Athar Javeth¹, S. Salina², Poonam Joshi³

¹College of Nursing, All India Institute of Medical Science, Kalyani, West Bengal, ²Co-operative College of Nursing, Thalassery, Kerala, ³All India Institute of Medical Science, Kalyani, West Bengal, India.

E-mail: atharjaveth05@gmail.com, salina.surabhi@gmail.com, poonam. nursing@aiimskalyani.edu.in

Introduction: Cancer-related fatigue (CRF) is one of the most prevailing manifestations experienced by cancer patients undergoing various treatment modalities such as chemotherapy or radiation therapy. It has a significant negative influence on various dimensions of quality of life, such as physical, emotional, social, cognitive and spiritual aspects. Research evidence portrays numerous interventions for the management of CRF. However, a few systematic reviews were done on aromatherapy for fatigue-associated cancer.

Aim: The review aims to explore the effect of various forms of aromatherapy on CRF among cancer patients.

Methods: Different databases such as PubMed, Embase, CINAHL and Google Scholar will be searched for randomised controlled trial articles which evaluated the effect of aromatherapy on CRF in adult patients, and fatigue was the outcome of interest. Data will be extracted by two independent reviewers, and the Cochrane Risk of Bias tool will be utilised to assess the methodological quality of randomised controlled trials (RCTs).

Results: Meta-analysis will be done using a random effect model. Subgroup analysis will be conducted based on the type of cancer and the forms of aromatherapy, if applicable. The review protocol was prospectively registered with the PROSPERO database.

Conclusion: This systematic review will be constructed on the findings of previously conducted RCTs which aid in strengthening the evidence base in the management of CRF. The findings of this systematic review can be utilised in various oncology clinical settings for better utility.

Keywords: Cancer-related fatigue, Aromatherapy, Systematic review, Meta-analysis, Cancer.

Joris Gielen¹

¹Centre for Global Health Ethics, Pittsburgh, Pennsylvania, USA. E-mail: gielenj@duq.edu

This abstract presents new research which has not been presented or published before.

Introduction: In India, the concept of euthanasia is often used in a broad sense, covering a wide range of treatment decisions, including forgoing treatment and the administration of lethal drugs to suffering terminally ill patients. A meaningful argument can be made to restrict the use of the term to this latter kind of euthanasia. Although not legal in India, it is important to know physicians’ and nurses’ attitudes to this type of euthanasia as this knowledge can inform education about palliative care alternatives to euthanasia. Unfortunately, the number of available studies on this topic is limited and the included samples are small.

Aim: This study intended to assess the prevalence of approval of euthanasia with lethal drugs among nurses and physicians in India through a meta-analysis of the data of the past 10 years.

Methods: This meta-analysis followed the 2020 PRISMA guidelines. PubMed, EMBASE, PsycINFO and CINAHL were searched. Data were extracted using a data extraction sheet in covidence. The risk of bias was assessed using MMAT.

Results: Four reports contained usable data, notwithstanding the identified or unclear risk of bias. The pooled data included information on the euthanasia attitudes of 519 participants (239 nurses and 280 physicians) from two states (Delhi and Karnataka). Approval of euthanasia ranged from 12% to 20% in the four reports. The pooled prevalence of euthanasia approval was 16% (Random effects model, 95% confidence interval 0.13–0.19).

Conclusions: The meta-analysis revealed that the prevalence of euthanasia approval was within a similar range across the studied populations. Only a small minority supported euthanasia.

Anuja Damani¹, Bharathi Parkala², M. Surya Gayathri²

¹Department of Palliative Medicine and Supportive Care, Kasturba Medical College, MAHE, ²RRT&DT Program, MCHP, MAHE, Manipal, Karnataka, India. E-mail: anuja.damani@gmail.com

Introduction: Assessing how and where end-stage kidney disease (ESKD) patients die, helps understand illness trajectory and timely elicit end-of-life care preferences. It helps identify appropriate opportunities and triggers for advanced care planning (ACP) discussions. This will, thus, enhance the quality of end-of-life care provision. The aim was to determine the medical condition during death, cause and place of death of ESKD patients on maintenance haemodialysis (HD).

Methods: A single-centre retrospective review of hospital records of deceased HD patients from 1 January 2016 to 30 April 2022. The study was approved by the Departments of Nephrology and Palliative Medicine and from the Institutional Ethics Committee (IEC 219/2022). Data were recorded by the investigators and were analysed using descriptive statistics.

Results: Of the 98 patients, 26 (26.5%) patients died at home, 8 (11.1%) were discharged against medical advice, and 64 (88.9%) died in hospital. Among hospitalised patients, the common causes of death were infection (87.5 %), followed by cardiac and cerebrovascular complications (56.3%). Factors associated with the mortality pattern in the hospital setting were evaluated based on the location of death in the hospital, therapeutic interventions they received and ACP. Most of the patients died in the intensive care unit (82.8%), followed by the ward (17.2%). Forty-eight (75%) patients died on ventilator support, and withholding/ withdrawal of artificial life supports was considered in 25% of patients.

Conclusions: Most ESKD patients on maintenance HD die in hospital settings, with infection being the leading cause of death. Patients are hospitalised, receive more invasive life-sustaining treatments and have poor adoption of ACP discussions in the care plan.

Richa Randhawa¹, Nipun Lamba¹, Sudha Sarna¹, Seema Khandelwal¹

¹Department of Palliative Medicine, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India.

E-mail: rrandhawa534@gmail.com

Background: Cancer-related pain is complex and multi-dimensional. There is a need for non-pharmacological and innovative approaches. Trans-cutaneous electrical nerve stimulation (TENS) has a significant role to play.

Introduction: TENS devices are portable and easy to use with few or no side effects or contraindications. TENS is the usage of mild electrical current through electrodes that stimulate nerves and can be used for cancer pain.

Case Report: A 59-year-old male with K/C/O non-cell lung carcinoma (left) (squamous cell carcinoma with bone metastasis), type 2 diabetes mellitus/ hypertension/coronary artery disease/peripheral artery disease, status post six cycles of chemotherapy (Paclitaxel + Carboplatin) followed by immunotherapy with pembrolizumab four cycles and last cycle one month ago, came to our hospital for immunotherapy cycle. On admission, the patient complained of severe pain in the back, shoulders and arms, unable to lift the left arm with a numeric rating scale (NRS) of 7–8.

Materials and Methods: TENS application was decided and was applied for 40 min bilaterally on shoulders. Four such applications were given on consecutive days.

Results: Relief of pain by 30–40% by 1^st day, 60–70% by 2^nd day, 80% by ^3rd day and 90–100% on the 4^th day. The patient laid comfortably by the end of the 4^th Cycle with NRS of Zero.

Conclusion: TENS is safe and improves cancer pain significantly. TENS was well tolerated by the patient. Thus, TENS is a beneficial adjunct for multimodal treatment of pain. It is inexpensive, relatively free from side effects and is portable.

M. S. Biji¹, Shoba Nair², Praveen Kumar Shenoy³, B. Satheesan⁴, Odette Spruijit⁵, Chitra Venkateswaran⁶, K. C. Rajasree⁷, K. Ratheesan⁸, D. K. Vijayakumar⁹

¹Department of Cancer Palliative Medicine, Malabar Cancer Centre, Thalassery, Kannur, ²Department of Pain and Palliative Medicine, Amrita Institute of Medical Sciences, Kochi, Departments of ³Clinical Haematology and Medical Oncology, and ⁴Surgical Oncology Malabar Cancer Centre, Thalassery, Kerala, India, ⁵Department of Palliative Care, Western Health Network, VCCC, Melbourne, Australia, ⁶Department of Palliative Care and Psycho-Oncology, Believers Church Medical College, Thiruvalla, ⁷Department of Pain and Palliative Medicine, Amrita Institute of Medical Sciences, Kochi, ⁸Department of Cancer Registry and Epidemiology, Malabar Cancer Centre, Thalassery, ⁹Department of Surgical Oncology, Amrita Institute of Medical Sciences, Kochi, Kerala, India.

E-mail: bijims@gmail.com, shobann@aims.amrita.edu, vppraveen233@gmail.com, director@mcc.kerala.gov.in, Odette.Spruijt@petermac.org, chitven@gmail.com, drraji14@gmail.com, rksrivalsam@gmail.com, dkvijaykumar@aims.amrita.edu

Introduction: Cancer patients use their spirituality to cope with their experiences. However, spiritual well-being is less frequently addressed due to limited availability of validated tools in regional languages.

Aim: This study aimed to validate the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being-Expanded (FACIT-Sp-Ex) tool in Malayalam and to assess its feasibility among advanced cancer patients receiving palliative care.

Methods: The study was carried out at the outpatient department of Cancer Palliative Medicine of Malabar Cancer Centre between November 2022 and June 2023. Initially, the FACIT-Sp-Ex tool with 23 items was translated into the Malayalam language with a forward–backward translation procedure. This was followed by pilot testing in ten advanced adult cancer patients receiving palliative care who could read and comprehend the Malayalam language. After answering the draft version of the validated tool, patients responded to questions from a Malayalam-translated cognitive debriefing script.

Results: The majority (70%) of the patients were female. The mean age of patients was 45.90 (standard deviation [SD] = 7.62) years. Carcinoma breast (50%) was the most common type of cancer. All the patients knew their diagnosis, while only 80% knew the prognosis. Almost 90% of the patients were receiving some form of palliative anticancer treatment. All patients completed the draft version of the validated tool. The mean spiritual well-being score measured using this validated tool was 71.20 (SD = 15.10). Cronbach’s alpha reliability coefficient was calculated to be 0.88. Analysis of the debriefing interviews revealed that the Malayalam version was easy to complete, relevant and appropriate.

Conclusion: Linguistic validation and cognitive debriefing produced the Malayalam translated FACIT Sp Ex tool conceptually equivalent to the original FACIT Sp Ex tool, with good internal consistency of the items in the tool and it is feasible for its use.

Ethics approval No.1617/IRB-IEC/13/MCC/18-10-2022/6

CTRI no-REF/2022/12/061195

S. Rathipriya¹, Thendral Ramasamy²

^1,2Pain and Palliative Care, Cancer Institute WIA, Chennai, Tamil nadu, India.

E-mail: rathipriya22@gmail.com

Introduction: Patients with advanced cancer presenting with progressive oedema have poor quality of life and death. In cancer, anasarca has multifactorial aetiology, and there is limited evidence in the literature regarding the successful management of this debilitating symptom.

Case Description: This is a 46-year-old female with carcinoma cervix and multiple soft-tissue metastases. One week after her second cycle of palliative chemotherapy, she presented with complaints of generalised oedema and low back pain. A multidisciplinary team, including palliative care physicians, nurses, physiotherapists and interventional pain team, was involved in the management. Her pain was treated with oral morphine and gabapentin in addition to central desensitisation therapy administered by the interventional pain team. Her anasarca was managed with a compression bandage for her extremities and the use of high-dose intravenous steroids, intravenous infusion of furosemide and hypertonic saline. This resulted in a remarkable improvement in her generalised oedema. She went home and was on a telephonic follow-up. A month later, she was admitted to the hospice with a recurrence of oedema and died without much symptom distress.

Conclusion: Anasarca in patients with advanced cancer can be managed adequately using a combination of intravenous high-dose steroids, loop diuretics, hypertonic saline and multicomponent compression bandage.

REFERENCES

1. Mercadante S, Villari P, Ferrera P, David F, Intravaia G. High-Dose Furosemide and Small-Volume Hypertonic Saline Solution Infusion for the Treatment of Leg Edema in Advanced Cancer Patients. J Pain Symptom Manage 2009;37:419-23.

2. Gradalski T. Multicomponent Compression Bandaging Combined with Diuretic Therapy of Anasarca Secondary to Palliative Chemotherapy: A Case Report. J Palliat Med 2021;24:144-7.

3. Gradalski T. Diuretics Combined With Compression in Resistant Limb Edema of Advanced Disease-A Case Series Report. J Pain Symptom Manage 2018;55:1179-83.

J. Jefrilla Nancy¹, V. V. Meenakshi¹

¹Department of Pain and Palliative Care, Cancer Institute WIA, Chennai, Tamil Nadu, India.

E-mail: jefrilla@gmailf.com

Introduction: Opioids form the cornerstone of pain management in oncology and, yet, have the potential for abuse, resulting in life-threatening adverse effects. Overdose with two different opioids is uncommon and infrequently reported in the literature.

Case Description: A 42-year-old man with a diagnosis of metastatic rectal carcinoma receiving palliative chemotherapy was brought to emergency in a state of unresponsiveness and bradypnoea with an alleged history of consumption of several tablets of both morphine and tramadol. With a clinical diagnosis of opioid overdose, treatment was initiated with intermittent naloxone boluses 40 mcg and supportive care was provided. Bradypnoea persisted despite five boluses; hence, an infusion was started at 80 mcg/h with close monitoring in a high dependency area until the patient was stabilised. A detailed history from the patient’s wife revealed that he had expressed some suicidal ideas a few days ago. Despite this, he had access to the entire supply of prescribed opioids.

Conclusion: Identifying and managing opioid overdose is essential as early intervention is lifesaving. Although opioids are prescribed and dispensed in required quantities with the intention of alleviating pain, the possibility of misuse by family members as well as the patients themselves must be considered. Thus, it is crucial to screen patients for substance abuse, psychiatric conditions and psychological distress as precipitators of abuse and educate the family to manage the medications of patients who are at risk cautiously. Since symptoms of the two opioids overlap and can complicate the management, this case report helps to gain inputs on how to manage it.

Akshay R. Tabiyar¹, Varun Yadav¹, Bhavna C. Patel¹, Priti Sanghvi¹

¹Department of Pain and Palliative Medicine, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India.

E-mail: akshaytabiyar123@gmail.com

Introduction: High output ileostomy is defined as an ileostomy output of more than 1.5 L/day with signs of watery output and to empty bag more than eight times a day. It leads to dehydration, electrolyte imbalance and acute kidney injury.

Aim: This study aimed to reduce the amount of ileostomy output and stabilise electrolyte imbalance and acute kidney injury that occurred due to it.

Case Description: A case report of a 60-year-old female patient, a known case of metastatic malignant phyllodes tumour with ileostomy in situ, presented with complains of increased output from stoma more than 2 L/day, which required to empty stoma bag more than 8 times/day along with weakness, vomiting and lower limb pitting oedema. On blood investigation, hyponatremia, hypomagnesaemia and hypoalbuminemia were found with acute kidney injury. For high output stoma, we started a capsule of omeprazole 20 mg once a day, a tablet of loperamide 2 mg half an hour before food and fluid replacement by 500 mL of normal saline and ringer lactate and also advised diet modification with high fibre diet, protein powder, apple, bread, biscuits, etc.

Results: After one week, she reports a decrease in stoma output (<1.1 L/day) with a reduction in emptying of the stoma bag to 4/day. Serum level of sodium 136 and magnesium 1.8 with creatinine value of 0.90 found after one week.

Conclusion: We observed that high ileostomy output can be managed effectively by a high dose of antidiarrheal agent loperamide along with proton pump inhibitors.

Lakshmi Abishek Krishnan¹, Mithili Sherigar¹, Seema R. Rao¹

¹Bangalore Hospice Trust – Karunashraya, Bengaluru, Karnataka, India. E-mail: lakshmi.abhishek@karunashraya.org

Introduction: Pain management is the 5^th vital sign and an important component of quality of life. Evidence-based pain management is a prerequisite of quality palliative care. This study aims to explore the effectiveness of pain management based on the World Health Organization (WHO) analgesic ladder in advanced cancer patients in a hospice setting.

Methods: This is a retrospective review of inpatients admitted to the hospice over three months who were reviewed. The pain score on the numeric rating scale, type of pain and the medication prescribed at the time of admission and after 48 h were analysed.

Results: Fifty-nine charts were reviewed. The mean age was 62.9 (32–90). Among them, 52.4% were female. The predominant cancers were head and neck (32.2), followed by gynaecological (25.4) and gastrointestinal (23.7). The mean ECOG score was 2.59 (0–4). There was significant improvement in pain score, with the mean pain score on admission was 5.9/10 and 2.61/10 after 48 h. Charts show that mixed pain (62.7%) was the most common type of pain, along with nociceptive pain (33.9%). The most prescribed opioid was morphine (50.0%), followed by tramadol (22.0%). The commonly prescribed adjuvants were pregabalin (50.8%).

Conclusion: Pain can impact the quality of life adversely and add to immense suffering. This study demonstrates that by identifying the type and quantifying the intensity of pain and with the appropriate use of analgesic and adjuvants using the WHO pain ladder, pain relief can be achieved within 48 h.

Keywords: Palliative care, Referral, Hospice, Pain.

Ishita Sarkar¹, Keshav Sharma¹, Mithili Sherigar¹

¹Bangalore Hospice Trust – Karunashraya Institute of Palliative Care Education and Research, Bengaluru, Karnataka, India.

E-mail: ishita.sarkar@karunashraya.org

The idea of ‘accompaniment’ arose in deliverance theology in Latin America and drifted into liberatory forms of psychology as ‘psychosocial accompaniment’. Accompaniment necessitates a reorientation of the subjectivity, interpersonal practices and critical understanding of the accompanier so that (s)he can stand along with others who wish to listen, observe, advocate, and have space to grow critical inquiry and research and joint imagination and action to address desired and needed changes. Therapeutic accompaniment accomplishes the task of supporting a person with health problems, whether physical or mental, in those areas where they cannot manage independently. The following case study is based on the life story of a 74-year-old male patient with carcinoma of the pancreas. He was in terminal delirium, which made it difficult to communicate with him due to his poor cognition and slurred speech. Regional language was another factor which was a challenge to communicate with him. The elderly show a lower understanding of complex sentences and instructions compared to other age groups as a result of loss in functionality. Therefore, therapeutic accompaniment was a tool which aided in overcoming the barrier, as mentioned above, to communication which was encountered during interacting with the patient. It helped him develop autonomy, improve social skills and interact with the environment more healthily. To conclude, therapeutic accompaniment became the most adequate and appropriate form of technique to overcome the challenging barriers to communication in end-of-life care. Being by the side of the patient and providing support to the patient by actively attending to the non-verbal and verbal cues led to improving the quality of life and enhanced the process of end-of-life care.

