Poster Presentation

Attributes of psychosocial distress from the perspectives of head and neck cancer patients

Shalini G. Nayak

Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Karnataka, India

E-mail: shalini.mcon@manipal.edu. Mobile: 9481375675

Background: Patients diagnosed with head and neck cancer (HNC) face unique challenges in comparison to other types of cancers. Sources of psychosocial distress are multifactorial and recognising key attributes would facilitate better understanding of the experienced distress, potentially enabling directed intervention strategies.

Objective: The current research was conducted with the objective of exploring the key attributes of psychosocial distress from HNC patients perspective to develop a tool.

Methods: The study adopted a qualitative approach. The data were collected from nine HNC patients receiving radiotherapy through focus group discussion. Data were transcribed, read and re-read through for searching the meanings and patterns, to familiarise with the data and obtain ideas on experiences related to psychosocial distress. Similar experiences identified across the dataset were sorted and then collated into themes. Detailed analysis of themes and related quotes of the participants are reported with each theme.

Results: The codes generated from the study are grouped under four major themes; some symptoms are distressing, Distressing physical disability inflicted by the situation, Social Curiosity- a distressing element, and Distressing uncertainty of future. The attributes of psychosocial distress and magnitude of psychosocial problems were reflected from the findings.

Conclusion: Psychosocial health of the HNC patient is greatly impacted due to disease and/or treatment. Dynamic patterns of attributes identified from the study contributed in developing a tool on psychosocial distress. Findings of this study also necessitate the need for constructing an intervention for psychosocial distress based on the attributes from the HNC patients perspective.

Role of radiation therapy in mammary analogue secretary carcinoma of salivary gland

Prince Kumar

Department of Radiation Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India

E-mail: Reticent123@gmail.com. Mobile: 9655466031

Introduction: Recently recognised entity previously diagnosed as Zymogen granule poor Acinic cell Carcinoma Shows morphologic and molecular features similar to the secretory carcinomas of the breast occurs in men and women in both major and minor salivary glands IHC-Positive for S100, MUC4 and Mammaglobin (very specific) specific, novel chromosomal translocation ETV6-NRTK3 fusion gene. t (12; 15) (p13; q25).

Case Report: A 45-year-old gentleman presented with a complaint of painless swelling over the right parotid gland swelling was insidious in onset and progressive on examination - 4 x 4 cm, nodular, mobile and nontender swelling found in Right Parotid region. Facial nerve was NOT involved FNAC-Mammary Analogue Secretory Carcinoma Superficial Parotidectomy was performed: Tumour was grey-white in colour, lobular, measuring 2.8 x 1.4 x 0.8 cm and breaching the capsule. He received adjuvant radiation 66Gy/33 fractions with Volumetric Arc Radiation Therapy (VMAT). During course of treatment no significant acute reactions was observed.

Discussion: MASC is a newly recognised malignant salivary gland tumour that recapitulates the histology and genetics of SC of the breast reported cases of MASC encompass a broad range of clinical behaviours, from indolent to aggressive. The mean disease-free survival being 92 months (Chiosa et at.). It has high incidence of local recurrence and lymph node metastasis than Acinic cell carcinoma, longer follow-up is warranted (Chiosea et at.) standard of care for low-grade malignant salivary gland tumours is radical surgical resection. Post-operative radiation is reserved for close (<5 mm) margins/incomplete resection, perineural invasion.

Spirituality in the golden years

Bhoopathy

Baptist Hospital, Bengaluru, Karnataka, India

E-mail: naidums2003@gmail.com. Mobile: 9845797006

Aim: Spiritual care should be inclusive part of geriatric standard care.

Background: Patients with terminal disease and in pain are looking for answers like why me. Hence, there is a dire need for spirituality in their life so that they can gain self-knowledge about themselves and life. Development of a spiritual culture among patients, their families and community will go a long way in helping patients.

