Acute Palliative Care – Is it a Workable Concept in India?

World Health Organization advocates that good palliative care should be available for all people with chronic serious life-limiting illnesses.[1] Since its inception in the 1960s, Palliative Medicine is now an established discipline around the world, having evolved into a specialist branch, incorporating different kinds of shared models, with seamless transition between services like outpatient clinics, inpatient units, home-based care and hospices.[2] Bruera and Hui have proposed different conceptual frameworks like the Solo Practice Model, Congress Practice Model and Integrated Care Model for better clinical practice in palliative care.[3] Luckett et al. have conducted a review on identifying the effective components of models in palliative care.[4] Different service programs are now in existence, including palliative medicine in Accident and Emergency Department,[5] Intensive Care Units[67] and stroke units.[8]

Acute Palliative Care is directed toward the management of patients with severe physical and/or psychosocial distress in patients with chronic life-limiting illnesses. It requires an extensive knowledge about symptom management, expert communication and clinical decision-making skills, and collaboration with primary teams for effective comprehensive palliative care. Acute Palliative Care Units (APCU) are new programs integrating palliative care and oncology, which have proven to be of benefit in acute symptom control and enhancing quality of life of patients.[9] These units have not only been established in cancer centers, but APCUs in academic medical centers have been shown to be of benefit by providing cost-effective acute care to patients with chronic advanced physical illnesses.[10] Albanese et al. have looked at the financial impact of APCU.[11]

Our second case report had a 17-year-old patient with metastatic synovial sarcoma, who developed anaphylaxis and delirium due to administration of intravenous levofloxacin for community-acquired pneumonia.[12] Both anaphylaxis and delirium are life-threatening medical emergencies needing prompt management, which was done in our palliative medicine clinic initially, followed by observation in the Emergency Services and respite admission in hospice later. Prompt identification and management of reversible causes of distressing symptoms, both physical and psychological, due to anaphylaxis and delirium alleviated the distress, facilitated recovery and discharge, and improved quality of life.

Our first case study involved a 63-year-old hypertensive and diabetic lady with metastatic cancer of the ovary, under our home care services, who developed acute onset right-sided involuntary movements.[13] Prompt blood investigations revealed hyperglycemia, which was managed with insulin. An urgent brain imaging revealed lacunar infarct in left lentiform nucleus. Early identification of the clinical picture and etiology with acute management of Hemichorea Hemiballismus (HCHB) syndrome caused resolution of severely distressing and disabling physical symptoms of abnormal involuntary movements, providing relief to the patient as well as her caregivers.

Our third patient, with a diagnosis of metastatic cancer of gall bladder, was diagnosed with Ramsay Hunt Syndrome, which resolved on prompt treatment with antiviral and antibiotic drugs with adequate analgesia.[14] The impact was noticeable in both the patient and his caregiver, as it reduced both the physical and emotional distress significantly.

A consistent barrier, which keeps coming up when discussing referrals to palliative medicine/care services, is perception of palliative care being synonymous with end of life care. Van Mechelen and colleagues have given their views on the definition of palliative care patient, which according to them, should include ‘progressive life-threatening disease with no possibility of remission or modifying the course of the illness’.[15] This definition is apt for the patients who are described in the case scenarios. True to the definition of palliative care, we, in palliative medicine, are responsible for addressing our patients’ physical health and issues related to psycho-socio-spiritual concerns, communication, decision-making and end of life care. All the three patients described above developed treatment (case report 1), comorbidity (case report 2) and infection-related (case report 3) complications, respectively, in their disease trajectory of advanced cancer. Acute Palliative Care in the above cases, focused on prompt symptom management, which alleviated patients’ distress, improved quality of life, despite existence of life-limiting disease, and helped in improving caregivers’ concerns, which would have come up due to patients’ clinical features. It also helped in plans for transition of care and further management. There is evidence that Acute Palliative Care Units decrease admission to Intensive Care Units, reduce mortality, provide better delirium control, lead to higher patient satisfaction and meet family's needs.[1617] Although, we do not have an APCU in our tertiary care cancer centre, the application of the concept of Acute Palliative Care demonstrated benefits of similar nature to our patients by actively treating complications, facilitating person-centered goals of care and aiding in transition and discharge plans.

Palliative Medicine has recently been granted formal specialty status by American Board of Medical Specialties.[18] There is also a considerable debate between the concepts of generalist versus specialist palliative care.[18] Salins, in his editorial in the May-August 2014 issue of Indian Journal of Palliative Care, had put forth the proposal for “Time for change” for palliative care in India.[16] Acute Palliative Care and Acute Palliative Care Units are an integral part of the strides being taken by specialist palliative medicine and hence, are required for enabling this change. We need to broaden our paradigm and make our discipline of palliative medicine at par with the specialist status that it receives in all developed countries. Thus, having Acute Palliative Care as a workable concept in our clinical practice, research and education, is a desirable step in the right direction.