Keywords: Communication skill, Therapeutic accompaniment, End-of-life care, Palliative care.

Aishwarya Bhaskar¹, Michelle Normen¹

¹Bangalore Hospice Trust – Karunashraya Institute of Palliative Care Education and Research, Bengaluru, Karnataka, India.

E-mail: aishwarya.b@karunashraya.org

Legacy making is part of dignity therapy, which addresses patients’ emotional and existential needs receiving Hospice or Palliative care. Leaving a legacy is the act of leaving behind something that future generations can remember. It ensures that memories of a person continue to exist beyond their lifetime. Folkman theorised the concept of meaning-based coping which helps in reducing the impact of negative life events. Engaging the patient in meaningful activities will improve quality of life and promote generativity. It has also been researched that legacy therapy reduces the burden on physical symptoms due to psychological components. This case study focuses on the story of Mrs. Muniyamma (name changed), a female patient aged 51 diagnosed with Carcinoma Buccal Mucosa. Although she received education only till 6^th grade, she was fluent in English, Kannada, Hindi and Tamil and had worked as a cook for over 20 years. However, due to her progressive disease and wound on her chin, even after receiving chemotherapy, she was forced to quit her profession. This initiative helped Mrs. Muniyamma create a meaningful legacy, and her loved ones can cherish her memory even after she has passed away. They also gave a sense of fulfilment. After the intervention, the patient said, ‘When I could turn back, I had nothing. I was a zero. But I realised that there is something about my life. And it was brought out through this book’. This case study explores the intervention used in legacy making, which involved documenting the recipes cooked by her. These recipes were compiled into booklets titled ‘The Joy of Cooking’, as suggested by the patient herself. On 1 May 2023, the patient launched the book at our hospice centre – Karunashraya, Bangalore Hospice Trust.

Keywords: Legacy, Meaningfulness, Memory, Hospice, Palliative care.

Jagdish¹, S. Srikanth², Manoj Kamal², Bharat Paliwal³, Jyotirmay Dhenwal³, Meenu Yadav⁴, Rashi⁵

Departments of ¹Community and Family Medicine, ²Anesthesia and Critical Care, ³Nursing, ⁴Medical, ⁵All India Institution of Medical Science, Jodhpur, Rajasthan, India.

Introduction: Home-based palliative care is pivotal in improving the quality of life for individuals facing life-limiting illnesses. This study conducted in Jodhpur, Rajasthan, India, explored the challenges encountered by home-based palliative care providers in patient identification, referral and enrolment.

Objective: The primary aim was to elicit perspectives of home-based palliative care providers on challenges in patient identification and referral of patients who may benefit from home-based palliative care services. The study seeks to contribute insights informing strategies for improving the efficiency and effectiveness of home-based palliative care delivery.

Methodology: Through qualitative study with a case study approach, in-depth interviews were conducted during June-September 2023 among three doctors, three nurses, one physiotherapist, one social worker and ten patients receiving home-based palliative care services along with their caregivers in Jodhpur, Rajasthan. The sample size was determined by information saturation. Thematic analysis of transcripts was carried out in the analysis.

Results: Key challenges identified include geographical limitations, lack of public awareness, shortage of trained health-care providers, social stigma impacting caregiver involvement, budget constraints, legal limitations on nurse prescriptions, burnout among caregivers and staff, insufficient volunteer support, communication issues and the absence of a government policy on palliative care in Rajasthan.

Conclusion: This study sheds light on multifaceted challenges faced by the home-based palliative care team in Jodhpur, offering insights crucial for targeted interventions, policy development and resource allocation. By understanding and addressing these challenges, we can enhance the delivery of home-based palliative care, ultimately improving the overall quality of life for patients facing life-limiting illnesses in Jodhpur.

Anjali Govind¹, Anuja Pandit²

¹Department of Palliative Medicine, AIIMS, ²Department of OncoAnaesthesia and Palliative Medicine, NCI AIIMS, Delhi, India. E-mail: agovind.964@gmail.com

Introduction: Metastatic spinal cord compression (MSCC) is one of the most distressing sequelae of cancer. Even with proficient management, treatment is aimed at preserving function rather than to reverse back the established symptoms. The life expectancy is usually <6 months after being diagnosed, and hence, the primary aim of such patients is to improve the general quality of life. The association of MSCC with high morbidity and mortality highlights the need for concomitant palliative care. In our study, we wish to assess patients with MSCC who present to our centre, and we shall be following the path that the disease leads them through during the period of 1 month.

Aim: This study aimed to assess emotional well-being in patients with MSCC presenting to the Palliative Medicine Department at AIIMS New Delhi and NCI Jhajjar.

Methods: After getting clearance from the Institute Ethics Committee, patients will be recruited. Patients will be explained about the study and informed consent will be taken. Patients will be asked in detail about the various complaints which impact the quality of life or the outcome using a questionnaire-based validated scale of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ C-30). Emotional well-being will be assessed using the Hospital Anxiety and depression scale (HADS). Patients will continue to receive therapy deemed necessary by the oncologists, which will be noted. All patients recruited in the study will be assessed at baseline using EORTCQLQ 30, HADS, Karnofsky Performance scale and numeric rating scale, and also on their follow-up visits at 10 days and 1 month.

Results and Conclusion: Under scrutiny will be published at the time of presentation.

Ruhi Ravindra Kumar Dandge¹, Vandana Bhasin¹

¹KITES Senior Care-GCC, Bengaluru, Karnataka, India

E-mail: rheadan757@gmail.com, drruhi.i@kitesseniorcare.com; vandana.b@kitesseniorcare.com

Introduction: Over the past few years, we have seen some major changes in the global demographics, with India’s population growth being one of the most significant ones. This demographic surge has been attributed to advancements in medical practices over the decade, leading to extended life expectancies. In light of evolving circumstances, the convergence of the two domains of ‘Geriatric Care’ and ‘Palliative Care underscores the necessity for an increasingly strategic, patient-centred and comprehensive multidisciplinary approach tailored to the needs of chronically ill elderly individuals. Families of ageing patients play an integral role in palliative care decision-making and delivery of quality care.

Aim: This study aims to evaluate and analyse the existing knowledge and awareness of Geriatric Palliative Care among the employees at KITES SENIOR CARE.

Methods: A semi-structured qualitative survey questionnaire was designed based on LIKERT’s scale. The survey was conducted virtually with the help of Google Forms. The population of the study included corporate employees of KITES Senior Care who had ageing family members (over 60 years of age) with chronic illnesses.

Results: The participants had limited knowledge of ‘GERIATRIC Palliative Care’.

Conclusion: There is a need to provide training and raise awareness about geriatric palliative care among family members of the ageing population, nurses, physicians and allied health-care staff in India. This will help in improving the quality of end-of-life care provided to the elderly.

Anoushka Arora¹, Parth Sharma², Shreyas Patil³, Siddhesh Zadey⁴

¹Association for Socially Applicable Research, Pune, Maharashtra, Smt. Nathiba Hargovandas Lakhmichand Municipal Medical College, Ahmedabad, Gujarat, ²Association for Socially Applicable Research, Pune, Maharashtra, Department of Community Medicine, Maulana Azad Medical College, New Delhi, ³Association for Socially Applicable Research, Pune, Maharashtra, ⁴Association for Socially Applicable Research, Pune, Maharashtra, Department of Epidemiology, Mailman School of Public Health, Columbia University, NYC NY USA GEMINI Research Centre, Duke University School of Medicine, Durham NC USA, Dr. D. Y. Patil Medical College, Hospital, and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India.

E-mail: anoushkaarora.arora@gmail.com, parth.sharma25@gmail.com, patil19.shreyas@gmail.com, sidzadey@asarforindia.org

Introduction: India has a massive and continuously increasing burden of cancer. The World Health Organization recognises palliative care under the human right to health. Despite this, <4% of people requiring palliative care have access to it, necessitating a need to scale it up.

Aim: This study aimed to calculate the unmet need for palliative care in patients with cancer for the scale-up of services.

Methods: As India is a resource-limited country, we propose that the initial focus should be to scale up services to provide at least all patients with stage 4 disease with palliative care. The unmet need for palliative care was calculated for these patients by subtracting the number of patients receiving palliative care for stage 4 cancer from the total disease burden for the same. Data were extracted from the Report of National Cancer Registry Programme 2020.

Results: Out of 20,753 people with stage 4 disease, 19,348 (98.4%) did not receive palliative care. The unmet need was 98.2% and 98.6% for males and females, respectively. Cancer tongue, hypopharynx, nasopharynx, and oropharynx have a 100% unmet need in females. Cancer nasopharynx and hypopharynx have a 100% unmet need in males. The least unmet need for females and males was seen for stomach cancer at 96.4% and 96.27%, respectively.

Conclusions: The unmet need for palliative care in India requires urgent attention. Future studies should look at geographical variations in access to palliative care to promote region-specific interventions.

Vasundhara Sharma¹, Varun Yadav¹, Ravi Umrania¹, Preeti Sanghvi¹

¹Department of Palliative Medicine Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India. E-mail: vasundharasharma80@gmail.com

Introduction: According to the International Classification of Childhood Cancer, osteosarcoma and Ewing sarcoma are the two primary types of malignant bone tumours found very common in children. According to Western country research, clinical manifestations of these bone tumors are pain, tingling, burning sensation, pathological fractures, dyspnoea, and headache, with multiple psychological and social issues. For the Indian population, there is a lack of such data.

Aim: This study aimed to assess symptom burden in paediatric bone tumour patients and the impact of palliative treatment on it.

Methods: This was a prospective analytical study including patients of age <18 years with advanced primary bone malignancy receiving palliative care. We collect demographic data and the SSPedi tool (Symptom Screening in Paediatrics) for symptom burden at baseline, 1^st month, 2^nd month, and 3^rd-month follow-up to know the impact of palliative treatment.

Results: A total of 20 patients enrolled in the study. We found that the most frequent symptoms were pain (100%), tingling (95%), altered taste (95%), feeling worried (95%), and bothered due to a change in look (95%) at baseline. Most severe symptoms (score > 2) at baseline were pain (3.5 ± 0.68), feeling sad (2.1 ± 1.16), feeling scared (2.05 ± 1.09), tiredness (2.01 ± 1.04), feeling angry (2.05 ± 0.82) and bothered due to changes in look (2.05 ± 0.88). Significant changes were noted for frequency and severity for most of the physical and psychological symptoms at 3^rd month follow-up (P < 0.005).

Conclusion: Paediatric patients with advanced primary bone malignancy suffer from very high symptom burden, and palliative treatment helps significantly to improve symptom burden and its severity in these populations.

Dr. Japhia David

Department of Gynaecology, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India

Introduction: Mixed germ cell tumours represent a rare variant of malignant ovarian germ cell tumours commonly present among the adolescent age group. The growths of these tumors are aggressive but exhibit an excellent prognosis. A social approach to management remains a challenge for these patients.

Aim: This article reports a rare case of mixed germ cell tumour addressing the patient’s social aspect of care.

Methods: A 19-year-old unmarried girl presented with a complaint of abdominal pain for the past 1 month. A clinical workup revealed a 14*18*25 cm solid-cystic unilateral ovarian lesion requiring surgical intervention.

Results: The pre-operative preparation primely included mental preparation of the patient and the family members, explaining the pros and cons of the surgery with unilateral oophorectomy and the need for adjuvant chemotherapy. After appropriate informed consent, fertility-sparing staging laparotomy was performed. The final histopathology report suggested a high-grade mixed germ cell tumour of stage IIA with varied components of choriocarcinoma (50%), embryonal carcinoma (30%), yolk sac tumour (15%), and mature teratomatous glandular component (5%). The patient received three cycles of adjuvant chemotherapy. Post-treatment observation for 6 months revealed the patient was disease-free.

Conclusion: Surgery and chemotherapy play a main role in management. Counselling for the same among the sociocultural hindrances is a main concern in young patients with germ cell tumour. Hence, a socio-centric approach is warranted in the management of these patients.

Pulluri Sai Sowmya¹, Praveen Kumar Kodisharapu¹, Praneeth Suvvari¹

¹Department of Pain and Palliative Medicine, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India.

E-mail: pullurisai22@gmail.com, drprawin78@gmail.com, praneethsuv@gmail.com

Introduction: Refractory cancer pain is defined as pain which is not respond to standard opioid therapy with Oral Morphine Equivalent >200 mg >24 h. Despite following the World Health Organization step ladder, which is the gold standard approach to treat cancer pain, 10–20% of patients have inadequate pain relief – refractory cancer pain. Ketamine and Lignocaine have been used in various studies in refractory pain management.

Aims: We aim to compare the efficacy (>50% relief), side effects, and relapse of acute pain crisis within 6 weeks between patients who were given ketamine and lignocaine.

Methods: This is an interventional, prospective, and randomised control study. Patients with refractory cancer pain were selected for a trial of parenteral ketamine (0.3mg/kg/h) or lignocaine(2 mg/kg/h) – two infusions over 6 h with 12 h apart. Patients were assessed for the efficacy of pain relief using a numeric rating scale and then followed up for 6 weeks.

Results: Efficacy of pain relief in terms of pain relief % for ketamine – 59% ±16 and lignocaine – 43% ±9. Side effects are seen with ketamine more than lignocaine. Relapse within 6 weeks is for ketamine – 53% and lignocaine – 50%.

Conclusion: This is an ongoing study, but preliminary results showed that lignocaine has the least side effect profile, but ketamine showed better efficacy in terms of refractory cancer pain relief.

Vibha P. Kumar¹, Vasundharaa Nair¹, Anil T. John¹, Nandini Vallath¹

¹ST. Johns Medical College and Hospital, Bengaluru, Karnataka, India. E-mail: vibhapkumar9@gmail.com

Introduction: Disability and functional limitations associated with complex emotional responses affect the overall psychosocial well-being of a person. The grief of disability is an important aspect of coping that entails validation and addressal, for rehabilitation to be impactful. The prevailing model of psychosocial adaptation to disability is associated with grief theories to conceptualise and understand disability experiences and ensure better outcomes.

Objectives: (1) Primary: Describe patterns of grief and loss using a modified Kubler-Ross curve of change in young patients with disability, from the onset of their functional impairment, across different interventions undergone, up to and including the period of functional recovery. (2) Secondary: Raise awareness among rehabilitation professionals on the relevance of recognising and acknowledging phases of grief and addressing them as they emerge while serving people with functional impairment/disability.

Methodology: This was a case study type of methodology. IEC clearance from SJMCH Institute’s Ethical Committee. Five patients were selected based on eligibility and inclusion criteria – patients referred to the pain and palliative outpatient department (OPD) or inpatient department with severe pain above 5/10 on a numeric rating scale (NRS) scale, had any kind of inability to move or weakness in limbs after trauma, road traffic accident or atrophy of muscles due to prolonged deconditioning. Tools to assess include patients – general assessment of disability, semi-structured interviews, NRS scale, and SF-34 version that help determine daily function from time of engagement in hospital/OPD until the stage of recovery, collegiate disability experiences, and associated emotional experiences throughout this phase.

Results: Displayed by individual graphical representations with phases of grief aligned with functional limitation and pain score of five patients emerged. Correlations and comparisons of these phases showed interesting outcomes. Details discussed in person.

Conclusion: Integrating emotional experiences, planning symptom management, supportive care, and rehabilitation enhanced overall quality of life.

David Davey¹

¹Golden Butterflies Children’s Palliative Care Foundation, Chennai, Tamil Nadu, India.

E-mail: daviddavey74@gmail.com

Introduction: ‘Paediatric Palliative Care: Enhancing Quality of Life for Children with Chronic and Life-limiting Illnesses’ is a significant area of healthcare that profoundly impacts the lives of children and their families dealing with serious and long-term illnesses. Paediatric palliative care is a multidisciplinary approach that addresses physical, emotional, and psychological needs. Its primary goals are to improve symptoms, manage pain, and provide vital emotional support. While this field continues to evolve, it plays a pivotal role in ensuring that children and their families facing life-altering medical conditions can lead better lives. Golden Butterflies Children’s Palliative Care Foundation (GB) is a non-profit organization committed to meeting the needs of child patients and their families through comprehensive care provided by a multidisciplinary team. Social workers take the lead in improving the quality of care, offering support from the initial diagnosis through to the end of life for child patients and their siblings. This initiative involves various art and recreational activities, emotional support for caregivers, and maintaining a supportive presence throughout the entire journey, even after the bereavement period.

Aim: This abstract reviews the impact of ‘Paediatric Palliative Care: Enhancing the Quality of Life for Children with Chronic and Life-Limiting Illnesses.’

Methods: This was a retrospective analysis of data by a systemic review of the care provided using a multi-disciplinary approach.

Results: The child patient was registered under GB from the time of diagnosis and received comprehensive care from GB’s multidisciplinary team. (1) Social workers employed various art techniques to engage both the child patient and their affected siblings. (2) The child patient was diagnosed with B-ALL in 2022, with a curative intent until January 2023. (3) Throughout care, GB’s multidisciplinary team engaged child patients in diverse art and recreational activities to keep them engaged. (4) Siblings were actively involved in addressing the unique challenges they faced, such as a lack of attention, disrupted routines, and distractions from their education. (5) Social workers also conducted a puppet show to help the child patient cope with his medication and enhance his quality of life. (6) As the child patient’s prognosis worsened, doctors and social workers explained the situation to the parents, emphasising the importance of ensuring the best possible quality of life. (7) Emotional support and compassionate listening were provided to the parents as they shared their emotions during this challenging time. (8) In the child patient’s final days, a toy gun was provided to fulfil the child’s request, bringing immense joy.

