference in the ratings of the pain severity by nurses and psychiatrists. Conclusions: Pain assessment is essential for the comprehensive management of pain. Training health professionals in pain assessments is very essential.
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Home-based palliative services under two local self-government institutions of Kerala, India: An assessment of compliance with policy and guidelines to local self-government institutions p. 65
Rajeev Jayalakshmi, Chatterjee Chopra Suhita
DOI:10.4103/0973-1075.197947  
Background: In contrast to India's poor performance in palliative and end-of-life care, the state of Kerala has gained considerable attention for its palliative care (PC) policy. This study tried to understand the structure, organization, and delivery of the program currently offered to the rural population, and its conformity to the state's PC policy and guidelines for Local Self-government Institutions (LSGIs). Materials and Methods: A descriptive research design involving a review of Kerala palliative policy and guidelines for LSGIs was followed by direct field observation and interviews of stakeholders. Two LSGIs in rural Kerala served also by a nongovernmental organization (NGO), were selected. Data were collected from health workers (doctors, nurses, and PC nurses), government stakeholders (LSGI members and representatives of the National Health Mission), and the health workers and officials of NGO. Results: The program in two LSGIs varies considerably in terms of composition of the palliative team, infrastructure and human resource, cost, and type of service provided to the community. A comparative assessment with a nongovernmental service provider shows that the services offered by the LSGIs seemed to be restricted in scope to meet the needs of the resource-stricken community. Compliance with policy guidelines seems to be poor for both the LSGIs. Conclusions: Despite a robust policy, the palliative program lacks a public health approach to end-of-life care. A structural reconfiguration of the delivery system is needed, involving greater state responsibility and political will in integrating PC within a broader social organization of care.
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A concept analysis of holistic care by hybrid model p. 71
Madineh Jasemi, Leila Valizadeh, Vahid Zamanzadeh, Brian Keogh
DOI:10.4103/0973-1075.197960  
Purpose: Even though holistic care has been widely discussed in the health care and professional nursing literature, there is no comprehensive definition of it. Therefore, the aim of this article is to present a concept analysis of holistic care which was developed using the hybrid model. Methods: The hybrid model comprises three phases. In the theoretical phase, characteristics of holistic care were identified through a review of the literature from CINAHL, MEDLINE, PubMed, OVID, and Google Scholar databases. During the fieldwork phase, in-depth interviews were conducted with eight nurses who were purposely selected. Finally, following an analysis of the literature and the qualitative interviews, a theoretical description of the concept of holistic care was extracted. Results: Two main themes were extracted of analytical phase: “Holistic care for offering a comprehensive model for caring” and “holistic care for improving patients' and nurses' conditions.” Conclusion: By undertaking a conceptual analysis of holistic care, its meaning can be clarified which will encourage nursing educators to include holistic care in nursing syllabi, and consequently facilitate its provision in practice.
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Estimation of palliative care need in the urban community of Puducherry p. 81
A Praveena Daya, Sonali Sarkar, Sitanshu Sekhar Kar
DOI:10.4103/0973-1075.197959  
Context: The coverage of palliative care services is inadequate in India. Data on number of people needing palliative care and disease conditions needing palliative care needs to be estimated prior to planning of service in any area. Aims: To estimate the prevalence of need of palliative care in an urban area of Puducherry. Settings and Design: Exploratory cross-sectional study conducted in two areas, Senthamarainagar and Thiruvalluvarnagar having about 500 households each in Muthialpet area in urban Puducherry. Materials and Methods: All residents were interviewed using a structured questionnaire containing sociodemographic details, information regarding chronic illness and a screening tool to identify people in need of palliative care. Statistical Analysis: Variables such as sociodemographic characteristics were expressed in percentages. The main outcome variable, the number of people in need of palliative care was expressed in the prevalence percentages. Results: A total of 3554 individuals were surveyed in 1004 households. A period prevalence of need of palliative care in this community was 6.1/1000 population. The prevalence among those aged ≥15 years was 8/1000 population. The mean age of people requiring palliative care was 62 years. The most common disease condition in need of palliative care was old age-related weakness (41%). Most of them were women (17/22) and from lower socioeconomic class (6/22). Conclusions: Around 6/1000 population was identified to be in need of palliative care. The prevalence was highest among the elderly women, low socioeconomic class, widowed, those with less education, and those suffering from age-related weakness.