Methods: 15 elderly patients selected randomly and orally questioned about (1) need for longevity of life, (2) aspiration to live with family, (3) need for more medical benefits, (4) need for more counselling and (5) importance to die gracefully and peacefully.

Results: About 80% said no to living long at any cost. About 50% do not want to stay with family and would prefer old age community centre with good facilities. About 70% said government and hospitals need to do more for them. About 80% feel government existing are sufficient, but need better implementation. About 90% feel private healthcare is costly and this stresses them.

Discussion and Conclusion: Elderly care culture should be imbibed by youngster in schools. Importance of spirituality should be taught in all stages of life. Awareness of importance of spirituality in overall elderly care in the hospital and among doctors, nursing staff should be developed in a systemic fashion. It should be standardised and protocol driven including regular assessment of cognition, social and emotional assessment and specifically tailored counselling and other support systems. Approaching death with grace is spirituality.

Golden butterflies magic envelop: An innovative art and recreational package during COVID-19

Ramalakshmi

Golden Butterflies Children’s Palliative Care Foundation, Chennai,

Tamil Nadu, India

E-mail: ramviyenar95@gmail.com. Mobile: 6380660206.

Background and Aim: Golden butterflies (GB) provides counselling and arts-based therapy for child-patients and their families; finance for nutrition, tests and treatment; a home away from home; and conducts trainings and awareness programs on palliative care and counselling, in Chennai. GB magic envelope was initiated in response to the COVID-19 pandemic, when group sessions of art and recreational therapy with as child-patients was no longer possible. Magic Envelope is an A4 envelope that includes a small therapeutic craft activity, a puzzle, colouring/drawing sheets and a gift “all age appropriate. All raw materials required to do the craft activity are enclosed, along with child-friendly illustrations/pictorial instructions/cues. Assembling of these edutainment kits is done by GB volunteers, guided by an art-based therapist. As a pilot, magic envelopes were couriered to six child-patients at their residences. This study was conducted to evaluate the effect of engaging with GB magic envelopes on child-patients and their caregivers.

Methods: Telephonic interviews using a structured questionnaire were conducted with 6 caregivers of child-patients, who had been consistently receiving magic envelopes for 6 months.

Results: GB magic envelope was found to have kept the child-patient engaged, alleviated their boredom during the pandemic and stimulated their creative talents. Observing the child-patient creatively occupied was de-stressing for their caregivers. Interestingly, siblings of the child-patients also evinced interest in completing the activities.

Conclusion: Magic Envelope edutainment kits can be used as a safe alternative to face-to-face group sessions with child-patients.

Introducing a psychosocial care pathway for a comfortable dying at home

T. J. Jose Babu

Alpha Palliative Care, Thrissur, Kerala, India

E-mail: drjosebabu@gmail.com. Mobile: 9074342844

Background and Aims: Ensuring a good death is one of the aims of palliative care. Pain and symptom management alone is not sufficient to add life to their days. This pilot study among advanced cancer patients by implementing a novel care pathway developed by Team Alpha aims to improve the quality of dying and death.

Methodology: Thirty advanced cancer patients were included in this pilot study. Home based interventions such as life review, communication using a question prompt list, discussions on unfinished businesses, living will, legacy projects and vigil plan (which constitutes the care pathway) were done serially by a trained social worker. Bereavement visits were done to take feedback and death review was conducted by the palliative care team. Results: The interventions such as life review and discussions using question prompt list were carried out on all the participants (100%). About 96% of participants responded to questions on unfinished businesses and also on living will. About 75% of the participants responded positively to the discussion on Legacy projects. About 88% of participants responded to Vigil plan.

Discussion and Conclusion: The Life review step had a positive impact and the participants were relieved a lot after venting out. Questions on unfinished business helped them to set priorities. The advance directives were documented. Patients have been inspired to write messages to their kids, to be cherished even after death. Vigil plan discussed about the arrangements at the last hours. This ‘care pathway’ improves the quality of dying and death experience among advanced cancer patients as per bereavement feedback and needs further study.