Conclusion: GB’s holistic approach, led by compassionate social workers, has significantly improved the quality of life for children with chronic and life-limiting illnesses. Our commitment to comprehensive support, engaging activities, and emotional care highlights the positive impact of paediatric palliative care. This work underscores the difference made in the lives of these children, ensuring they receive care, comfort, and moments of joy throughout their journey.

(Note: The abstract summarises key points from the original report.)

Reshma G. Nair¹, James Das¹

¹Pallium India Palliative Care, Thiruvananthapuram, Kerala, India. E-mail: rreshmagn.20@gmail.com

Introduction: Stroke is the major cause of disability, which can also lead to the death of an individual. In post-stroke, a person’s quality of life can be severely affected, often limiting Activity in Daily Life. Physiotherapy helps patients with stroke to restore as much movement and function as possible. It focuses on improving strength, mobility, coordination, balance and proprioception.

Aim: This study aimed to study the impact of physiotherapy in post-stroke patients by assessing the changes in functional status.

Methods: This study was to assess the functional independence in post-stroke patients, Functional Independence Measurement (FIM) scale was used. The FIM scale was administered during admission in the palliative care unit and also assessed the effect of stroke rehabilitation before and after admission.

Results: This impact study was done on 30 stroke patients, with a mean age of 59.67 years, comprising 73% males and 27% females. FIM measurement before and after shows a high correlation, and t-statistics is significant at <0.001. The result shows physiotherapy in palliative settings can bring a radical improvement in functional independence of patients (pre- and post-rehabilitation) with cerebrovascular accidents, while few cases show minimal improvement.

Conclusion: Loss of functional movement, which is one of the most frequent complications of a stroke, significantly impacts daily life. Physiotherapy can improve functional independence in patients with post-stroke and, thus, enhance the quality of life. Thus, physiotherapy enhances the restoration of functional independence post-stroke and plays a crucial role in rehabilitation.

James Das¹, Reshma G. Nair¹

¹Pallium India Palliative Care, Thiruvananthapuram, Kerala, India.

E-mail: james.das@palliumindia.org

Introduction: Almost every neurological and musculoskeletal condition cause functional independence and may result in a drastic change in a patient’s activities of daily living (ADL).

Aim: This case study depicts a patient admitted to a palliative care setting with some neurological conditions (quadriplegia) that affect the ADL. This case study documents from the initial assessment until discharge and highlights the main problems encountered by the patient, the physiotherapy team, and the outcome.

Methods: Physical therapy exercises (Exercise therapy) and modalities (Electrotherapy) were introduced to the patient.

Results: FIM score measures pre-test score as 32 and post-test score as 98.

Conclusion: A high score value indicates that physical therapy can help to improve the functional independence and the ADLs of patients with neurological conditions/diseases.

Adipti Pantha¹, Arati Poudel¹, Sunita Bhandari¹, Amrita Thapa¹, Namuna Shrestha¹, Daniel Munday¹

¹INF Green Pastures Hospital, Pokhara, Nepal. E-mail: adipti.pantha@nepal.inf.org

Introduction: In low-middle-income settings like Nepal, palliative patients’ family caregivers experience multifaceted burdens, particularly in rural communities with limited healthcare access and low health literacy. No previous studies have explored the palliative caregivers’ burdens in rural Nepal.

Aim: This study aimed to examine the experience of palliative caregivers in rural Nepal, assessing the burden of care and the support they receive.

Methods: A cross-sectional descriptive study in 18 rural communities in Lamjung and Rukum-West districts, selected for maximum ethnic and socioeconomic variability. People with palliative care needs (PWPCNs) were identified in a house-to-house survey. Their caregivers were interviewed about caregiving burdens and support received using a pre-tested questionnaire.

Results: Fifty-eight PWPCNs were identified. 52/58 (90%) had caregivers at home. 42/52 (81%) were female; 23/52 (40%) were daughters-in-law, and the median age was 51.5 years (Range 21–81). Caregivers had provided care for a median of 5 years (3 months–21 years). 36/52 (69%) caregivers expressed that they were not completely aware of the condition of PWPCN. 43/52 (83%) reported experiencing a burden in caring. In order of frequency, 38/52 (73%) reported emotional exhaustion, 35/52(67%) reported tasks too demanding, 35/52 (67%) reported social life affected, and 31/52 (60%) physical exhaustion. 43/52 (83%) received support from family, 33/52 (61%) from neighbours and 24/52 (46%) from friends. Practical help was the commonest received, and financial support from family. 15/52 (29%) received help from community groups, mostly in the form of loans.

Conclusion: Caregiving responsibility was mostly born by women, particularly daughters-in-law. Most experienced burden in caring despite receiving some support from family and neighbours. Targeted interventions are being designed to ease burden and enhance the support system.

Keywords: Burden, Caregiver, Nepal, Palliative care, Rural ethnic community.

Arati Poudel¹, Sunita Bhandari¹, Amrita Thapa¹, Adipti Pantha¹, Daniel Munday¹, Namuna Shrestha¹

¹INF Green Pastures Hospital, Pokhara, Nepal. E-mail: arati.poudel@nepal.inf.org

Introduction: Comparative multiple case study research enables the exploration of intricate phenomena, offering insights into palliative care needs. A case is built through recording experiences and perceptions of people with palliative care needs (PWPCN), their careers, and key informants. By analysing the distinctive aspects of each case, shared patterns and unique differences can be highlighted, providing a thorough understanding of the phenomenon in focus. This method was used to explore palliative care needs, health seeking behaviour, and caring practices in remote areas of rural Nepal.

Aim: This study aimed to demonstrate the use of comparative multiple case study research for palliative care in rural Nepal.

Methods: Cases were constructed through purposively selected PWPCN identified using SPICT-LIS through house-to-house survey in two rural districts. Semi-structured interviews with PWPCN, their careers, and key informants were audio recorded, transcribed, translated into English, and coded. Themes were identified in the text. Narratives for each case were constructed, and similarities and differences across cases were analysed. Results: Twenty cases were constructed using 52 interviews. Narratives revealed that PWPCN are in need of more psycho-social and emotional support. They were unable to easily access healthcare due to poor local provision, poverty and difficult terrain. Low health literacy influenced health-seeking behaviour. Carers were mostly women who often suffered from emotional fatigue.

Conclusion: Findings enabled understanding of the lives of PWPCN and their careers. The study is facilitating the development of appropriate interventions for healthcare workers and communities. Further analysis is ongoing, and findings will be presented.

Allu Ramana¹

¹Sparsh Hospice, Hyderabad, Telangana, India. E-mail: alluramana88@gmail.com

Introduction: Resource navigation helps one find important information, guidance, and support in end-of-life care (EOLC). Resource navigation provides a structure to the otherwise stressful situation for the patient and family.

Aim: The resource navigation system was to improve the support system in terms of information on care options, support groups in the community, livelihood support, medical equipment, alternative livelihoods, logistics, and funeral support.

Methods: Resource navigation starts with initiating conversations with the families caring for a terminal patient to understand their needs and match the support that is available in the community. It also starts with patients understanding their care options in line with their advanced care planning if available or in line with their needs, beliefs, values, and requirements. Resource navigation works by identifying the existing resources and evaluating how these can help the patient handle the disease progression comfortably and how to avoid unnecessary expenditure for the family. This can help the family feel supported by the community during their tough times. Resource navigation can help families find their new routine post-bereavement.

Results: Navigating a support system encompassing all dimensions of care was to ensure the optimum usage of resources for holistic care of the patient and family and also to optimise the financial burden on the family.

Conclusions: Resource navigation is to join the dots of resources in the community to help improve the experience of poor prognosis for both the patient and family, pre- and post-bereavement.

Vahini Bodasingi¹

¹Sparsh Hospice, Hyderabad, Telangana, India. E-mail: vahini.peddinti@gmail.com

Introduction: The role of the social worker (SW) is to align medical decisions with patient values and preferences in the event that the patient cannot communicate.

Aim: Advocacy for advance care planning (ACP) and also to navigate the ACP conversations with patients, families, and carers.

Methods: The role of SW is to facilitate discussion about ACP and encourage patients to start planning early. As this is a sensitive conversation, the SW should be able to come up with contextual conversation starters, keeping in mind the sociocultural background of the patient. As ACP is about being prepared for future healthcare needs, facilitating preparation upholding one’s values, beliefs and preferences is crucial. Help the patient to understand what to consider at the time of ACP. Help the patient recollect their past health-care experiences, evaluate present health condition, and plan future health goals. Initiating conversations with patients about appointing a substitute decision maker and explaining their role in ensuring that the ACP is passed on to the healthcare providers for implementation. SWs can help the patient in documenting these decisions to ensure their success. SWs should encourage the patient to discuss these decisions with the family to avoid collusion while executing the ACP.

Results: Create a safety net of ACP for the patient to help avoid aggressive measures or futile interventions in his healthcare plan.

Conclusion: SW’s involvement in ACP can help the patient and their family to take important decisions regarding healthcare.

Medari Monika¹

¹Department of Palliative Care, Sparsh Hospice, Hyderabad, Telangana, India. E-mail: medarimonika1994@gmail.com

Introduction: Non-malignant wounds, commonly referred to as benign wounds, encompass a diverse array of injuries that do not involve cancerous growth. These wounds can significantly impact the quality of life for affected individuals, leading to pain, impaired functionality, and potential complications if not properly managed.

Aim: This observational study explores the efficacy of topical insulin in managing non-malignant wounds, specifically bedsores, within the context of hospice care. The research aims to evaluate the impact of insulin treatment on wound healing, pain mitigation, and the overall quality of life for a cohort of ten hospice patients.

Methods: Ten hospice patients with non-malignant wounds, including bedsores, were selected for the study using purposive sampling. The intervention involved the application of insulin following a standardised protocol. The assessment included regular monitoring of wound healing, pain levels, and patient’s quality of life using established scales and patient feedback.

Results: The study provides compelling evidence supporting the integration of topical insulin in the management of non-malignant wounds, including bedsores, among hospice patients. The observed benefits, including accelerated wound healing, pain reduction, improved quality of life, minimised complications and cost-effectiveness, underscore the potential of insulin as a valuable addition to hospice wound care protocols.

Conclusion: These findings advocate for further research and the adoption of topical insulin therapy in standard wound management practices, aiming to enhance the overall quality of care for hospice patients with non-malignant wounds.

R. J. Devika¹

¹Pallium India, Thiruvananthapuram, Kerala, India. E-mail: drajendran1995@gmail.com

Background: Healthcare professionals in palliative care settings are exposed to hard situations like death, end-of-life care, and due to other personal reasons, which often lead to burnout. It is critical to analyse this phenomenon of burnout among healthcare workers in palliative care settings.

Aim: This study aims to explore the healthcare workers experiences and perspectives on burnout and stress in a palliative care setting.

Methods: Doctors, nurses, medical social workers, and psychologists were purposively recruited for this qualitative study from a palliative care setting in South Kerala between June and October 2023. An interpretative phenomenological analysis approach has been used throughout.

Results: In-depth interviews were conducted with seven healthcare professionals who had professional experience ranging from 2 to 10 years. Following analysis, results have shown that healthcare workers have been undergoing severe suppression, where they consciously block unwanted thoughts and impulses caused while taking care of palliative care patients.

Conclusions: The findings reveal the importance of improving the mental health and well-being of health-care professionals working with end-of-life care patients in palliative care settings. The importance of mental health and well-being interventions for health workers in palliative care was highlighted. Healthcare professionals require emotional and stress-free training and programs to equip them better to have a stress-free work environment.

Keywords: Burnout, Stress, Mental health, Emotional well-being, Palliative care, Interpretative phenomenological analysis

Hridhi S. Shibu¹

¹Aisha Memorial Hospital, Thiruvananthapuram, Kerala, India. E-mail: hridhi.shibu@palliumindia.org

Introduction: Cancer affects not only the one who is surviving the disease but also the caregivers. Chronic illness like cancer involves high caregiving demands and long-term dependencies that cause more strain on caregivers.

Aim: This study aimed to examine the nature and extent of caregiving burden on the primary caregivers of patients suffering from cancer. The coping strategies of caregivers and the quality of life of cancer patients were also examined. The study extended its scope to the development of a caregiving burden and adaptation of the Coping Response Inventory.

Methods: The data were collected using a quality of life questionnaire mainly focusing on caregivers in a palliative care centre in Kerala. The tool used was the caregiver burden scale consisting of structured questionnaires which specifically focus on the experience, barriers, and challenges faced by care takers.

Results: The findings of the study showed that about 76% of caregivers face a burden. Implications were discussed relating to caregiver burden during the palliative phase of illness, which include social responsibility of caretaking, dependency, lack of personal time, stress, economic issues, tolerance of abusive behaviour from patients, and depression.

Conclusion: The findings of this study could help identify primary carers who require more immediate assistance. The quality of life of the carer is negatively impacted by the patient’s dependency and symptoms during the final stage of life. This study also identified more active centres in urban settings and concluded that physical, psychological, and social support were the common needs among caregivers and healthcare professionals in palliative care.

J. Johnsurya¹

¹Pallium India, Thiruvananthapuram, Kerala, India.

E-mail: john.surya@palliumindia.org

Background: Cancer is regarded as a serious public health issue for which early detection and intervention stand mandatory. It is a leading cause of death and leads to psychological distress. In 2018, there were 18 million cases of cancer, and it is expected to reach 29 million cases by 2040. Psychosocial interventions are essential for the enhancement of the well-being of the patient.

Aim: The purpose of this study is to identify the level of psychological distress among cancer patients.

Methods: A cross-sectional survey using the anxiety depression stress scale was used.

Results: Among 30 respondents, the study captured psychological distress such as stress, anxiety, and depression. Around four-fifths of the respondents had a severe level of anxiety followed by stress; more than half of the respondents had a severe level, and for depression, less than three-fourths of the respondents reported having a severe level. Anxiety is severe and reported more often because the patient gets panic and nervousness quite often when compared to depression.

Conclusion: When someone is diagnosed with cancer, they frequently feel abandoned by society and the medical community, which adds to their fear. In addition to their physical suffering, they experience psychological, spiritual, and social traumas. Various forms of distress can be controlled and reduced through various social work interventions.

Rajendra Dutt Bijalwan¹, J. Sreejini¹, A. J. Shalini¹

¹Pallium India Trust, Thiruvananthapuram, Kerala, India. E-mail: rajendra@palliumindia.org

Introduction: The availability of palliative care services in the government institutes in the states of Uttarakhand and Haryana has been very limited. Hence, there was a need to facilitate new palliative care units in government hospitals under the guidelines of the National Programme for Palliative Care (NPPC) Programme. This program was introduced in 2012 for all the states of India by the Ministry of Health and Family Welfare, Delhi. Pallium India worked in collaboration with the National Health Mission (NHM) and the Directorate of Health Services (DHS) of the states of Uttarakhand and Haryana for the implementation of this programme.

Aim: This study aimed to initiate palliative care services in each healthcare unit of Uttarakhand and Haryana.

Methods: This study was done through communication, advocacy, team building, removing barriers, resource mobilization and implementation with the NHM cell and the government medical institutes.

Results: Uttarakhand and Haryana health department (NHM) issued an official order in the name of Pallium India as a partner to implement the NPPC programme in the state. As a result, palliative care centres became active in some hospitals in both states. Doctors and nurses in the profiles of medical officers, staff nurses, and Community Health Officers were trained in palliative care/medicine/nursing and hands-on training. An opioid availability workshop was also conducted for both states.

Conclusions: In collaboration with a civil society like Pallium India, under the NPCC programme, the states of Haryana and Uttarakhand have been able to catalyse a total of 13 palliative care centres in their states – four in Uttarakhand and nine in Haryana.

Adelina l. Uyvico¹

¹Department of Paediatric Palliative Care, National Children’s Hospital, Quezon City, Philippines.

E-mail: adelinauyvico@gmail.com

Introduction: Pain screening and assessment for children in the Emergency Department (ED) are frequently neglected. This study addresses the implementation of pain assessment as the 5^th vital sign to paediatric patients admitted to the ED.

Aim: The study aims to improve documented pain assessment from <30% to 70% of paediatric patients admitted to the ED.

Methods: A document review of ED patients (April to May 2022) and a survey of the ED Staff were conducted. Root Cause Analysis identified gaps in knowledge and practice, including insufficient orientation, inadequate understanding of paediatric pain, and a lack of available pain assessment tools. An action involved staff training and orientation sessions, distribution of pain assessment tools, and a 2-week pilot test.

Results: Post-intervention, knowledge, and practice improvements were observed. The 2-week monitoring revealed a rise in pain assessment documentation from 23.53% to 81-83% among doctors and 52.38% to 100% for nurses.

Conclusion: In April and May 2022, < 30% of patients admitted to the ED had documented pain assessments. A Root Cause Analysis identified deficiencies in staff training, orientation to hospital standards of care, and availability of pain assessment tools. Interventions included orientation and lectures on pain assessment for ED staff, along with the provision of assessment tools. Post-intervention, daily monitoring revealed substantial improvements, with documentation increasing from 23.53% to 81-83% among doctors and 52.38% to 100% for nurses.

Nitin Pandey¹, Lekha Raval¹, Bhavna Patel¹, Priti Sanghavi¹

¹Department of Palliative Medicine, GCRI, Ahmedabad, Gujarat, India. E-mail: nneiloo918@gmail.com

Introduction: Neuroblastoma is the most common extracranial solid tumour in infants and children, representing 8–10% of all childhood tumours. One in four children will die from disease progression. These patients present a unique set of challenges at the end of life. Paediatric palliative care focuses on improving the quality of life of children and parents.

Aim: This study aimed to highlight the commonly faced issues in the care of children suffering from metastatic neuroblastoma and ways to improve the quality of life care with a multidisciplinary team approach.

Case Description: A 4-year-old child, a known case of malignant neuroblastoma was brought up to our department with complaints of excessive crying due to pain in both legs. The patient also had difficulty breathing along with high-grade fever. Parents were anxious about the prognosis and distressed due to the life-limiting illness of the child. They were worried about financial support and had spiritual distress.