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Do-not-resuscitate order: The experiences of iranian cardiopulmonary resuscitation team members p. 88
Abdolghader Assarroudi, Fatemeh Heshmati Nabavi, Abbas Ebadi, Habibollah Esmaily
DOI:10.4103/0973-1075.197946  
Background: One dilemma in the end-of-life care is making decisions for conducting cardiopulmonary resuscitation (CPR). This dilemma is perceived in different ways due to the influence of culture and religion. This study aimed to understand the experiences of CPR team members about the do-not-resuscitate order. Methods: CPR team members were interviewed, and data were analyzed using a conventional content analysis method. Results: Three categories and six subcategories emerged: “The dilemma between revival and suffering” with the subcategories of “revival likelihood” and “death as a cause for comfort;” “conflicting situation” with the subcategories of “latent decision” and “ambivalent order;” and “low-quality CPR” with the subcategories of “team member demotivation” and “disrupting CPR performance.” Conclusion: There is a need for the development of a contextual guideline, which is required for respecting the rights of patients and their families and providing legal support to health-care professionals during CPR.
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REVIEW ARTICLE Top

Palliative care social work in India: Current status and future directions p. 93
G Ragesh, Lithin Zacharias, Priya Treesa Thomas
DOI:10.4103/0973-1075.197949  
Palliative care (PC) involves total care for persons suffering from life-threatening illnesses and their families. Social work as a profession and an academic discipline is gaining momentum in India for the past few decades. A large number of professional social workers are working with individuals, families, and communities to provide PC in India. Authors have presented the current status of PC social work interventions and discussed the future directions in the practice, research, and training in PC and end-of-life care.
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CASE REPORTS Top

Role of ketamine and methadone as adjunctive therapy in complex pain management: A case report and literature review p. 100
Wasek Faisal, Judith Jacques
DOI:10.4103/0973-1075.197956  
Assessment and management of complex cancer pain always remains a major challenge for any palliative care team, given its heterogeneity of underlying pathophysiology and limitations of any pharmacotherapy. Here, we present a case of complex pain management in a young patient with a life-limiting illness, highlighting the issues of organic and nonorganic contributors of pain and provide some insight into the role of ketamine and methadone as adjunctive therapy to opioid analgesics. A brief literature review is also done to provide the context of use of these adjunctive drugs in this setting.
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Thyroid mass: Metastasis from nasopharyngeal cancer - an unusual presentation p. 104
Shirley C Lewis, Anil K D'cruz, Amit Joshi, Rajiv Kumar, Shubhada V Kane, Sarbani Ghosh Laskar
DOI:10.4103/0973-1075.197951  
Thyroid gland is an uncommon site of metastasis, and metastasis to the gland secondary to nasopharyngeal carcinoma is seldom seen. We were only able to identify eight reported cases in the literature. A 61-year-old man, diagnosed case of nasopharyngeal cancer–second primary ( first primary-oropharynx), was found to have a thyroid nodule on routine follow-up positron emission tomography-computed tomography (PET-CT) scan. There was no evidence of metastases at any other sites. The thyroid nodule was confirmed as metastatic carcinoma by fine needle aspiration cytology. He was treated with multimodal treatment comprising of surgery followed by reirradiation with concurrent chemotherapy. Subsequently, at the first follow-up (2 months after completion of all treatment), the patient remained asymptomatic, but the response assessment with PET-CT scan was suggestive of lung metastases with no evidence of locoregional disease. Although thyroid parenchymal metastasis is an uncommon occurrence and signifies a poor prognosis, in appropriately selected patients, aggressive therapy with reirradiation and chemotherapy may improve local control and quality of life.
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Repetitive transcranial magnetic stimulation as a promising potential therapeutic modality for the management of cancer-related pain: An Issue that merits further research p. 109
Amir Emami Zeydi, Ravanbakhsh Esmaeili, Farshad Hasanzadeh Kiabi, Hassan Sharifi
DOI:10.4103/0973-1075.197950  
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