Psilocybin and medical cannabis in palliative care using real world evidence

R. Praveenlal

Fellow in Palliative Medicine

E-mail: praveenlalravi@gmail.com. Mobile: 9447382516

Background: Cancer patients often develop a chronic psychosocial distress having depressed mood, anxiety and reduced quality of life, up to 40% of cancer patients meeting criteria for a mood disorder. Psilocybin and medical cannabis tend to have promising effects on management of cancer related distresses.

Aim: The aim of the study was to bring Psilocybin and medical cannabis as an integral part of palliative medicine using real world evidence to enhance quality of life and empathy.

Methodology: Randomised article search in various data bases including Science Direct, Scopus, Google Scholar, PubMed and EMBASE using bullion terminologies.

Results: Majority preferred CBM over placebo for cancer/therapy related symptom management. In most cases, no serious adverse events were attributed to THC: CBD. High dose psilocybin produced large decrease in depressed mood and anxiety with increase in QOL, life meaning and optimism and decrease in death anxiety. Six month follow-up these changes were sustained with 80% of participants.

Conclusion: Historically safe profile of cannabis could make data from other clinical trial more admissible to formulate reliable clinical practice guidelines. Single dose psilocybin produces substantial and enduring decrease in depressed mood and anxiety with increase in QOL.

Reference: RR Griffith et al. Psilocybin produces substantial decreases in depression and anxiety in patients with life-threatening cancer: Journal of psychopharmacology vol 30, 2016. Carhart Harris et al.: Neural correlates of psychedelic states determined by fMRI studies with psilocybin; PNAS, Feb 7 2012 Vol 109. Cannabis in palliative care: ANN Palliat med 2018.

Multidisciplinary team involvement to overcome body image distress in a palliative care patient with facial edema A case study

Srushti Hiremath

Consultant Physiotherapist

E-mail: srushti.hiremath@ciplacare.com. Mobile: 9561681438

Introduction: Facial oedema is common and distressing symptom among patients who have undergone head and neck surgery/radiation therapy. Up to 75% of patient’s manifest facial oedema and approximately 77% patients have body image distress in head/neck cancer.

Case: A 51-year-old male patient diagnosed with Ca right retro molar trigone area and operated for right hemi mandibulectomy with the right radical neck dissection with flap, presented to us with severe facial oedema, non-healing wound at right submandibular region and sever pain at wound site which was aggravated on facial/neck movements. He had difficulty in eye opening, expressing his emotions through facial expressions and overall communication was hampered. We noticed him observing his own face in the mirror frequently. He was embarrassed about his looks, drooling from his mouth and didn’t wish to meet anyone. His body image distress caused frustration, anxiety, anger and irritability.

Discussion: Aggressive pain management led to reduction in pain. Patient became more open for communication and suggestions. Nursing care of wound with dressing and bandaging reduced odour and oosing. Physiotherapy was started which resulted in drastic reduction in facial oedema. Psychosocial interventions were carried which helped patient to express and cope with body image. This resulted in reduction in anxiety and frustration. He was encouraged to communicate and express his feelings in written format. Thus, the entire team came together to target this complex distress of the patient. Patient cantered goals helped him to overcome his distress and smile on his face was truly satisfying for us as team.

Palliative care in elderly Covid-19 patients

Aditya Kumar Chauhan

Government Medical College, Haldwani, Uttarakhand, India

E-mail: adidon27@gmail.com. Mobile: 9410349997

Background: While the whole population is at risk from infection with the COVID-19, elderly people with comorbidities are at higher risk for severity and fatality. These patients whose outcome are not certain and have end of life situation calls for good palliative care.

Aims: The aim of the study was to provide good palliative care including supportive care and pharmacological treatment symptomatically.

Methods: A group of 71 patients were taken, age >65 years and all recommended pharmacological measures according to patient condition were adapted with psychological therapy.