Management: After assessment of the patient, physical symptoms such as pain and dyspnoea were treated with a low dose of oral morphine along with paracetamol. The dose was adjusted on subsequent follow-up for optimum symptom relief. We also stated non-pharmacological measures for dyspnoea. Repeated family meetings were arranged for shared decisions regarding further treatment plans. We had involved NGOs for financial support.

Conclusion: We observed that with a multidisciplinary team approach, we were able to improve physical, psychological, social and spiritual distress.

Michelle Normen¹, Soumitra Shankar Datta^2,3,

Seema R. Rao¹, Mithili Sherigar¹, Samir Kumar Praharaj⁴

¹Bangalore Hospice Trust- Karunashraya, Bengaluru, ²Department of Palliative Care and Psycho-oncology, Tata Medical Centre, Kolkata, West Bengal, India, ³Institute of Clinical Trials and Methodology, University College London, London, UK, ⁴Department of Psychiatry, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India.

E-mail: michelle.normen@karunashraya.org

Introduction: End-of-life conversations are critical to patient-centred care in oncology and palliative care. In India, end-of-life communication is hindered by cultural taboos, language barriers, and communication norms, which affect patient-provider discussions and decision-making processes. This survey aims to understand healthcare professionals’ communication experiences in end-of-life care.

Methodology: This cross-sectional online survey was distributed to healthcare professionals in oncology and palliative care settings across diverse healthcare institutions. The survey encompassed questions probing the frequency, importance, and challenges of engaging in end-of-life discussions and the role of communication skills.

Results: Forty healthcare professionals consented to participate in the survey; among these, most of the respondents were female (57.5%). The oncologists (27.5%), psychologists/psycho-oncologists (25%), and palliative care physicians (22.5%) were from oncology (50%) and palliative care (hospital/hospice/homecare) (47.5%) settings. The average years of experience was 12.7 (1–49 years). Most respondents reported engaging daily in end-of-life care conversations (47.4%) and felt that these conversations were moderately difficult (67.5%). Most (87.5%) opined that physicians should initiate end-of-life care conversations. When exploring communication skills, the majority reported feeling somewhat confident (52.5%) and had received communication skills training (72.5%) in various formats. Almost all respondents (97.5%) reported that enhancing communication skills could improve patient satisfaction in end-of-life care.

Conclusion: This survey highlights the opinions of healthcare professionals on communication experiences in end-of-life care conversations. These conversations were fairly difficult and needed to be initiated by the physician. Healthcare professionals also emphasised the need for communication skills training to improve the quality of end-of-life care.

Keywords: End-of-life care, Health-care professionals, Communication, Oncology.

Disha D. Jethva¹, Akshay R. Tabiyar¹, P. V. Anju¹, Priti Sanghavi¹

¹Department of Palliative Medicine, The Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India.

E-mail: disha.jethva@gcriindia.org

Introduction: Music therapy can be a safe place for cancer patients, especially in palliative care, to overcome fear, anxiety, anger, depression, pain, and a range of emotional responses. Music therapists work alongside other healthcare professionals as an interdisciplinary team. Music therapy is a part of a complementary supportive therapy to mainstream medical treatment. Thus, the study aims to understand the clinical importance of music therapy in cancer pain and palliative care.

Methods: Music therapy sessions were conducted using methods and techniques such as relaxation training, musical experience, receptive listening experience, song reminiscence, lyric discussion, chanting, songwriting, verbal discussion, non-verbal communication, and sing-along. Data were statistically analysed using the Statistical Package for the Social Sciences version 20.0.

Results: The present study revealed valuable insights into the positive impact of music therapy sessions on cancer patients. The major outcomes observed after the music therapy sessions included a notable reduction in anxiety, depressive thoughts, pain perception, also an enhancement in mood among cancer patients in pain and palliative care.

Conclusion: In the broader scope of cancer palliative care, music therapy contributes as a valuable adjunctive therapy, offering comfort, emotional support, and a pathway to meaning and connection during a challenging time. Finally, as the exploration and comprehension of the impact of music therapy persists, it becomes evident that its role in the holistic care of cancer patients is both meaningful and promising to improve the overall quality of life for cancer patients.

Pubali Biswas¹, Parth Sharma², Siddhesh Zadey³

¹Association for Socially Applicable Research, ²Association for Socially Applicable Research, Department of Community Medicine, Maulana Azad Medical College, New Delhi, India, ³Association for Socially Applicable Research, Pune, Maharashtra, India, Department of Epidemiology, Mailman School of Public Health, Columbia University, NYC NY USA GEMINI Research Centre, Duke University School of Medicine, Durham NC USA Dr. D. Y. Patil Medical College, Hospital, and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India.

E-mail: biswas.pubali@gmail.com, parth.sharma25@gmail.com

Introduction: The burden of chronic diseases and the need for palliative care is increasing in India. Private insurance coverage plays a pivotal role in mitigating the financial burden of chronic disease care.

Aim: This study aimed to assess the coverage of palliative care services by private insurance providers in India, delving into the nuances of plans and their limitations.

Methods: The top 12 private health insurance providers were identified after reviewing eight Indian policy broker websites. A qualitative evidence synthesis was done after reviewing policies with the highest premium and critical care plans of each listed private provider. Official brochures from these policies were analyzed systematically, using keywords (palliative care, terminal care, hospice care, cancer, geriatrics, older patients, end-of-life care, pain, and chemotherapy) identified following a literature review along with an in-depth analysis to assess the coverage of palliative care services for chronic diseases with a focus on cancer.

Results: Among 12 comprehensive care plans and 12 critical care plans analysed, ‘cancer’ was mentioned in 50% of comprehensive and all critical care plans, while ‘chemotherapy’ appeared in 33% of comprehensive and 8.3% of critical care plans. All other keywords were absent in all plans. An in-depth review found that only two plans mentioned clear inclusion criteria for cancer. All critical care plans had a maximum entry age limit of 65 years. The definition and parameters of cancer care coverage were frequently ambiguous.

Conclusions: There is a need for greater attention and clarity to incorporate comprehensive palliative care coverage for cancer and other chronic illnesses.

P. V. Anusree¹, Rajika¹

¹Department of Psychology, Pallium India, Pallium India, Thiruvananthapuram, Kerala, India.

E-mail: anusree.pv@palliumindia.org, rajika.kurup@palliumindia.org;

Introduction: Mental health issues in palliative care settings are seldom addressed adequately. Depression is thought to be common among people with life-limiting illnesses (LLIs). Assessing the severity of depression is important to improve the quality of life of those affected.

Aim: This study aimed to assess the severity of depression among people with LLIs who are receiving palliative care.

Methods: Patients identified to have psychosocial issues were administered the multipurpose validated Patient Health Questionnaire–9, which is used to screen for and grade the severity of depression in a person. Microsoft Excel was used for analysing the relevant data.

Results: Out of the 60 study participants, half were females, and the mean age of participants were 54 years. Cancer accounted for 50% of the illnesses while the remaining had various non-cancer illnesses. It was found that among those with cancer, the mean score of depression was higher at 18.46 out of 27 points compared to 13.23 among those with non-cancer illnesses. Females had higher mean depression (16.83/27) than males (14.86).

Conclusion: The severity of depression is higher in people with cancer, and females are more prone to getting depression. Hence, it is recommended that palliative care programmes should focus more on screening people with LLIs for depression to identify it and administer appropriate interventions.

T. Angelin Johny¹, Nikhila Karanth¹, Anu Abraham¹, R. Kalaivani¹, Nanda C. Prem¹, Ann Maria Roy¹, Nandini Vallath¹

¹Department of Pain and Palliative Medicine, St John’s Medical College Hospital, Bengaluru, Karanataka, India.

E-mail: angelinjohnyt@gmail.com, nikhilakaranth@gmail.com, anuabraham510@gmail.com, kalaivani2000ravi@gmail.com, nandacprem@gmail.com, annmariaroy0000@gmail.com, nandini.vallath@stjohns.in

Introduction: Conservative kidney management (CKM) can be an alternative to patients with end-stage kidney disease (ESKD) who are unfit or who make an informed decision not to pursue conventional kidney replacement therapy like HD. We present a sequential approach to facilitate CKM in a 60-year-old nun-sister, Sr. M, school principal with diabetic nephropathy, hypertension, and ESKD (Serum creatinine – 5.6 mg/dL and estimated glomerular filtration rate – 8 mL/min/1.73m²), on thrice-a-week HD, referred to palliative care unit (PC) on request from her family and congregation. She was found unconscious at her workplace, after staying non-compliant with nephrology advice 5-years after her chronic kidney disease -stage-3B-diagnosis. An initial evaluation in the dialysis unit was after clinical improvement from pneumonia septicaemia with intensive care and HD. Interactions with nephrologists helped comprehend her condition to be irreversible. At the family’s request, the PC team facilitated her transition from HD to CKM through multiple communication sessions. Symptoms were controlled; urine output of <350/day was enhanced by parenteral and later oral furosemide, medications were titrated, fluid intake was monitored, and diet modified. Once ESAS improved from 62/100 to 25/100, KPS from 20 to 50, and urine output reached >1000 mL/day, she was transitioned to home-based care. Physiotherapy interventions and psychological support helped with activities of daily living and emotional well-being. She was relatively symptom-free after that, with ESAS 40/100 and KPS 30, 1-week before death, and had a peaceful death at home 43 days after dialysis withdrawal.

Conclusion: CKM calls for a distinct approach, a different set of communication, and clinical skills that support symptom control and functionality until end-of-life while navigating the care plan as per the preferences of an empowered patient to not be on life-long dialysis.

R. Manoj¹, Amelia Sahana Michael¹, T. Madhavi¹

¹Department of Pain and Palliative Medicine, Aster CMI Hospital, Bengaluru, Karnataka, India.

E-mail: manojrmanor4@gmail.com, mscasmi2015@gmail.com

Introduction: Reintroduction of carbohydrate-rich foods through oral/ Rylestube/Total parenteral nutrition in palliative care patients after a period of prolonged malnourishment results in an underdiagnosed life-threatening condition called refeeding syndrome (RFS). This entity comprises metabolic derangements that are life-threatening, such as hypophosphatemia, hypokalaemia, and hypomagnesaemia.

Aim: This study aimed to raise awareness about RFS among palliative physicians involved in their care and planning of supportive care of patients with gastrointestinal tract malignancies/surgeries/disorders/oral mucositis.

Methods: We present a case of RFS in a patient diagnosed with malignancy of the right lateral border of the tongue. Post Grade 3 mucositis, patients undergoing chemoradiation developed Grade 3 mucositis, loss of weight, decreased oral intake, and fatigue. Resultant malnourishment occurred from the patient’s autonomous decision to refuse Ryles tube insertion. We present the diagnosis challenge, the investigation, and the management of RFS.

Results: The patient with RFS was discharged in a symptomatically stable condition.

Conclusion: RFS is an underdiagnosed fatal condition. Palliative patients are at a great risk of developing RFS. We need further studies in palliative patients to identify, diagnose, and manage potential fatalities in our cohort of patients.

H. Prashanth¹, Amelia Sahana Michael¹, Raghavendra Ramanjulu¹

¹Department of Pain and Palliative Medicine, Aster CMI Hospital, Bengaluru, Karnataka, India.

E-mail: prashanth112dbpur@gmail.com, drragraj1@hotmail.com;

Introduction: Oral mucositis (OM) is the most debilitating side effect of radiation and chemotherapy administered as a single modality or concurrently. Referral to the Palliative Department (PD) for Grade 2–3 mucositis management occurs when there is significant symptom distress. Prevention of OM with antioxidants (L glutamine/Zinc/Selenium) has been studied individually. To the best of our knowledge, the effect of administering five of these agents in 1 formulation has never been studied in this cohort of patients.

Aim: The aim of this was to observe the effect of a combination powder (CP) of L-glutamine, astaxanthin, copper sulphate, ascorbic acid, zinc sulphate, and selenium on Grade 2–3 mucositis. The primary endpoint is improvement by one Grade of mucositis. The secondary endpoint is improvement in oral intake as per the World Health Organization grading of mucositis.

Methods: The retrospective cohort study was conducted over 6 months, with the Institutional Ethical Committee’s approval. Subjects included those referred to the PD with Grade 2–3 OM, more than 18 years of age, on CP. Those on steroids/benzydamine excluded from the study. Twice a day administration of CP (15 g) in 100 mL water – 20 mL swished for 2–3 min and spat out and remaining 80 mL swallowed/through Ryles tube. Follow-up till end point achieved.

Results: Of 30 patients included in the study, 18 (60%) had Grade 2 OM, and 12 (40%) had Grade 3 OM. The mean time duration to the primary endpoint was 6 days, and to the secondary endpoint was 8 days.

Conclusion: CP has shown clinical and symptomatic benefit in the management of Grade 2–3 mucositis in the Palliative Outpatient Department. Further studies are needed.

S. Sruthi¹, S. Shivani¹, R. Agashini¹, S. Republica¹, K. Gauthaman¹

¹Aura Holistic Wellness Centre, A Unit of RMD Pain and Palliative Care Trust, Chennai, Tamil Nadu, India.

E-mail: auratheholistic@gmail.com, rmdacademyforhealth2019@gmail.com

Introduction: Stroke is a leading global cause of mortality and disability, with 15 million people suffering annually. It affects both the patient and their family physically, psychologically, socially, and emotionally and, hence, warrants Palliative Care (PC) intervention, providing holistic rehabilitation to improve the overall quality of life (QoL).

Aim: This study aimed to study the role of holistic rehabilitation (HR) in a patient who was afflicted with a cerebrovascular accident (CVA).

Methods: This was an interventional study of a 75 y/M patient with post-traumatic CVA with left hemiparesis. Comorbidities included type-II diabetes mellitus, hypertension, and coronary artery disease. Holistic rehabilitation was provided, which included (i) physiotherapy (passive physio, electrical stimulation, and muscle re-education) and nutritional and psychological counselling.

Results: HR (3 months) helped the patient to walk independently, indicating a regain of muscle strength. Electrical stimulation improved the motor activities in the right upper and lower limb muscle group by 20–40%. Oropharyngeal muscle strength improved as the patient could swallow porridge and fruit juices. The patient was gradually weaned off the RT-feed, and there was an improvement in the caloric intake (1450–2320) and protein value (56–90). In addition, cognitive-behavioural therapy (CBT) reduced mood swings and aggressive tendencies.

Conclusion: Early intervention with physiotherapy and CBT helped the patient regain his physical strength and his psychological behaviour. Furthermore, the family members were very much comfortable in providing the needed care, unlike the early phase of a cerebrovascular accident, thereby improving the QoL of both the patient and caregiver. Therefore, the institution of HR is recommended for PC patients.

Keywords: Holistic rehabilitation, Palliative care, Cerebrovascular accident, Physiotherapy, Psychotherapy, Quality of life.

V. S. Navinesh Nivedhan¹, S. Republica¹, K. Gowthaman¹

¹A unit of RMD Pain and Palliative Care Trust, Chennai, Tamil Nadu, India. E-mail: rmdacademcyforhealth2019@gmail.com

Introduction: The significance of active bladder and bowel care (ABBC) in palliative care (PC) remains unrecognised. Several ABBC protocols have been formulated in recent years, but there is a lack of guidelines in their implementation (Kyle, 2011).

Aim: This study aimed to assess the effectiveness of ABBC in PC to overcome patient discomfort and improve the quality of life (QoL).

Methodology: A qualitative analysis of the effectiveness of ABBC was analysed in a 79/M dementia (Alzheimer’s) patient who had abdominal distension, mild-breathing difficulty, altered sensorium, agitations, and violent behaviour toward family members/caregivers. Physical examination revealed lower abdominal fullness, pain in the right iliac fossa, and a hard, irregular mass. ABBC protocol was followed along with counselling to both patient and family members. QoL assessment was evaluated using the DOMS scale.

Results: The abdominal distension was confirmed to be secondary to decreased bladder evacuation and impacted faeces. Altered sensorium and dementia are a common cause for impaired bladder and bowel care. Bladder catheterization and manual evacuation of the impacted stools (hard pellets) led to immediate pain relief in the patient and attendant violent behaviour. Proper hydration and nutrition led to normal bladder and bowel activity. Urea and creatinine returned to normal levels.

Conclusion: It is uncommon for impaired bladder/bowel in PC patients following chronic illness. However, this is easily neglected in most instances. Early identification and care not only relieve the discomfort but also improve the QoL of both patients and caregivers. It is, therefore, imperative that ABBC guidelines are routinely followed.

Keywords: Palliative care, Active bladder and bowel care, Quality of life.

Maya Nair¹, Deepali Kumar¹, Pankaj Singhai¹, Swapnil Kumar Barasker²

Departments of ¹Palliative Medicine and ²Anaesthesiology, SAMC and PGI, Indore, Madhya Pradesh, India.

Introduction: Severe brain injury puts a significant caregiving burden. Caregiving at home is considered the most suitable option for long-term care, but family often finds themselves incapable of doing so after discharge. Professional caregivers are not easily available and put an additional financial burden. We hypothesised that nurse-led family empowerment can help families in better caregiving.

Aim: This study aimed to understand the impact of family empowerment on the clinical outcome of patients with severe brain injury.

Methods: A retrospective clinical audit was conducted of patients with severe brain injury admitted to the palliative care department of a tertiary care teaching hospital between April 2022 and December 2022. A Likert-based scale ranging from 0 (no confidence) to 10 (fully confident) was used to record the response of the family in confidence to provide intended care to the patient at the time of admission and discharge. Data were analysed using an Excel sheet.

Results: Out of a total of 21 patients, only two were female, and the rest were male. The mean age of patients was 40.19 ± 16.99 years. The patients were admitted to the ward with a range of a minimum of 16 to a maximum of 60 days and a mean of 35.14 ± 12.95 days. There was a significant difference (<0.05) between the admission score (0.52 ± 0.51) and discharge score (7.95 ± 1.02) of the family’s confidence to provide care.

Conclusion: Nurse-led empowerment made families more skilled and confident in managing the daily needs of their patients and led to impactful clinical care of patients with severe brain injury.

M. Arjun¹, I. Archana¹, T. Usha Rani¹, Srinivas Kalyani¹, Gayatri Palat¹, Jagadeswara Reddy¹, Soundarya¹

Introduction: Rabies is a rapidly progressive, acute infectious disease of the central nervous system in humans and animals. Rabies is transmitted through bite exposure, with dog bites responsible for most human cases reported worldwide. India contributes to almost a third of the global disease burden.

Aim: This study aimed to explore the experience of providing palliative care to a child suffering from acute rabies encephalitis sequelae and to have an understanding of the disease trajectory and symptom burden.

Methods: This study was a descriptive case report.

Case Summary: A 6-year-old female child was referred from Government Fever Hospital with a history of the World Health Organization Class III stray dog bite 1 month back and had received three doses of post-exposure rabies vaccination (incomplete) but no rabies immunoglobulin. The child was on ventilator support for 2 months and, after weaning off, was given a palliative care handover for further management, for which the child was shifted to a paediatric hospice facility. During the child’s course in hospice, she developed symptoms of neuroirritability, seizures, and spasticity, which were adequately managed. Discussions with the family were also done to understand their insight regarding the child’s condition prognosis and to have a care plan. It was a unique experience from a palliative care perspective in taking care of a child suffering from acute rabies encephalitis sequelae.

Conclusion: Palliative care has a significant role to play in rabies, especially in resource-limited settings of third-world countries, by improving the quality of life and decreasing the symptom burden. National guidelines will also help in defining the role of palliative care in the management of post rabies sequelae.

Experience of a palliative nurse from northern Kerala in chronic wound healing by advanced wound dressing using amniotic membrane-derived products

P. C. Sreevidya¹, Rari Rahman¹, Shamsudheen¹, Uwais¹, Shinsi Kasim¹, Sahal Thafheem¹

¹Iqraa-Thanal Pain and Palliative Care Centre, Kozhikode, Kerala, India. E-mail: sreevidyapc722@gmail.com

Introduction: Healing of pressure ulcers in palliative patients is a challenge that is a time-consuming process that needs significant resources and expertise.^[1] Persistent inflammation, cell senescence, growth factor deficiencies, and elevated concentrations of destructive proteases are inherent characteristics of chronic wounds that make the healing process difficult. Advanced wound care dressings like amniotic membrane-derived products have shown proven benefits in chronic wounds in terms of faster healing due to the presence of regenerative factors that promote growth, angiogenesis, and anti-inflammation.^[2]

Aim: This study aimed to understand the impact of advanced wound care products in the chronic wound healing process.

Methods: We share our experience in the management of chronic wounds among selected palliative patients with amniotic membrane-derived products. Patients with clean chronic wounds with a considerable loss of viable tissue were selected. After the basic wound care procedure, the amniotic membrane-derived product was applied over the wound. The dressing was changed every 3–5 days. The wound condition on day 1 and day 30 was assessed and compared clinically, along with photographs.

Results: The healing of chronic wounds was better in terms of faster healing and increased volume of granulation tissue when compared with the normal wound care process.

Conclusion: Advanced wound dressing materials such as amniotic membrane-derived products have shown better and faster healing of chronic wounds among palliative care patients. Even though it is expensive, judicious use of the same among selected patients will improve the wound condition and, thereby, the quality of life of the patient and family.

REFERENCES

1. Cornish L. Preventing and Managing Pressure Ulcers in Patients Receiving Palliative Care. Nurs Older People 2021;33:34-41.

2. Schmiedova I, Dembickaja A, Kiselakova L, Nowakova B, Slama P. Using of Amniotic Membrane Derivatives for the Treatment of Chronic Wounds. Membranes (Basel) 2021;11:941.

Amrita Thapa¹, Arati Poudel¹, Sunita Bhandari¹, Adipti Pantha¹, Daniel Munday¹, Namuna Shrestha¹

¹INF Green Pastures Hospital, Pokhara, Nepal. E-mail: amrita.thapa@nepal.inf.org

Introduction: Nepal has increasing numbers of people with palliative care needs (PWPCNs). Access to healthcare in remote areas is often limited. Education levels and health literacy are low. Government health insurance is universally available. To develop appropriate palliative care provision, an understanding of health-seeking behaviour (HSB) is essential. Aim: This study aimed to assess the HSB of PWPCN in rural Nepal.

Methods: A cross-sectional descriptive house to house survey of PWPCN conducted in eighteen rural communities selected to achieve maximum representation using a pretested questionnaire was undertaken. Results: Fifty-eight PWPCN were identified from 2320 surveyed, 2.5% of the population. 44/58 (76%) had received a diagnosis: cardiovascular 23/44 (52%), chronic obstructive pulmonary disease 9/44 (20%), and cancer 6/44 (14%). For getting to the nearest health facility, 31 (53%) went on foot; 14 (24%) used public transport and 7 (12%) were carried. Thirty-eight (66%) visited the nearest facility when unwell: 13/38 (28%) because it was the best service, 8/38 (24%). After all, it was closest and 2/38 (6%) due to cost. The reasons for 20 not visiting the nearest facility included 10 (50%) not offering suitable services, 7 (35%) too far, and 3 (15%) poor service. Of the 44 with a diagnosis, 25 (56%) had some follow-up, but only 7 (28%) regularly. Forty-one (71%) used health insurance; 12/17 (71%) said that it was not available, 3/17 (18%) that it was too difficult to arrange, and 2/17 (12%) that it was too expensive. Thirty-two (55%) said that cost prevented them from accessing healthcare.

Conclusion: The HSB of PWPCN in rural Nepal is complex. Most access local health facilities. Costs prohibited some from accessing healthcare despite health insurance being available. A qualitative study is exploring HSB in more depth.

Shalini Arora Joseph¹, M.R. Rajagopal¹, J. Sreejini¹,

Rontu Sangma¹, Rajendra Dutt Bijalwan¹, Sunanda Samal¹, S. Lalit¹, Syed Mohammad Askari Naqvi¹, Jatin Bhukal¹

¹Pallium India Trust, Thiruvananthapuram, Kerala, India. E-mail: shalini@palliumindia.org

Introduction: In India, the National Programme for Palliative Care (NPPC) was introduced in 2012 for developing palliative care services in all secondary and tertiary hospitals. National Health Policy, 2017, included palliative care services at the primary level. Both programmes have great potential for making palliative care available for needy patients through government institutions if the gap in implementation is filled.

Aim: This study aimed to develop palliative care services at all levels of government healthcare institutions through the implementation of NPPC and Ayushman Bharat Programmes.

Methodology: The facilitation team of Pallium India liaised with state health departments and officials to develop palliative care services in government hospitals. The team consisted of six trained facilitators working in different regions of the country, guided by the head of the facilitation division. They developed relationships with government agencies, healthcare institutions, and professionals and shared their knowledge and experience. They facilitated training and provided hand-holding for implementation, budgeting, human resource recruitment, opioid access, and resource mobilisation.

Results: The team facilitated the development of 42 government palliative care units in district hospitals, medical colleges, community health centers, primary health centres, and health and wellness centres across India in the past 3 years.

Conclusions: Pallium India’s work has demonstrated the value of working with governments to facilitate the implementation of the NDPS Amendment Act 2014, NPPC 2012, and National Health Policy 2017 and to develop state policies or programs for palliative care. Civil society action can be valuable in filling the implementation gap when legislation, policies, or programmes of government achieved limited success in their objectives.

M. Daniel Francis¹, Jenifer Jeba Sundararaj², Ramu Kandasamy³

¹Staff, Baptist Hospital, Bengaluru, Karnataka, ²Professor and Head, ³Social Worker, Department of Palliative Medicine, Christian Medical College and Hospital, Vellore, Tamil Nadu, India.

E-mail: danielfrancis86@gmail.com, jenifer.jeba@cmcvellore.ac.in, ramusw@gmail.com

Introduction: It is an undeniable fact that people experiencing poverty suffer more when chronic illnesses occur in the family. This study aimed to comprehend the socioeconomic impact of life-limiting illnesses on low-income families, informing new palliative care models to mitigate poverty risks.

Aim: Explore the socioeconomic effects of illnesses on poor patients and families receiving palliative care. The study also enquired how palliative care was of assistance to these families and how palliative care models can help in reducing socioeconomic burdens.

Methods: Fifteen semi-structured interviews (eight patients and seven caregivers) were conducted, supplemented by record reviews and data synthesis using Open Code 4.0 software. Economic hardships, social impacts, and disruptions due to illness were explored through open-ended questions. Transcriptions, coding, and theme synthesis were employed for analysis.

Results: Semi-structured interviews with patients and relatives revealed overwhelming financial strains on lower socioeconomic families, depleting savings, loan burdens, and asset liquidation to cover medical expenses. Economic repercussions led to work cessation, hindered education, strained familial relationships, and triggered suicidal tendencies. The financial support and rehabilitative interventions by the specialist palliative care team provided crucial medical support and addressed socioeconomic needs, preventing extreme poverty for most families.

Conclusions: Illness imposed severe socioeconomic challenges on low-income families. This jeopardised education, housing, and livelihoods. Identification of this impact and providing comprehensive support prevented the worsening of poverty, highlighting the critical role of financial support interventions. This highlights the necessity for tailored palliative care programmes that consider the socioeconomic context to prevent these families from spiralling into poverty due to health crises.

Syed Mohammad Askari Naqvi¹, Rontu Sangma¹, Rajendra Dutt Bijalwan¹, Sunanda Samal¹, S. Lalit¹, Jatin Bhukal¹, J. Sreejini¹, A. J. Shalini¹

¹Pallium India Trust, Thiruvananthapuram, Kerala, India. E-mail: syed.naqvi@palliumindia.org

Introduction: Less than 4% of needy patients receive palliative care services in India due to the lack of availability of these services, opiophobia in the medical fraternity, and overall lack of demand from the masses. This has led to a deeper need to develop palliative care services in every corner of India.

Aim: This study aimed to increase the presence of soothing care centres across India to cater to the needy population.

Methodology: Pallium India facilitation team of six Regional Facilitators, under the guidance of their Lead, work together, liaison with the National Health Missions, Directorate of Health Services, government hospitals, private medical institutes, and individuals to develop palliative care services in their settings. The teams work with both the government and non-government institutes, their officials, and the medical fraternity to create Outpatient, inpatient, and home care services depending on the available resources. The team facilitates training, handholding, implementation, budgeting, human resources recruitment, opioid access, and funding for the new budding centres.

Results: The team facilitated 111 palliative care centres across 21 states and four UTs in the last 3 years, working with the centres to enhance their quality of care, documentation, communication, and management of palliative care patients.

Conclusions: Through the facilitation and collaborative work, Pallium India is able to create more accessible palliative care services for needy patients, reaching out to them in the remotest areas like tribal region in Chhattisgarh, Himalayan regions of North East, areas outcasted for HIV patients and far off villages of many states.

Manisha Pawar¹, Sime Chacko², Jayatia Deodhar³, Shymali Poojary³, Rekha Kuchekar⁴

Department of ^1,2Oncology, ^3,4Palliative Care, Tata Memorial Hospital, HBNI University, Mumbai, City in Maharashtra, India.

Objectives: Primary: The objective of this study was to study the number and types of selected nursing interventions done in the past 6 months from the client’s records at the palliative care outpatient department (PC-OPD). Secondary (1): The objective of this study was to find out the medication, types of IV fluids, analgesics, and types of wound dressing advised from clients’ records at PC-OPD. (2) To evaluate the patient outcomes for the selected nursing interventions. (3) To find out the association with sociodemographic variables.

Material and Methods: Approval from IEC-II dated 5 September 2023 with project no 4270. After CTRI approval on 20 September 2023, data were collected. As per inclusion criteria were patients, records were screened from 21 September 2023 to 18 October 2023. Nursing intervention records and procedure book records maintained in the PC-OPD at Tata Memorial Hospital (TMH) were assessed. Nine hundred and three cases were reviewed, out of which 110 cases were rejected as per exclusion criteria. A Consent waiver form was approved. A total of 793 cases were analysed from the records. The exploratory analysis was performed using the Statistical Package for the Social Sciences version 25.

Results: The type of nursing intervention on pain variable showed maximum that patients had mild pain 439 (55.4%), followed by moderate pain 86 (10.8%) and severe pain 1 (0.1%). Opioids that were maximum used were Inj. Fentanyl 51 (6.43%). For the constipation variable, proctoclysis enema 18 (2.3%) had good results. Wound discharge 62 (7.8%), bleeding 59 (7.4%), foul smell 18 (2.3%) and bed sore dressing was required for 3 (0.4%). The analgesics that were used in maximum were Inj. PCM 246 (31.0%).

Conclusions: Nursing documentation had demonstrated a higher level of amenability in relation to nursing assessment with interventions of patients attending PC-OPD at TMH.

K. K. Fida Sherin¹, Rari Rahman¹, P. A. Ajisha¹, Shamsudheen¹, Uwais¹, Sahal Thafheem¹, Shinsi Kasim¹

¹Iqraa-Thanal Pain And Palliative Care Centre, Kozhikode, Kerala, India.

E-mail: fidasherinnkk@gmail.com

Introduction: Pain and Palliative Care, ‘a home, away from home’, was an initiative taken a few years back with a primary objective of commitment to holistic patient care and support, acknowledging that effective palliative care extends beyond medical interventions. The partnership aims to provide a continuum of support that encompasses not only the physical aspects of the patient’s condition but also attends to their emotional, social, and spiritual well-being by creating a unique ecosystem where expertise from both entities converges to provide comprehensive, patient-centered care. By combining the specialised services of a palliative clinic with the resources of a not-for-profit hospital, the collaboration ensures that patients receive a cohesive and patient-centric experience.

Aim: This study aimed to present the structure, demographics and pattern of providing holistic patient care of IQRAA pain and palliative care.

Methods: The centre works a collaborative program along with a not-for-profit hospital and an NGO within the city and takes care of about average of 300 patients per year. The basic principle follows need-driven health-care innovation.

Results: The initiative taken in August 2021 found a great place within the community and now what we experience is the development of a specialised palliative clinic with the infrastructure and resources of the not-for-profit hospital, which provides complete patient care 24 × 7. A total of 468 patients and 1174 home care visits have been recorded from 2021 to 2023. Of the total 250 patients registered this year, 48.8% came under the age category of 60–80 years, and 25.6% were above the age category of 80 years. The rest were between 40 and 60 years and below 20 years. About 29.2% were diagnosed with cerebrovascular accidents, onco-cases and chronic kidney disease were seen between 5% and 6%. Other conditions, along with neurological, came under 60%.

Conclusion: By promoting the integration of palliative care services across different healthcare settings, the collaboration sets a precedent for a more compassionate and inclusive healthcare system. The emphasis on holistic patient care not only improves the quality of life for individuals facing life-limiting illnesses but also serves as a model for future healthcare initiatives seeking to address the complex and interconnected needs of patients comprehensively.

Dipali Bhatt¹, Dinesh Kumar¹, Rekha Macwan²

¹Department of Community Medicine, Pramukhswami Medical College,

²Department of Palliative Care, SKH, Karamsad, Gujarat, India. E-mail: dipalibhatt40@gmail.com, drdineshkl@charutarhealth.org, rekhasm@charutarhealth.org

Introduction: Palliative care focuses on improving the quality of life for patients with serious life-limiting illnesses. By understanding patient patterns, healthcare facilities can anticipate future demand for palliative care services and optimise resource allocation.

Aim: By analysing historical data and trends, the aim is to accurately predict the future demand for palliative care services and to improve the overall quality of palliative care delivery to enhance the patient experience within an outpatient setting.

Methods: This is a retrospective analysis of case records from July 2016 to December 2022 from the palliative care outpatient department (OPD) at the tertiary care centre in Karamsad, Gujarat. For the historical data and trends, the total number of patients from each year (2016 to 2022) was classified into the group of new patients, old patients, and in-ward patients for reference. The data for telephonic conversations were captured, and the number of home visits was also counted. Analysis was performed using Epi Info 7 and Medcalc.

Results: Result was calculated in the form of numbers and visits of new patients, old patients, inward references, telephonic follow-up and home visits. The graphical representation was made for new patients, old patients, and inward references (A total of 2331, 7618, and 623 patients, respectively) from 2016 to 2022. A total of 1992 phone follow-ups were conducted to remind the patient of their follow-up visit and to know about their health conditions. Phone follow-up is very crucial to remind patients of their next visits, especially when they are on strong opioids. A total of 106 home visits were also conducted by palliative care physicians and nurses. A total of 179345 morphine tablets (10 mg) and 598 fentanyl patches (25 mcg/h) had been prescribed from 2016 to 2022 for pain management.

Conclusions: With time, the number of patients and the demand for strong opioids increases. The follow-up visits were improved, due to which there was a decrease in phone follow-up. The forecasting of OPD data enables healthcare facilities to optimise resource allocation to provide appropriate support for patients with serious illnesses.

Keywords: Forecasting of data, Resource allocation, Strong opioids, Home visit.

Reshma Sreekumar¹

¹Trivandrum Institute of Palliative Sciences, Pallium India, Thiruvananthapuram, Kerala, India.

E-mail: reshma.sreekumar@palliumindia.org

Introduction: Pain is a common symptom experienced by patients with cancer throughout the trajectory of their illness. A recent meta-analysis found that the overall prevalence of pain was 44.5%, and moderate to severe pain was experienced by 30.6% of the patients.

Aim: The aim is to find out the usage of various opioids prescribed for patients with pain, either for cancer or non-cancer pain management.

Methods: A retrospective analysis of the case sheets of patients during the period from 1 January 2023 to 31 October 2023 was done.

Results: A total of 5108 unique patients were under the care during the above period. 1413 (28%) patients received opioids, out of which 552 (39%) were given tramadol, and the rest, 891 (61%), received opioids for moderate to severe pain, which includes morphine, fentanyl, and methadone.