Results: A total of 71 patients were taken which were all severely ill and provided with timely therapeutic approach and psychosocial support to reduce the suffering and outcome. Out of which 38 patients improved and 33 patients expired.

Conclusion: Elderly patients are particularly susceptible to adverse clinical outcomes in COVID-19 pandemic. Both pharmacological methods and psychosocial support improve the outcome even in severely ill cases of elderly patients.

Effect of palliative radiotherapy on malignant fungating wound of breast cancer

Deepika Sharma

DNB Resident

E-mail: 1991.deepika30@gmail.com. Mobile: 9671674290

Background and Aims: Incurable malignant fungating ulcer in breast cancer patients invariably suffer from general symptoms such as breast pain, bleeding, ulceration and discharge, malodour and thus require palliative radiotherapy. Hypofractionated RT has many advantages in palliative settings, but very few studies on incurable malignant wound have been conducted. This study will be conducted to see effects of hypofractionated RT on symptomatic patients.

Methods: Twenty patients with incurable malignant fungating ulcer underwent hypofractionated palliative RT were retrospectively analysed. RT was performed at a total dose of 20gy in 5 fractions with 4Gy per fraction. The treatment effects were evaluated with respect to symptom improvement, tumour response and treatment related toxicity.

Results: The main symptoms that the patients complained of before RT were pain, bleeding and discharge, malodour and fungating wound. Rest of the results to be elaborated in poster presentation.

Discussion and Conclusion: Hypofractionated radiotherapy could safely and effectively relieve symptoms among incurable malignant fungating wound in breast cancer patients.

An interesting case of rheumatological bone disorder mimicking metastatic bone tumour

Prajakta Dilip Bhagat

Tata Memorial Centre, Mumbai, Maharashtra, India

E-mail: paarijaat90@gmail.com. Mobile: 9004549363

Introduction: Malignancy and autoimmune disorders can present with diagnostic complexities. Patients presenting with any unusual bump and lump in the bone can often be mistaken for malignancy.

Case Description: A 40-year-old Muslim lady presented to oncology OPD with the right ankle swelling for 1 year, biopsy confirmed the presence of osteoid producing malignant tumour consistent with osteosarcoma, CECT chest showed symmetrical pattern of involvement with some calcified areas suggestive of ?metastasis. Patient was advised palliative amputation which she did not consent to. She was referred to Palliative Medicine unit for further symptom management. On evaluation patient had severe left shoulder pain and movement restriction. MRI shoulder showed bulky left subscapularis muscle, fluid collection with synovial thickening in subacromial and subdeltoid bursae, with fluid within the biceps tendon sheath, minimal joint effusion, few prominent retropectoral and interpectoral nodes. Based on MRI findings, rheumatologist opinion was sought. Patient was evaluated for any underlying autoimmune condition/ connective tissue disorder affecting joints/muscles. Furthermore, an orthopaedic opinion was sought to identify any underlying local/systemic infective aetiology. At present, patient is under evaluation to assess whether there is an underlying malignancy or other systemic condition mimicking the same.

Discussion: Systemic and rheumatological disorders should be differentiated from malignancy. If not diagnosed correctly can result in undue suffering, pain, affecting patient’s quality of life, financial loss and adding up to psychological stress. We must have high index of suspicion for connective tissue and autoimmune disorders, if the clinical, radiological, pathological and laboratory investigations don’t show concordance.

COVID-19 response with online deceased body care training

B. K. Manju

Green Pastures Hospital, International Nepal Fellowship, Pokhara, Nepal

E-mail: manju.bk@nepal.inf.org. Mobile: 9779805156829

Introduction: Community organisations like churches take responsibility caring for bodies of their deceased members. During May/June 2020, in early response to the COVID-19 pandemic while initial numbers were low in Nepal, Green Pastures Hospital Palliative Care team offered online training in small interactive sessions using WHO guidelines adapted by Nepal Medical Association via Zoom platform to 65 church leaders on managing deceased bodies in COVID-19 context. Information and useful resources were shared and follow-up poster and guidelines were sent to participants. The link to a video made by PC team demonstrating safe care (using a dummy) was shared with participants 6 weeks after the initial training.