Conclusion: Opioids are the mainstay for the management of severe pain. The result of this study indirectly indicates that only 17.5% of patients experienced moderate to severe pain which is about 50% less than the prevalence from the meta-analysis. The limitation might be that it did not look at the recorded pain severity but looked at the consumption of opioids.

Vrinda Satija¹, Varun Yadav¹, Bhavna C. Patel¹, Priti Sanghavi¹

¹Department of Palliative Medicine, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India.

E-mail: vrinda.satija97@gmail.com;

Introduction: Functional or mechanical obstruction of intestine which prevents physiological passage of food through the bowel due to malignancy is referred to as malignant bowel obstruction (MBO). The extent of the disease and the underlying pathology determine whether the bowel obstruction is partial or complete. MBO is a very frequent and distressing outcome in patients with abdominal or pelvic cancer. Patients having MBO suffered from various distressing symptoms. When surgery is not feasible, comprehensive medical management is required to manage distressing symptoms of MBO as steroids have a central antiemetic, anti-inflammatory, anti-secretory, analgesic, and non-specific effect on general well-being, which can be beneficial when administered for MBO.

Aim: This study aimed to find out the usefulness of steroid therapy in patients having MBO.

Methods: Retrospective observational study of patients having MBO admitted under the palliative medicine department from 22 September to 23 August. After meeting the inclusion criteria, demographic data was collected on these patients. ESAS-r CSS tool was used to assess symptom severity at baseline and after 5 days of steroid therapy of dexamethasone 4 mg twice daily along with adjuvants.

Results: A total of 20 patients were recruited having MBO. The most common malignancy found were Intestinal (30%) and rectum (20%), followed by ovary (15%), cervix (15%), other abdominal malignancy (15%) and extra-abdominal (5%). According to severity, pain (7.25 ± 1.08), nausea/vomiting (7.05 ± 1.24), constipation (7.6 ± 1.46), loss of appetite (5.15 ± 1.68), and insomnia (4.6 ± 1.95) found most severe. After 5 days of treatment with steroids, the severity of pain (2.5 ± 1.56) and nausea/vomiting (1.95 ± 0.97) were reduced significantly in the majority of patients. Constipation was reduced in 20% of patients.

Conclusion: Steroid therapy was found useful in the palliative treatment of MBO to reduce burdensome symptoms.

J. Snowin Delphy Clara¹, T. Arthi¹, P. J. Mary Shilpa¹, Sherene Daphne Joshua¹, Nandhini¹

¹Golden Butterflies Children’s Palliative Care Foundation, Chennai, Tamil Nadu, India.

E-mail: clara.gb2020@gmail.com

Introduction: Child patients with life-limiting or life-threatening conditions seldom have opportunities to enjoy their childhood, nor do their caregivers have respite from grueling treatment schedules. ‘Recreational Activities’ of Music Evening, Movie Evening, and Yoga Session are monthly activities happening at the Institute of Child Health and Hospital for Children – Government Hospital since June 2023. Nearly 300+ child patients and caregivers participated in these activities, comprising a minimum of 20–25 participants in each session.

Aim: This study aimed to understand if ‘Recreational Activities’ achieved its stated objective and to learn about the participants’ well-being.

Methods: Feedback was sought on five questions from ten child patients and caregivers.

Results: Caregiver respondents were aged 30–45 years (seven females and three males), while child patients were aged 6–14 years (six females and four males). The children were undergoing treatment in the Oncology, Surgery, Nephrology, Cardiology, and Haematology departments at the Government Hospital in Chennai. Five respondents enjoyed all three recreational activities. The majority of the child patients felt that movie and music evenings were more interesting than yoga sessions. Seven child patients expressed a longing for these kinds of days inside the hospitals, away from medications and injections. All the caregivers were very happy about the activities, and they were overwhelmed seeing their children being happy. Caregivers expressed that they were relaxed during the yoga sessions.

Conclusion: The recreational activities of music, movies, and yoga showed that self-care was more important and that laughter is a good medicine not only for children but also for caregivers and families.

Vaisakh Haridas¹, Saurabh Vig¹

¹Department of Oncoanesthesia and Palliative Medicine, AIIMS New Delhi, Delhi, India.

E-mail vaisakhth@gmail.com, saurabh377@yahoo.com

Introduction: Malignancies of the aerodigestive tract (head and neck and oesophagus) have a significant contribution to cancer burden all over the world. These types of cancers accounted for 9.2% of new cancer cases in the year 2020. As per our literature search, no study has focused on enteral feeding modalities and their long-term use to relieve dysphagia in head and neck and oesophageal cancer patients with no curative intent available and on supportive care. Thus, we plan a study to follow-up this subgroup of patients.

Aim: This study aimed to study the feeding practices and their associated outcomes in advanced aerodigestive tract malignancies in patients on supportive care presenting to outpatients and inpatients.

Methods: This study is an ambispective and observational study. After obtaining ethical clearance and CTRI registration (no: CTRI/2023/10/05925), the study was started in October 2023. Both retrospective and prospective data will be collected. Type of feeding, adequacy of nutrition assessed by weight of the patient, complications of the procedure, total expenditure of procedure, patient satisfaction using mod EORTC questionnaire, and caregiver satisfaction will be assessed.

Results: Since this is an ongoing study, results will be drawn after including the patients during the time of presentation.

Conclusion: The study is under scrutiny and conclusions will be drawn during the time of presentation.

I. Arockiamary¹, Aashima Mria Johnson¹, Alena Paul¹, R. Sowmiya¹, Abirami Prem¹

¹KMCH College of Nursing, Coimbatore, Tamil Nadu, India. E-mail: arockiamary@kmchcon.ac.in

Case Report: A case of a 71-year-old male came with acute exacerbation of chronic obstructive pulmonary disease and a history of breathlessness for 6 years aggravated by walking, relieved by rest and medication, progressive, increased past 2 months, H/O cough – 2 months, sputum scanty, white, not foul smelling, not blood-stained, H/O Left shoulder pain – 1 month not radiating and relieved by pain medicines. History of the stage -I lung carcinoma (right middle carcinoma lung) and radiotherapy received; there is a history of recurrent hospital admission for breathlessness treated with O2, salbutamol inhaler, and antibiotics. He has a personal history of a mixed diet, has been a smoker for 20 years, stopped 30 years ago, has reduced appetite, and sleep disturbance present. He was supported by his wife, had no children, no income, source of income was bank savings, worried about the future, had chronic insomnia, was worried about breathlessness, and was afraid to live alone. Non-pharmacologic strategies such as fan therapy, exercise programs, and pulmonary rehabilitation can also be beneficial. In addition, this poster presentation will describe the holistic aspects (physical, psychological, social, and spiritual) of palliative care in the ward.

Lakshmi Haritha¹, Jenifer Jeba Sundararaj¹, Shanthi Prasoona Thotampuri¹, Jewell Joseph¹, Balamugesh Thangakunam²

Departments of ¹Palliative Medicine and ²Pulmonary Medicine, Christian Medical College, Vellore, Tamil Nadu, India.

E-mail: kgharee@gmail.com

Introduction: Sjogren’s syndrome is a slowly progressive chronic systemic autoimmune disease. Pulmonary manifestation occurs in 10–20% with dyspnoea (62%) and cough (54%) being the predominant symptoms. Cough can occur due to dry airways, interstitial lung disease, non-Hodgkin’s lymphoma, pleural effusion, and pulmonary embolism. Opioids through central anti-tussive action, Gabapentin through central desensitisation, and inhaled lidocaine through inhibition of cytokine production can help with the relief of cough.

Aim: This study aimed to highlight the need to integrate palliative care in the management of Sjogren’s syndrome and ensure good symptom relief.

Methods: This study was a case report.

Results: We report a 74-year-old man with Sjogren’s syndrome and associated interstitial lung disease with progressive distressing incessant dry cough and grade 1 mMRC dyspnoea for 3 months. He was started on systemic steroids equivalent to prednisolone 0.5 mg/kg once daily and a combination of inhaled corticosteroids and long-acting beta-2-agonists. Even after 3 weeks of treatment, there is no relief from the distressing cough. He was already on treatment with proton-pump inhibitors for probable gastro-oesophageal reflux disease. Specialist palliative care consultation was requested for symptom relief. Codeine could not be given since only a combination with anti-histamine preparation is available, and it worsens mucosal dryness. He was, hence, commenced on oral morphine (30 mg/day), 2% lignocaine nebulisation, and gabapentin (600 mg/day), after which he had satisfactory relief of cough (>50%).

Conclusion: Symptoms associated with Sjogren’s syndrome, especially cough, can be distressing. Alongside disease-directed treatment, an intensive multi-strategic approach to palliate cough should be undertaken. Integration of palliative care in the management of Sjogren’s syndrome should be considered.

Aanchal Arora¹, Anurag Gola², Vignesh Loganathan³, Subitha Lakshminaryanan², Sitanshu Sekhar Kar²

¹Department of Community Medicine, PGIMER, Chandigarh, Departments of ²Preventive and Social Medicine and ³Radiation Oncology, JIPMER, Puducherry, India.

E-mail: aanchalarorabh8@gmail.com, golaanurag@gmail.com, vkylogs@gmail.com, drsitanshukar@gmail.com

Background: Hypertension is a leading cause of premature deaths, with cardiovascular diseases (CVDs) accounting for one-third of total deaths in India. The prevalence of hypertension in the country is 29.8%, and only 12% of those affected have their blood pressure under control (<140/90 mm Hg), which can lead to life-threatening complications.

Objective: The objective of this study was to estimate the control status among adult patients with hypertension at a selected rural primary health centre in Puducherry from January 2019 to December 2022. A cohort analysis approach was employed.

Methods: All 505 registered patients living with hypertension were followed retrospectively and prospectively over the duration. Records were reviewed, and monthly blood pressure readings from 2019 to 2022 were recorded, assessing control status at 6 and 9 months for each quarter.

Results: Of the total registered patients (505), 41.2% were male, and 58.8% were female, with an age range of 31–88 years. Common comorbidities included diabetes and other heart diseases, with 9.9% lost to follow-up. As of December 2022, only 53% of patients had controlled blood pressure. Quarter-wise control status varied, with the prevalence of controlled hypertension ranging from 51.9% to 64.5% at 6 months and 52.5% to 65.4% at 9 months in 2019. Similar patterns were observed in 2020 and 2021.

Conclusion: Addressing health determinants and implementing systematic monitoring can enhance the control status of hypertension, as currently, only half of the patients seeking treatment have their blood pressure adequately controlled.

G. Vinothini¹, S. Republica¹, K. Gauthaman¹

¹RMD Group of Hospitals and RMD Pain and Palliative Care Trust, Chennai, Tamil Nadu, India.

E-mail: rmdacademcyforhealth2019@gmail.com

Introduction: Endometrial carcinoma (EC) is the most prevalent gynaecological cancer and is a major cause of morbidity and mortality. Its diagnosis and management require inter-professional teamwork.

Aim: This study was the institution of palliative care (PC) in a patient suffering from endometrial carcinoma (EC) by a multi-disciplinary team to reduce the burden of disease and enhance the quality of life (QoL) of both patients and caregivers.

Methods: A 70-year-old female presented with abnormal vaginal bleeding, unbearable pelvic pain, lymphedema, foul-smelling vaginal discharge, severe anaemia, with comorbidities including type 2 diabetes mellitus and hypertension. Speculum examination revealed increased endometrial thickness (12 mm). Tissue biopsy and histopathology revealed endometrial adenocarcinoma with cervical stroma and vaginal invasion. Lactate dehydrogenase was elevated. Magnetic resonance imaging and positron emission tomography scan confirmed a stage-II endometrial carcinoma (EC) based on FIGO classification.

Results: The patient and family members were counselled and explained the importance of early intervention for the prevention of pain and secondary infection. The patient gained trust and courage to undergo a total abdominal hysterectomy with bilateral salpingo-oophorectomy. Adjuvant radiation therapy was given. Lymphedema was substantially reduced. A major challenge was bladder catheterization due to vulva oedema and obstruction secondary to infection and discharge. Continued vaginal washes, antibiotics, and antimycotics reduced infection and foul discharge. Blood transfusion bladder and bowel care were provided. Blood sugar and hypertension were kept under control. The interdisciplinary team effectively managed pain, relieved incapacitating symptoms, and also provided psychosocial support and spiritual care.

Conclusion: Early institution of PC in a patient suffering from EC helped in the reduction of the disease burden and effectively controlled pain, which greatly improved the QoL of both the patient and her caregivers.

Keywords: Endometrial carcinoma, Palliative care, Quality of life, Psychosocial, Spiritual.

Rajika Kurup¹, P. V. Anusree¹

¹Pallium India, Thiruvananthapuram, Kerala, India.

E-mail: rajika.kurup@palliumindia.org, anusree.pv@palliumindia.org;

Introduction: Various life-limiting illnesses cause pain due to nerve involvement. An alternative form of therapy called guided imagery, a body-mind intervention, has been found effective when provided along with other pain medications.

Aim: This study aimed to identify the impact of guided imagery therapy in a patient with traumatic paraplegia having neuropathic pain.

Methods: Five sessions of guided imagery were done, during which the patient was given instructions to visualise certain pictures and imagine appropriate sounds. Each session was conducted for about 45 min by a trained clinical psychologist. The pain scores were assessed before and after each session.

Results: The patient was a 35-year-old male having traumatic paraplegia after a fall from a tree. He was on multiple medications for neuropathic pain, despite which adequate pain relief was not being achieved. Five sessions of guided imagery therapy were done as described above. The average pain score before the session was found to be nine out of ten. Whereas, after the session, the average pain score had reduced to five out of ten.

Conclusion: Guided imagery may be effective as a supplementary therapy to the other conventional treatment done for neuropathic pain. Further studies need to be done to explore the effectiveness of this technique.

Archana Vajjala¹

¹Department of Palliative Medicine, MNJ Institute of Oncology and Regional Cancer Centre, Hyderabad, Telangana, India.

E-mail: archana.vajjala@gmail.com; Mobile: 9491111066

Introduction: People who identify as transgender (trans) or another gender-diverse identity are heavily marginalised populations in health and social care systems. Healthcare workers of late have started to pay more attention to the healthcare experiences of LGBT patients and caregivers in oncology concerning their needs.

Need and Support Strategies: Trans patients experience a broad range of health disparities, leading to devastating health outcomes such as discrimination and biased care. Understanding the LGBTQ patient’s medical needs is essential for a holistic approach (patient-centred). Follow an evidence-based approach to total pain and symptom management with considerations of sociocultural and mental health factors. Proactive referrals of patients and families/caregivers to other members of the interprofessional palliative care team. Engage patients and families/caregivers in ACP discussions.

Challenges: The long-standing prejudice, stigma, discrimination, and oppression have resulted in delays and avoidance in seeking medical care, disparate physical and mental health outcomes, and mistrust of the healthcare system.

Barriers: Gaps in competency training for providers, paucity in research studies, variable resource allocation, financial constraints, and non-protective regulatory policies and practices.

Conclusion: LGBT patients and their caregivers have unique needs related to palliative care. A holistic team-based approach coupled with empathic communication and a non-judgmental mindset are fundamental steps that can offer an effective, successful and trusting relationship to both patients and caregivers is the key to providing competent and effective care.

Sajjan¹

¹Pallium India, Thiruvananthapuram, Kerala, India. E-mail: sajanvs4080heavenly@gmail.com

Introduction: Pallium India, a palliative care facility in southern India, introduced the concept of an implementation team, which includes a nurse with adequate experience and track record, travels to another palliative care centre to provide technical expertise and to demonstrate various palliative care interventions to the host team.

Aim: This study aimed to enumerate the technical expertise provided by a nurse as part of a palliative care implementation team to a host palliative care facility

Methods: The concept of the Implementation Team was developed and informed to various palliative care organisations. Perceived needs related to nursing care were asked for from interested facilities. The implementation team, with an experienced nurse, travelled to the host facility, where an exchange of knowledge and practices was facilitated.

Results: A palliative care facility in the northeastern state of Assam was supported with knowledge about the documentation, storage, and dispensing of various opioids, carrying morphine in a home care service setting, and giving a morphine trial to those with life-limiting illnesses in acute severe pain. Furthermore, the role and technique of subcutaneous injections and infusions in a palliative care setting were discussed and demonstrated. The method to organise a home care kit for easy storage and transport of medications and items required for nursing procedures like catheter insertion and wound cleaning was also reviewed.

Conclusion: Utilising an implementation team may offer an effective educational approach, providing hands-on training for a host team to implement nursing techniques in the practical aspects of their specific setting.

Vidya Viswanath¹, Priyanshu¹, Dolorosa Fernandes², Dharun Prasad², Alisha Karim¹, Neeharika Alapati³, Gayatri Karnik⁴, Raviteja Miriyala⁵

Departments of ¹Palliative Medicine, ²Preventive Oncology, ³Medical Oncology, ⁴Onco-Physiotherapy, ⁵Radiation Oncology.

Background: Cancer-related fatigue (CRF) is one of the most prevalent symptoms in patients with cancer, and non-pharmacological interventions (NPI) are the first line of management. In 2022, an audit was done to study the documentation of fatigue and NPI in 2021 and 2022. In 2021 (n = 391), 67% had fatigue documentation with no documentation of NPI. In 2022 (n = 433), 84% had fatigue documentation, and NPI was done in 34%. A standard operating procedure (SOP) was implemented to improve the documentation of CRF and NPI to a set standard of 100%, and this study was conducted with the aim of evaluating the effectiveness of the SOP.

Methodology: Along with the implementation of SOP, the departmental staff was trained and sensitised regarding the documentation of CRF and NPI. The data were collected for adult patients with a diagnosis of cancer over two periods: A month after the introduction of SOP for 2 consecutive months (February and March 2023) and again after 8 months (September 2023). Data analysis was done using Epi Info software.