Methods: An online structured questionnaire (using Google Forms) of 22 questions exploring views was sent to all participants 4 weeks after the training.

Results: 30/65 participants responded to the online questionnaire. 60% (18/30) respondents found this training very useful and 26% (8/30) quite useful for their work and ministry. For 56% (17/30) the content was very useful and for 43% (13/30) quite useful; whereas 40% (12/30) were very satisfied and 60% (18/30) quite satisfied with the delivery. About 70% (17/30) said using and removing personal protective equipment (PPE) was new and training helpful for 100%. The topic was very new for 86% respondents. After the training, 80% felt quite confident to safely care for a deceased body.

Discussion and Conclusion: This interactive online session and follow-up enabled respondents to develop new skills on safely using and handling PPE, deepen COVID-19 knowledge and feel empowered to care for deceased bodies in their communities.

Impact of pharmacist intervention in palliative care

Shubhangi Bhogale

Pharmacist

E-mail: shubhangi.bhongale@ciplacare.com. Mobile: 8010032542

Background: Social structure adaptation from joint families to nuclear families, with superadded effect of COVID19, most palliative care patients are now preferring home based care to getting hospitalised. Palliative care patients are on high-risk medications such as opioids, antidepressants, sedatives and oral chemotherapy, which have significant side effects, drug interactions and medication errors need to be avoided. To avoid complications, patient compliance with prescribed medication and instructions is of utmost importance. A pharmacist plays an important role in counselling, recording and reporting of deviations.

Objective: We aimed to assess the rate of deviation from compliance to medication and clinician instructions by patients and the scope of pharmacist intervention in terms of counselling, to avoid untoward effects.

Method: (i) Data analysis of completed medication reconciliation forms of homecare patients. (ii) Review of clinical outcomes determined by homecare team which included: number of patients screened by pharmacist, number of medications reviewed and interventions done. Sample Size: 30.

Results: Medication reconciliation forms filled for 30 patients, out of which 66.66% patients were non-compliant. Based on findings, simple interventions brought to light several loopholes in current system of prescription and compliance. Counselling by the pharmacist in addition to the clinical team could bring down medication errors manifold.

Conclusion: Pharmacist intervention in form of medicine reconciliation, documentation, counselling in palliative home care patients will lead to early identification, intervention by clinical team and ultimately reduction in medication errors, improving overall medicine management.

Telehealth pilot during COVID-19 pandemic

Tan Shermin

Green Pastures Hospital, International Nepal Fellowship, Pokhara, Nepal

E-mail: shermin.tan@inf.org. Mobile: 9810065704

Background and Aims: The coronavirus disease 2019 (COVID-19) pandemic has impacted access to healthcare in Nepal due to travel restrictions. To improve healthcare accessibility and provide psychosocial support to patients and caregivers in the early stages of the pandemic, a telehealth pilot for community-dwelling palliative care patients and caregivers residing within Gandaki Province of Nepal was conducted.

Methods: 15 patients and 16 caregivers were interviewed over the phone by trained healthcare professionals in May/June 2020 using a structured questionnaire. Urgent issues identified were escalated to our medical team, health education was provided and clients were referred to district care providers and government aid, for example, food where needed.

Results: About 47% patients and 67% caregivers were unaware of the symptoms of COVID-19; 40% patients and 31% caregivers were unaware about disease prevention. About 67% patients and 81% caregivers were unaware who to contact for non-COVID-related emergencies. About 20% patients and 27% caregivers had insufficient and/or serious concerns about food supply. None of patients and 13% caregivers reported feeling nervous and stressed in the past month, 93% patients and 88% caregivers were confident about their ability to handle personal issues and 86% patients and all caregivers reported having someone to seek help from when their emotional stress increased.

Discussion and Conclusion: Patients with palliative care needs are among those who are especially vulnerable to the impacts of COVID-19. Telehealth is a feasible way to increase COVID-19 awareness and prevention and improve accessibility to healthcare and food security among these patients.

Quality of life and mental health in caregivers of patients with cancer in palliative phase

A. L. Anjitha

DNB Resident

E-mail: anjitha1992@gmail.com. Mobile: 9497891405

Background: Cancer with metastases has shifted from being fatal in the short-term in most patients towards often being a chronic disease requiring long-term palliative treatment. In the palliative phase, primary caregivers (PC) who provide demanding care to severely ill patients undertake an increased responsibility and challenge of care provision. This may lead to negative as well as positive effects on PCs mental health and health-related quality of life (QOL). The caregiver situation influences the PCs due to stressful conditions, for example, care tasks over time, medical management, decision-making and dealing with emotional aspects, which may lead to subjective and objective burden or cost. Limited research has been done on mental health and health-related quality of life (QOL) of primary caregivers (PCs) to patients staying at home with advanced cancer. This study examines anxiety, depression and QOL in PCs of patients with cancer in the palliative phase.

Aim: The aim of this study was to examine anxiety, depression and QOL in PCs of patients with metastatic cancer in the palliative phase cared for at home compared with gender and age-adjusted norm data (norm).

Patients and Methods: The sample consisted of 40 PCs of patients receiving palliative treatment for various cancers. QOL was rated with the Medical Outcome Study Short Form (SF-36) and mental health with the hospital anxiety and depression scale (HADS). The findings were compared with age- adjusted norm data (norm). Result: Regarding the outcome of our study, we posed the following hypotheses: (1) PCs of both genders show higher levels of anxiety and depression and lower levels of QOL than norm. (2) In both males and females PCs depression, anxiety and QOL are associated with the patients performance status and their need for care in daily life activities. The outcome will be elaborated in the poster.

Conclusion: We anticipate an impaired mental health and QOL in many PCs compared to age- and gender-adjusted norm samples.

The effect of palliative radiotherapy in bone metastases

T. Rajavel

DNB Resident

E-mail: rajavelthangavel5991@gmail.com. Mobile: 944242047

Background and Aim: Bone metastases represent an important complication of malignant tumours. Despite improvement in surgical techniques and advances in the systemic therapies, management of patients with bony metastatic disease remains a powerful cornerstone for the radiation oncologist. The primary goal of the radiation therapy is to provide pain relief and preserving the quality of life. The aim of the study is to determine the effect of radiotherapy (i.e., response to pain) in bone metastases with various primary tumours.

Method: The sample consists of 50 patients with bony metastases of various primary tumours who received palliative radiation of 20Gy in 5 fractions with 4Gy per fraction at Mahavir Cancer Sansthan and Research Center were retrospectively analysed. The treatment effect was evaluated with response to pain by the International Bone Metastases Consensus Working Party on Palliative Radiotherapy.

Results: This study would tell the treatment response on 20Gy in 5 fractions which would be elaborated in poster presentation.

Conclusion: Multiple prospective randomised trials have shown pain relief equivalency for dosing scheme including 30Gy in 10 fractions, 24Gy in 6 fractions, 20Gy in 5 fractions and a single 8 Gy fraction. This is to conclude that, the effect of 20Gy in 5 fraction which is being practiced at our institution.

The importance of empathy in the hospital standard care culture

D. Bhoopathy

Bangalore Baptist Hospital, Bengaluru, Karnataka, India

E-mail: naidums2003@gmail.com. Mobile: 9845797006

Aim: The aim of the study was to build empathetic culture and environment in the hospital and palliative service.

Objective: The objective of the study was to implement empathetic components as medical tool to train medical and para medical staff in empathy culture.