Results: In the first round (Feb/March 2023), documentation of CRF and NPIs was found to be 93.4% and 87.9%, respectively. In the second round, the respective documentation rates were 96.7% and 86.5% for CRF and NPI. Common symptom clusters associated with CRF were loss of appetite (P < 0.01), loss of well-being (P < 0.01), and breathlessness (P < 0.001).

Conclusion: Implementation of SOP and sensitization of staff resulted in substantial and sustainable improvement in documentation of cancer-related fatigue and non-pharmacological interventions, and consequently a better understanding of symptom clusters.

Keywords: Cancer-related fatigue, Non-pharmacological interventions, Audit cycle.

Vidya Viswanath¹, Alisha Karim¹, Priyanshu¹, Dolorosa Fernandes², Dharun Prasad², Rohit Vadgaonkar³, Raviteja Miriyala³

Departments of ¹Palliative Medicine, ²Preventive Oncology, ³Radiation Oncology, Homi Bhabha Cancer Hospital and Research Centre, Visakhapatnam, Andhra Pradesh, India.

E-mail: karim.alisha07@gmail.com

Introduction: Management principles are based on the empirical Breathing-Thinking-Functioning model with non-pharmacological intervention (NPI) as the first line of treatment for chronic breathlessness. In 2022, an audit was done to study the documentation of breathlessness and NPI in 2021 and 2022. In 2021 (n = 391), 68% had documentation of breathlessness with no documentation of NPIs. In 2022 (n = 433), 80% had documentation of breathlessness, and NPI was done in 16%. A standard operating procedure (SOP) was implemented to improve the documentation of breathlessness and NPI to a set standard of 100%, and this study was conducted with the aim of evaluating the effectiveness of the SOP.

Methodology: Along with the implementation of SOP, the departmental staff was trained and sensitised regarding the documentation of breathlessness and NPI. The data were collected for adult patients with a diagnosis of cancer over two periods: A month after the introduction of SOP for 2 consecutive months (February and March 2023) and again after 8 months (September 2023). Data analysis was done using Epi Info software.

Results: In the first round (February/March 2023), documentation of breathlessness and NPI was found to be 93.4% and 91.4%, respectively. In the second round, the respective documentation rates were 96.7% and 93.5%. Common symptom clusters associated with breathlessness were fatigue (P < 0.0005) and anxiety (P < 0.00001).

Conclusion: Implementation of SOP and sensitisation of staff resulted in substantial and sustainable improvement in documentation of breathlessness and non-pharmacological interventions and, consequently, a better understanding of symptom clusters.

Keywords: Breathlessness, Non-pharmacological, Breathing functioning thinking model, Audit cycle.

V. Vikram¹, Republica Sridhar¹, K. Gauthaman¹

¹RMD Group of Hospital and RMD Pain and Palliative Care Trust, Chennai, Tamil Nadu, India.

E-mail: rmdacademyforhealth2019@gmail.com

Introduction: In healthcare, situations of breaking the bad news (BBNs) do happen while caring for patients (adults or children) suffering from life-threatening illnesses, including cancer and chronic neurological, renal, or endocrine disorders.

Aim: This study aimed to effectively convey the bad news and help the family members overcome grief and cope with bereavement.

Case Report: A 5 y/m child who had a known case of relapsed acute lymphoblastic leukaemia (B-ALL; T1:19) was treated with chemotherapy and immunotherapy (Bortezomib). The minimal residual disease was 16%. The patient suffered from high fever, acute kidney injury, pancreatitis, and septic shock. Morphine and fentanyl were used for pain control and dexmedetomidine for sedation. Given the disease’s refractoriness and poor prognosis, the family opted for palliative care at home.

Results: The general condition continued to deteriorate, and the patient suffered from high fever spikes and continuous pain. Symptomatic treatment and pain control were continued with morphine and/or fentanyl infusion and sedation. The patient survived for 20 days in home care settings. The palliative care (PC) physician meticulously followed the ‘SPIKES’ protocol to counsel the family members. Detailed explanation led to a better understanding of the disease and care provided, which helped the family members to overcome grief. The PC team continued their follow-up with the family during and after bereavement to facilitate optimal coping.

Discussion and Conclusion: Caring for a young patient with refractory cancer with having grave prognosis is challenging. BBN in home settings with patients being surrounded by family members, relatives, and caregivers is not an easy task. Following established protocols is it in pain management, or BBN is imperative.

Keywords: Leukaemia, Chemotherapy, Palliative care, Pain management, Counselling.

Suhana Sulfiker¹, Sushma Bhatnagar¹

¹Department of Onco-Anaesthesia and Palliative Medicine, AIIMS, New Delhi, Delhi, India.

E-mail: suhanasulfiker@gmail.com

Introduction: A palliative care consultation service (PCCS) helps the primary treating physician by providing medical recommendations, which are crucial in-patient care. An established palliative care department requires a PCCS in addition to outpatients and inpatient wards.

Aim: We aimed to evaluate the need and reach of PCCS to various departments in our hospital.

Materials and Methods: This is a retrospective single-centre observational study, which is being conducted at B.R.A. IRCH New Delhi for a period of 1 year in 2022. We included inpatient consultations received in the palliative medicine department from various speciality departments of AIIMS, New Delhi, over this period. Patient characteristics and symptom burden were assessed from the medical records.

Results: PCCS received calls varying between 60 and 137/month with an average of 75. A total of 903 patients were referred to PCCS by various departments, which include 427 males and 476 females, with their mean age being 57.4 ± 2.3. The majority of calls were received from medical oncology (37.8%) and radiation oncology (31.1%). Among non-oncological departments, a maximum number of calls were received from general medicine (36), pulmonary medicine (29), geriatrics (25), and neurology (19). A minimum number of calls was from the surgical department. The most common indication for referral was pain (76.2%), prognostication (32.4%), and end-of-life care initiation (18.6%). Less common indications included dyspnoea, nausea, and vomiting, constipation, fatigue, malignant wound, anxiety, and depression.

Conclusion: PCCS highlights the importance of integration of palliative medicine with other specialties for improving the quality of patient care. Similar model of care should be started at all levels of public health-care delivery system.

Pallavi Ghosh¹, Praveen Kumar Kodisharapu¹, Praneeth Suvvari¹

¹Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India.

E-mail: pallavighosh94@gmail.com, drprawin78@gmail.com, praneethsuv@gmail.com

Introduction: Amyotrophic lateral sclerosis (ALS) is an incurable, neurodegenerative disease of the motor neurons.^[1] Patients suffer from voluntary muscle paralysis, including loss of ability to swallow, walk, and eventually breathe.^[2] Alongside these dramatic physical changes, patients and their families confront numerous emotional, social, and spiritual challenges.^[3] Multifaceted needs of ALS patients and family needs multidisciplinary care with specialist palliative care physicians. However, no broadly accepted guidelines define the optimal integration of palliative care into existing clinical frameworks.^[4] In fact, most patients with ALS never interact with a specialist palliative care team at any point.^[5]

Aims: This study aimed to Establish the Effectiveness of Earlier Integration of Palliative Medicine in the management of ALS.

Methods: At the time of admission in HOSPICE, the intention was End of Life care. The patient was on continuous non-invasive ventilation (NIV) support (up to 15 L/min) and completely bedbound with psychological issues and severe caregiver burden. Over the course of 6 months, multiple supportive medications were started and titrated, but significant change was seen with anabolic steroids, initiation of opioids, and rigorous counselling. Facilitation of autonomy and self-reliance seemed the key to miraculous recovery.

Results: The patient at the time of discharge had motor power of 4/5 and only occasional NIV support. She was able to perform activities of daily living with minimal aid. She had a positive outlook and hoped for a peaceful, painless death.

Conclusion: Earlier integration of palliative care in the management of ALS can lead to significant improvement in quality of life in the physical aspect and also in psychological, spiritual, and caregiver aspects.

REFERENCES

1. Amyotrophic Lateral Sclerosis. In: StatPearls. Available from: https://ncbibookshelf (nih.gov) [Last accessed on 2024 Mar 12].

2. ALS Association. What is ALS? Available from: https://www.alsa.org/about-als/what-is-als.html [Last accessed on 2020 Feb 06].

3. Kukulka K, Washington KT, Govindarajan R, Mehr DR. Stakeholder Perspectives on the Biopsychosocial and Spiritual Realities of Living with ALS: Implications for Palliative Care Teams. Am J Hosp Palliat Med 2019;36:851-57.

4. Bede P, Oliver D, Stodart J, Van den Berg L, Simmons Z, O Brannagáin D, et al. Palliative Care in Amyotrophic Lateral Sclerosis: A Review of Current International Guidelines and Initiatives. J Neurol Neurosurg Psychiatry 2011;82:413-8.

5. Washington KT, Kukulka K, Govindarajan R, Mehr DR. Engaging Specialist Palliative Care in the Management of Amyotrophic Lateral Sclerosis: A Patient, Family, and Provider-Based Approach. J Palliat Care 2022;37:170-6.

Break-through Pain Episodes with Relevant Rescue Dose of Opioid Medications in an Inpatient Setting at a Tertiary Care Hospital

Kalaivani Ravichandran¹, Anu Abraham¹, Nikhila Karanth¹, Nandini Vallath¹

¹Department of Pain and Palliative Care, St. John’s Medical College and Hospital, Bengaluru, Karnataka, India.

E-mail: kalaivani2000ravi@gmail.com, anuabraham510@gmail.com, nikhilakaranth@gmail.com, nandini.vallath@stjohns.in

Introduction: Breakthrough pain (BTP) refers to the pain that ‘breaks through’ a baseline level of analgesia. Types of BTP are spontaneous BTP, end-of-dose pain and incident pain. Management of BTP is by rescue dose of analgesic (20% of 24 hour dose).

Aim: This study aimed to assess and improve the adequacy of management of BTP with a prescribed rescue dose of analgesic.

Methodology: Being a standards-based audit, we measured the percentage of adequacy by reviewing the inpatient files. The audit standard was set at 100% which required that every instance of BTP was responded to adequately. An initial audit was performed on 30 inpatient files over 2 months. Barriers were noted. Interventions were planned to create suitable awareness at different levels – (i) physicians, (ii) nurses and (iii) patients over 2 months. Reaudit was performed on 30 inpatient files over 2 months.

Results: About 58% of the inpatient files showed adequate management of BTPs in the initial audit, which improved to 80% in the re-audit. Although there was significant improvement in the re-audit compared to the initial audit, we were unable to achieve the set standard.

Conclusion: Through this audit, we learnt that there are complex barriers at multiple levels to ensure adequate management of BTPs. This necessitates regular quality improvement measures.

Richa Geo¹

E-mail: richageokottackal@gmail.com; Mobile: 8078038122

Introduction: Palliative medicine (PM) is an emerging new subspecialty. One of the main reasons for a smaller number of referrals to PM could be a misperception of PM among other doctors.

Aim: The aims of this study were as follows: (1) To understand the perspective of PM among other speciality trainees in a South Asian Teaching Hospital after 1 year of the introduction of a post-graduate training program. (2) To demonstrate whether there is a relationship between the perspectives and referrals to the PM department from other specialities.

Methodology: Design – Mixed method study. Sample – Postgraduate trainees of other specialities. Method – A survey questionnaire with 17 questions and an open-ended question was administered. Analysis – Analysis of quantitative aspects of the survey conducted using descriptive statistics and thematic analysis for the qualitative aspect.

Results: Seventy percentages of the residents’(n = 63/90) perception of PM changed for the better after interaction with PM postgraduate trainees. The total score, which was calculated to understand the perception through 12 quantitative questions, cumulated a mean of 48.12 (±5.039), which is more than the median of 30.5, which indicated a good perception. The score of perceptions of participants from departments with the maximum number of referrals (oncology departments) was 48.88 (±5.071), and other departments (non-oncology) were 47.96(±5.052). The main themes from the thematic analysis of qualitative data emphasised the need for more centres to start training in PM to spread awareness about PM to more doctors.

Conclusion: In a tertiary multi-speciality teaching hospital with oncology and non-oncology speciality departments, perception of PM was found to be good after interaction with palliative medicine PGs. Although oncology PGs had a slightly better perception compared to non-oncology PGs.

N. Sangeetha¹, Jenifer Jeba Sundararaj², Anu Susan Mathew¹, Seema Rao¹, Shirley Lewis³

¹KIPCER- Bangalore Hospice Trust – Karunashraya, Bengaluru, Karnataka,

²Department of Palliative Medicine, Christian Medical College, Vellore, Tamil Nadu, ³Department of Radiotherapy and Oncology Kasturba Medical College, MAHE, Manipal, Karnataka, India.

E-mail: sangeetha.n@karunashraya.org

Introduction: Implementation of a robust end-of-life care plan for patients with advanced illnesses is critical for enabling dignified death. The Care Plan for the Dying Person (CPDP) was developed in the hospice to standardise the provision of end-of-life care.

Aim: This study aimed to assess the implementation and documentation of the CPDP in the hospice.

Methods: Patients nearing the end of life are enrolled in the CPDP, which has several components, including recognising dying, symptom assessment, communication of prognosis and care plan and spirituality. A retrospective audit of the medical records of patients who died in the hospice in August 2023 was conducted. The standard for compliance with the CPDP for this audit was set as 80%.

Results: Sixty-four patients with advanced cancer died in August 2023. Dying was recognised in only 53.1% (n = 34) who were then enrolled into the CPDP. Among those enrolled, nurses were part of the multidisciplinary EOLC decision-making in 73.5% (n = 25). Symptom burden was documented in 47.1% (n = 16). Communication of prognosis with caregivers and patients was documented in 94.1% (n = 32). Communication of the care plans, including preferred place of death and after-death care, was documented in 69.5% (n = 24). Spiritual concerns were assessed and documented in 97% (n = 33).

Conclusion: The findings reveal a large gap in the recognition of dying, symptom assessment and communication of CPDP, which did not meet the audit standard. This highlights the need to deliberate on reasons for non-compliance and strategies to improve the implementation and documentation of EOLC practices in the hospice.

Keywords: End-of-life care, Cancer, Nursing, Hospice, Audit.

Satya Sita L. Kavalipurapu¹

¹Sparsh Hospice, Hyderabad, Telangana, India. E-mail: training@sparshhospice.org

Introduction: The significance of palliative care in healthcare settings has grown due to its holistic approach to addressing the multiple dimensions of total pain. To ensure its effectiveness, continuous and regular training is essential for the multidisciplinary team involved, including volunteers and caregivers, enabling them to provide comprehensive and compassionate care to patients in need.

Aim: This study aims to evaluate the effectiveness of well-structured and self-paced training programs in bridging knowledge gaps, enhancing skills, building capacities and exploring self-coping techniques for ethical dilemmas in palliative care.

Methods: The learning outcomes of each training programme have been assessed through evaluations and surveys conducted at the beginning and end of the training program.

Results: Based on the evaluations and surveys conducted, a notable improvement in understanding the concepts and the ability to deliver palliative care has been determined. The baseline and end-line study conducted for each training program validates the enhancement of participants’ skills and potential, resulting in a comprehensive approach to delivering high-quality care to the patients. As a result of the training, individuals who have been trained can now effectively work in their capacities, offering confident and competent support to patients in urban or rural settings.

Conclusions: Investing in standardised palliative care training with increased resources is necessary to address existing gaps. Affordable training courses, including simplified vernacular versions, should be introduced. With the expansion of training programs, palliative care can emerge as a potential career path in various geographical locations.

Rajeev Shrestha¹, Ruth Powys¹, Daniel Munday¹

¹INF Green Pastures Hospital, Pokhara, Nepal.

E-mail: rajeev.shrestha@nepal.inf.org, ruth.russell@inf.org, daniel.munday@inf.org

Introduction: The 2017 Nepalese National Strategy for Palliative Care is committed to universal palliative care provision. It stated all patients should have access to essential palliative care medicines recommended in 2007 by the International Association for Hospice and Palliative Care (IAHPC). However, a recent study revealed that not all listed medicines are available in Nepal or included on various government medicine lists. The more restricted Lancet Commission-recommended medicines in 2017 are available in Nepal. To ensure medicine availability, a comprehensive list and an advocacy strategy needed to be considered.

Aim: This study aimed to develop a palliative care formulary list for Nepal using expert consensus.

Methods: A six-step process was used: (1) Development of guiding principles by a core group of palliative medicine specialists and consultant pharmacists. (2) Development of data collection form incorporating IAHPC and Lancet commission list. (3) Form sent and feedback collected from international experts. (4) Meeting of national experts to discuss medicines for inclusion. (5) Drafting of an interim list of suggested medicines. (6) Interim list circulated for final consensus from national experts.

Results: Five of nine international palliative care experts approached and provided suggestions through email. Eleven national experts attended a meeting to discuss medical inclusion. The final consensus list is currently almost complete.

Conclusions: It has been possible to achieve consensus for a palliative care formulary list using a robust method. The list will facilitate symptom control guidelines and training resource development. Further, work will develop a formulary including defined dosage, advice on use, where each medicine should be available in the health system.

Jewell Joseph¹, Jenifer Jeba¹, K. Anitha Gladys¹, Ramu Kandaswamy¹

¹Department of Palliative Medicine, Christian Medical College, Vellore, Tamil Nadu, India.

E-mail: jewelljosh@gmail.com, jenifermugesh@yahoo.com, anithagladys06@gmail.com, ramusw@gmail.com

Introduction: Purple urine bag syndrome is an uncommon condition that occurs in patients with long-standing indwelling urinary catheters due to urinary tract infection (UTI) by bacteria producing sulfatase or phosphatase enzymes. This results in the formation of the pigments indigo (blue) and indirubin (red), together providing a purple appearance to urine. We report a patient with vertebral metastases from papillary thyroid cancer who developed purple urine bag syndrome.

Aim: This study aimed to highlight the importance of purple urine bag syndrome as a marker of underlying UTI, even in the absence of typical signs and symptoms.

Methods: This study was a case report.