Background: Bangalore Baptist Hospital (BBH) implemented empathetic components. Components (cognition, emotional and compassion): they are useful in training doctors (Dr), medical nurses ((GMN), Community Health Workers (CHWs), social workers (SW), volunteers (Vs), social service, guest relation members as well as Front line employees (FO) such as clerks, security and house keepers. BBH social service and Guest relation sections, Community Heath Division work hand in hand to assist the patient through the medical care.

Tools and Methods: 5Dr, 3GMN, 3SW, 5Vs, 3CHWs and eight patients, orally questioned about the empathy impact, its benefits, about it barriers and job satisfaction.

Results: About 90% Drs fallowed cognitive empathy beneficial in care planning in terminally ill patients. About 70% of SWs, CHWs and GMNs are happy with compassion empathy. About 80% versus adopted counselling and compassion empathy. About 90% patients benefited, linked to empathy tool. For Drs and nurses, the workload and lack of time became barriers in the performance of empathy. There is need to monitor the ethical standards care in and out palliative care patients of the hospital. Professional skill training should be provided to volunteers and paramedical staff. All medical departments of the hospital should collaborate well with the empathy culture.

The dying as teachers: how empathy for others acceptance in terminally Ill cancer patients receiving palliative care

G. Divya,

Department of Palliative Medicine, Bangalore Hospice Trust, Bengaluru, Karnataka, India.

E-mail: divyag@karunashraya.org. Mobile: 919483654348

Background and Aims: Death is often seen as a period of immense fear and pain. Patients have different reactions towards themselves and others during this phase, empathy often being one of them. Watching others dying can evoke intense emotions and could also serve as a medium for learning and accepting one’s own illness. Empathy for others could be a coping mechanism and also aid a counsellor in assisting them towards acceptance of their illness and subsequent psychological adaptation to their predicament. The aim was to analyse coping and positive/negative aspects of empathy in terminally ill cancer patients in late adulthood.

Methods: Retrospective observational design using case notes from indepth counselling sessions. Socio-demographic datasheet, Karunashraya Assessment Pro forma for Psychological and Spiritual Concerns and Case records were used to assess all patients.

Results: Cancer patients (n = 5) were chosen using purposive sampling based on the counselor’s personal journal records. They belonged to an urban background, aged b/w 55 and 72 years of age, on palliative care treatment and had undergone counselling sessions for about 2 months.

Discussion and Conclusion: The case records indicate that empathy has helped them finish unfinished business, acceptance of prognosis, feeling a sense of belongingness, reduced intensity of fear of dying and also helped them make end-of-life decisions. Empathy for others could be pathway through which patients in late adulthood reach acceptance for their illness. Further research needs to be done to explore how this might be different across age groups and if the same construct also could have potential side-effects.

Quality of life outcome in cancer patients living with intestinal stoma: A prospective cross-sectional study

M. S. Biji

Department of Cancer Palliative Medicine, Malabar Cancer Centre, Kannur, Kerala, India.

E-mail: bijims@gmail.com. Mobile: 9496048807

Background: The presence of stoma can have an impact on quality of life (QoL) of cancer patients. There are limited studies from India looking into quality of life of patients with stoma and hence this study.

Aim: The aim of the study was to study about the quality of life in cancer patients who have undergone intestinal stoma in the treatment of their cancer.

Methodology: This prospective study was conducted in the Stoma Clinic, Malabar Cancer Centre, Kannur, Kerala. All patients who had undergone ostomy in treatment of their cancer were administered Malayalam version of a City of Hope National medical centre quality of life questionnaire for patients with an ostomy.