Results: (Case Presentation). We report a man in his late 50s with paraplegia due to vertebral metastasis on a latex urinary catheter for 8 months, who, on the home visit by the specialist palliative care team, was found to have purple-coloured urine. Purple urine bag syndrome was diagnosed. The urinary catheter and collection bag were changed and urine culture was done, which grew pseudomonas aeruginosa, proteus vulgaris and citrobacter diversus. Based on antibiotic sensitivity, he was treated with oral amoxicillin-clavulanate 625 mg TID and levofloxacin 500 mg OD for 7 days. Catheter care was reinforced, following which the urine colour was reversed.

Conclusion: Although rare, purple urine bag syndrome can be alarming to the patient and family. Management includes a change of catheter and appropriate antibiotics. Purple urine bag syndrome is an indicator of underlying UTI, especially among palliative care patients on long-term catheterisation, who may not manifest classical signs and symptoms of UTI.

Shakeel¹, Rari Rahman¹, Sahal Thafheem¹, Shinsi¹, Najeeb¹, Shamsudheen¹

¹IQRAA Thanal Pain and Palliative Centre, Kozhikode, Kerala, India.

E-mail: shakeelkacs@gmail.com

Introduction: This paper unveils a transformative palliative care model presenting robust data on the vital role of physiotherapy in addressing the dynamic needs of palliative patients across inpatient and outpatient with a special focus on home care settings.

Aim: The study highlights the vital role of physiotherapy in palliative care, focusing on a patient-centred model. Transitioning seamlessly between hospital and home care, the analysis reveals a 50% improvement rate for initially worsening cases and a 35.9% improvement for static cases post-physiotherapy. This underscores the significance of physiotherapeutic interventions in positively impacting the physical health status of palliative care patients.

Methods: Our innovative model incorporates specialised physiotherapy rounds in designated hospital wings, proactive physio referrals in outpatient settings and a personalised home care approach within a 15-kilometre radius. Data-driven comprehensive assessments guide physiotherapy plans, ensuring sustained positive outcomes with meticulous follow-up activities.

Results: Demonstrating the model’s success, our data highlights impactful physiotherapeutic interventions addressing a spectrum of conditions, including cancer (38%), neurological disorders (24%), musculoskeletal challenges (15%) and geriatric issues (8%). Physiotherapists emerge as pivotal contributors, averting potential treatment pitfalls and providing tailored interventions for enhanced patient outcomes.

Conclusions: This integrated palliative care model, anchored by physiotherapy, represents a nuanced and patient-centred approach. By seamlessly bridging hospital and home care, the model showcases adaptability to evolving patient needs, thereby ensuring compassionate and effective palliative care delivery.

Unlike the traditional palliative medical team, which typically comprises doctors and nurses, the integrated palliative team, will include social workers, physiotherapists and speech and language pathologists to address both the physical and psychological well-being of the patients.

H. M. Preethi¹, Deepak Sudhakaran¹

¹Trivandrum Institute of Palliative Sciences, Pallium India, Thiruvananthapuram, Kerala, India.

E-mail: preethi.hm@palliumindia.org, deepak.sudhakaran@palliumindia.org

Aim: The aim of this study was to assess the education support provided by a palliative care facility to children of families affected by life-limiting illnesses.

Methods: A retrospective secondary data analysis of the education support provided to children of families affected by life-limiting illnesses from the years 2018 to 2023 was done. The Statistical Package for the Social Sciences was used for analysis.

Results: Over a period of 3 years, education support was provided to 396 students belonging to families adversely impacted by life-limiting illnesses. Out of these, 46% of the students belonged to the general category, 43% belonged to other backward communities, and 11% belonged to scheduled castes/tribes. A little over 50% of the support was provided for those studying in government institutes, followed by an almost equal number of students studying in aided and private institutes. Nearly 60% of the beneficiaries were studying in classes below 10^th grade, followed by those studying between 10^th and 12^th standards. About 10% of the beneficiaries were studying for professional and other courses after the 12^th standard. The average amount of economic support given to each family was Rs. 5730. The educational support provided consisted of course fees, textbooks/notebooks purchase allowance, uniform purchase allowance and travel allowance.

Conclusion: Families having patients with life-limiting illnesses get adversely financially impacted, and often, the children in the family need external support to continue their education. As part of comprehensive palliative care, the possible impact on the children’s education should be explored, and resources for supporting them should be identified.

I. P. Yadav¹, Rajendran¹, Sunil¹

¹Pallium India, Thiruvananthapuram, Kerala, India. E-mail: yadevi@medical-research.org

Introduction: In resource-limited tertiary care settings, efficient outpatient services are critical for effective palliative care delivery. At Government Medical College, Kollam, we identified significant delays in outpatient processes impacting patient care.

Aim: This study aimed to re-engineer the outpatient process in the palliative care department to reduce waiting times for registration, consultation and medicine procurement.

Methods: We conducted a process mapping study in a typical outpatient setting, measuring times for ticket issuance, surgery outpatient waiting and medicine procurement. We then conducted a fishbone analysis to identify the underlying causes of these delays. Based on this analysis, we pinpointed key drivers contributing to inefficiencies and developed targeted interventions to streamline the process. This was particularly important as we designed the upcoming palliative care outpatient service. Based on these findings, we developed interventions to streamline these processes.

Results: The observed average times were 65 min (95% confidence interval [CI] 85.3–44.6), 64.5 min (95% CI 83.97–45.02) and 83.5 min (95% CI 104.96–62.03), respectively. The introduction of an e-Health system allowed doctors to register patients directly, eliminating registration queues. A telephonic appointment system was set up, providing patients with exact consultation times, thereby minimising waiting periods. A dedicated window near the pharmacy was established for quicker medicine dispensation. In addition, a cultural shift was implemented, treating patients as guests, enhancing their overall experience. The interventions led to remarkable improvements. Times for ticket issuance and medication procurement were reduced to zero. In addition, the outpatient waiting time showed a significant negative 2 average of −3 min (95% CI 2.4 min to −8.4), indicating the palliative team waited for the guests.

Conclusions: The restructured outpatient process in the palliative care department at Government Medical College, Kollam, significantly reduced patient wait times and improved the efficiency of service delivery. This patient-centric approach underscores the importance of process optimization in healthcare settings, especially in resource-limited environments.

Snigdha Sharma¹, Bimla Sharma¹, Puneet Rathore¹, Pratibha Jha¹, Monika Bahri¹, Sunita Sharma¹

¹Sir Ganga Ram Hospital, New Delhi, Delhi, India. E-mail: snigdha2212@gmail.com

Introduction: Patients at the end of their lives need high-quality care in the form of symptom control, psychological and spiritual support and guidance regarding treatment options. Good communication by a palliative care provider, based on disease-specific prognosis and the principle of ‘shared decision making’, can save patients from undergoing futile interventions and families from financial burden. Such discussions must involve the ethical implications and legal considerations as well.

Methods: A retrospective analysis of 271 patients receiving palliative care in a tertiary care hospital in North India in the year 2023 was performed. Palliative care referral was sought in view of pain control, symptom management and advance care planning. Do not Intubate’ (DNI) and ‘Do not Attempt Resuscitate’ (DNAR) were also part of these conversations.

Results: Out of 271 patients, 241 (89%) were cancer patients. Out of these cancer patients, ‘pain’ was the most common symptom in 224 (93%) patients, followed by delirium in 164(68%). The remaining 11% of patients either suffered from cerebrovascular accident, fracture in old age or congestive heart failure. We also counselled terminal patients for DNI and DNAR; 60 (22%) patients gave written and verbal consent for DNI and DNAR, and three patients still went ahead with intubation. Out of these 60 patients, 37 (61.6%) were above 60 years of age. Most patients were from oncology unit 39 (65%), followed by internal medicine 7 (11.6%) and paediatric haemato-oncology 4 (6.6%). Fifteen (25%) patients of those who signed up for DNI/DNR accepted their natural course and chose to die at home with good supportive care. Bereavement care was provided to all families.

Conclusion: Good communication and symptom management can make end-of-life comfortable for both patients and families.

Introduction: The role of nurses in palliative care (PC) is significant. PC knowledge and attitude are identified as important tools in providing the best supportive care to patients. Research has demonstrated inadequacies in PC knowledge (pain management and misconception about PC) and attitudes and behaviours regarding PC.

Aim: This study aimed to evaluate the knowledge and attitude among nurses toward PC in a tertiary centre.

Methodology: A total of 180 nurses were randomly recruited. Demographic profiles, including age, gender level of education, work experience, socioeconomic status, habitat and their respective ward, were noted. They were divided into nine batches of 20 participants each. Pre-test evaluation using the PCQN scale and FATCOD-B scale was done, testing nurses’ knowledge and attitude. All groups were provided with study interventions, which included six lectures once a week for 6 weeks. Topics included introduction, psychosocial and spiritual care, pain management, death education, death with dignity and bereavement in PC. The post-course evaluation was done just after the course and also after 6 weeks using the PCQN and FATCOD-B scale.

Results: The study showed improvement in the knowledge and attitude among nurses after study interventions and effort when compared to the baseline data.

Conclusion: The intervention improved nurses’ knowledge and attitude toward PC. Educational training exerted a positive impact on nurses. It is recommended that PC should be incorporated into their teaching curriculum. The thrust toward PC by the national health policy may further strengthen this programme and improve the quality of PC services.

Geraldine Monteiro¹, Nandhini Vallath¹, Chetna Arokia²

^1,2Department of Pain and Palliative Medicine, St Johns Medical College Hospital, Bengaluru, Karnataka, India.

Introduction: The microflora and the pH of the oral environment are vital for maintaining healthy mucosa and for preventing opportunistic infections. Mouth rinses are known to influence the oral environment.

Aim: This study aimed to compare the efficacy and comfort of using Oral Bland Rinse (OBR) versus Chlorhexidine (CHX) rinses when used to preserve the intraoral milieu.

Methodology: A prospective crossover intervention study was conducted on 15 healthy volunteers selected on the basis of study criteria. A standardised OBR was compared with CHX rinse. Salivary samples were collected at pre-fixed time intervals and assessed for pH (tongue and salivary) and oral microflora over the study period of 4 weeks.

Results: There was no significant difference in terms of colony count between the two rinses, but more normal oral microflora were lost with CHX use (four people had a difference of more than 1000 in their oral microflora colony count). Both the tongue pH and salivary pH after OBR and CHX use were within the normal physiological range. A study of subjective experiences of the study participants suggested (i) Dryness of mouth, alterations with taste and adverse effects were more associated with CHX use. (ii) Due to cost-effectiveness and overall experience, 11 out of 15 people preferred OBR.

Conclusion: Through the study, it is clear that OBR is better for preserving the oral environment, but a study over a longer period of time is needed for more conclusive results which are being planned.

Malathi G. Nayak¹, Radhika R. Pai², K. Vasudeva Bhat³, Naveen Salins³

Departments of ¹Community Health Nursing and ²Fundamental of Nursing, Manipal College of Nursing, MAHE, ³Division of Paediatric Haematology and Oncology, Manipal Comprehensive Cancer Care Centre, Kasturba Medical College, ⁴Department of Palliative Medicine and Supportive Care, Manipal Comprehensive Cancer Care Centre Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India.

E-mail: malathi.nayak@manipal.edu

Conference: 31^st International Conference of Indian Association of Palliative Care (IAPCON 2023).

Date: February 9–11, 2024. E-mail: malathi.nayak@manipal.edu, adhika.r@ manipal.edu, vasudeva.bhat@manipal.edu, naveen.salins@manipal.edu; Mobile: K. Vasudeva Bhat - 9619114703

Introduction: The Paediatric Palliative Screening Scale (PaPaS) can be a useful tool for primary care clinicians to assess the palliative care (PC) needs of patients and their families.

Aim: This study aimed to assess PC needs in patients with cancer, educate oncology providers on PC need assessment and conduct an audit of patient records to evaluate the number of PC referrals after post-education.

Methods: This study assessed the need and education as a strategy to improve PC referral with paediatric patients with cancer using a descriptive study design. The study was done in paediatric oncology wards of Kasturba Medical College, Manipal. A purposive sampling technique was used to collect the data. The paediatric oncology teams assessed the PaPaS scores of 75 children with cancer in pre-intervention and post-intervention.

Results: The PaPas scale shows that in pre-intervention, 30 children were supposed to be referred to the PC department. However, only 11 (36.6%) were referred to PC in pre-intervention and post-intervention 31, which were supposed to be referred to the PC department, and only 19 (61.29%) of the children with cancer were referred to PC. More than 50% of referrals are increased after intervention. Health-care professionals taking care of children with life-threatening illnesses must be able to discuss with the family and the child in an age-appropriate way the possibility of death, physical and emotional suffering and management strategies.

Conclusion: A few measures will be needed to improve access to PCs, including increased awareness, better research, improved PC training and policy changes. This study is registered in the Clinical Trial Registry of India (CTRI/2022/07/044157).

Keywords: Education, Haematological malignancy, Need assessment, Palliative care, PaPas scale, Paediatrics.

Kunal Das¹, Naveen Salins¹, Anuja Damani¹, Krithika Rao¹, Shreya Nair¹

¹Kasturba Medical College, Manipal, Karnataka, India.

E-mail: kunal1.kmcmpl2022@learner.manipal.edu

Introduction: Hypoparathyroidism, which is a common complication following total thyroidectomy, can be transient in majority and permanent in 1.5% of the patients and usually occurs secondary to an inadvertent removal of parathyroid glands, mechanical or thermal injury or disruption of the vasculature. In some patients, it is observed that symptoms of hypocalcaemia can occur for the first time several years after the surgery, which is known as ‘delayed hypoparathyroidism’. Herein, we review pertinent clinical information on the incidence and treatment of hypocalcaemia associated with delayed hypoparathyroidism several years after total thyroidectomy in a 66-year-old patient in palliative care ward setting.

Aim: Delayed hypoparathyroidism secondary to total thyroidectomy is a rare phenomenon, and controlling the calcium levels in such patients improves quality of life.

Methods: This study was a case report.

Brief Report: A 66-year-old woman was admitted to our palliative medicine general ward due to reduced oral intake for 2 days, one episode of seizure noticed by patient caregivers, altered sensorium and reduced responsiveness to commands and speaking incomprehensible words. She had a history of previous diagnosis of Stage IV left breast carcinoma (infiltrating lobular carcinoma – pT1N3M1) with bone metastases, underwent left modified radical mastectomy under GA on October 10, 2013, continued on letrozole and zoledronic acid therapy since then, followed by the diagnosis of Papillary thyroid carcinoma, underwent total thyroidectomy under GA on 11 August 2014. Post-therapy whole body scan showed residual thyroid tissue for which she underwent oral therapy of 90 mCi I-131 on 01 September 01 2014, received last zoledronic acid administration 8 mg on 08 June 2023 and palliative radiotherapy 20Gy/5# to pelvis skeletal metastases on 14 June 2023. IV calcium gluconate infusion was started. Thyroid function indices were normal, and oral thyroxine supplements were continued. An oral administration of calcitriol 0.25 mcg tds and calcium carbonate 500 mg tds was then added. The patient gradually recovered, sensorium improved to being conscious and oriented to time, place and person since day 3 of admission and was discharged on day 5 post-admission from the palliative care ward. Her repeat ECG, once the calcium levels were partially corrected showed normal sinus rhythm with appropriate QT intervals, previous changes normalising. The patient was finally discharged with oral potassium, calcium and calcitriol supplements advice, with final day reports showing serum calcium 7.9 mg/dL (n.v 8.8–10.2 mg/dL), magnesium 1.7 mg/dL (n.v. 1.6–2.4 mg/dL) and potassium 3.2 mmol/L (n.v. 3.5–5.1 mmol/L).

Conclusion: Delayed hypoparathyroidism can lead to severe hypocalcaemia, which can be clinically missed as this patient discussed above initially presented to the outpatient department, walking by herself and her calcium level was 3.1 mg/dL. Hence, prompt evaluation and treatment for the same can lead to significant improvement in the quality of life for the patient.

S. Lalit¹, Rontu Sangma1, Sunanda Samal¹,

Rajendra Singh Bijalwan¹, Syed Mohammad Askari Naqvi¹, Jatin Bhukal¹, A. J. Shalini¹, Arathy Nair¹, J. Sreejini¹, Sreelekshmi¹, R. Jeena¹

¹Pallium India Trust, Thiruvananthapuram, Kerala, India. Volunteers: Krishnaraj Nambiar, Usha Krishnaraj, Oomen John, Indira, Bhagyasree, Leela Devi, Sheela Vijay, Jayasree, Balachandran, Nadeera, Madhu, Hari, Prasad Abraham, Rama, Rajeshwari.

E-mail: lalit.s@palliumindia.org

Introduction: Palliative care is still a developing concept in India, and only 4% of patients receive any pain management or palliative care. To increase the accessibility of palliative care for needy patients, the need for an information hub arose, leading to an urgent need for an updated and precise directory of Palliative Care Centres across India, recognising the pivotal role of palliative care in enhancing the quality of life for individuals facing life-limiting illnesses.

Aim: This study aimed to meticulously maintain a comprehensive online directory of Palliative Care Centres throughout India to improve accessibility and awareness of palliative care services.

Methods: The methodology involves a systematic approach to identify, verify and catalogue functional palliative care centres, through collaborative efforts with health-care providers and the strategic use of communication channels such as calls/e-mails. The data on opioid availability and OutpatientInpatient-Homecare services are periodically updated on the website of a centre on a 6-monthly basis. A team of volunteers and Regional Facilitators work to verify existing centres and add new centres. They contact the centre’s representative, gather service details, update the master database and the Website Manager adds/edits the centre on the website directory.

Results: The project has successfully developed and maintained a user-friendly online directory that serves as a valuable resource for individuals seeking palliative care services.

Conclusions: Frequent updates and thorough verification maintain the directory’s reliability as a trusted resource. It serves as a vital reference for patients, caregivers, medical professionals and telehealth helplines, facilitating access to palliative care centres.