Results: A total of 46 patients with median age 56.5 (39-73) years participated in the study. Majority (n = 40.87%) of them required stoma for colorectal malignancy. Males constituted more than half of the total patients (n = 27.59%). Majority (n = 45.98%) had received adequate information about stoma before their surgery. Nearly three-fourth (n = 32.70%) patients had permanent stoma. Thirty-seven (80%) of them used one-piece appliance. Twenty-eight (61%) changed their stoma bag once every 2 days. Half of the patients required help with their stoma care (n = 24.52%). More than three- fourth (n = 36.78%) of the patients did not go for any work following stoma surgery. Thirty-one (67%) patients had not resumed their sexual activity following stoma. On a 0 to 10 scale, the mean overall QoL score was 7.16 (SD- 1.24) with physical, psychological, social and spiritual well-being, being 8, 7, 6.85 and 6.74, respectively.

Discussion: Stoma QoL observed in our population was comparable with other International studies using the same tool.

Conclusion: The QoL among stoma patients was satisfactory.

Role of palliative amputation in a patient with metastatic lung cancer presenting with venous gangrene of foot

Sachin Ravji Gunde

Tata Memorial Centre, Mumbai, Maharashtra, India.

E-mail: gundesachin@gmail.com. Mobile: 8108663782

Introduction: Cancer is a hypercoagulable state. There is disturbance in the balance between pro-coagulant and anti-coagulant mechanisms. Venous gangrene is often associated with venous thromboembolism, the incidence of which is rare. Venous gangrene confers morbidity and is associated with poor prognosis. Palliation of venous gangrene is less reported in the literature.

Case Description: A 61 -year-old lady, with metastatic lung cancer, was referred to palliative medicine department for early palliative care. She had defaulted her cancer treatment. She developed pulmonary thromboembolism for which she was put on anticoagulant injections. This was later stopped as she developed haemoptysis and not resumed again. In further course, patient presented to us with complaints of excruciating pain and oedema of right foot. On examination, she had discoloured toes, absent anterior tibial artery pulse, line of demarcation over the foot and suggestive of gangrene. Her opioids were up-titrated and surgical opinion was sought. She underwent amputation of right foot with appropriate rehabilitation. Post this, her pain, analgesic requirement and other symptoms reduced significantly, with consequent improvement in quality of life.

Discussion: Pain of venous gangrene is vascular in nature and is not amenable to routine pain management. Surgery remains the mainstay of treatment along with effective anticoagulation. Palliative care expert through integrated team approach can help with symptom and stress management, appropriate care coordination and rehabilitation, which ultimately leads to improved quality of life of patient.

Palliative medicine and pulmonary medicine in a tertiary hospital, India effect of oral morphine on dyspnoea in cancer patients presenting to departments of onco- anesthesia and

Nengneivah Haokip

All India Institute of Medical Sciences, New Delhi, India.

E-mail: vahsyzongku@gmail.com. Mobile: 9650440818

Background and Aims: Clinical data are lacking in India supporting the practice and evidence of prescribing low dose oral morphine for dyspnoea in patients with malignancy and any chronic illness. Therefore, this study aims to demonstrate the effectiveness of oral morphine on dyspnoea in cancer patients presenting to a tertiary care hospital in India and simultaneously, the prevalence of associated factors affecting the quality of life in these patients.

Methods: This single centre prospective observational study measures the change in dyspnoea intensity using the numerical rating scale (NRS) before and after administering oral morphine at regular time intervals and an objective criteria of peripheral oxygen saturation was also recorded. A semi- structured interview was developed to maintain relevant clinical details. In addition, patients were asked to fill out self-assessment forms to study the prevalence of depression, anxiety and stress.

Results: Eight patients have been recruited under this study and are on-going with the aim to achieve a target sample size of 90. Seven patients reported decrease in dyspnoea intensity 60 min after morphine administration, two patients had relief after 30 min and one patient reported no change. No specific trend of change in SpO2 was observed. One patient reported extremely severe anxiety and moderate depression and stress on DASS-21 Scale.

Discussion and Conclusion: No definite comment on the effectiveness of oral morphine on dyspnoea can be made as the sample size is inadequate. This study after completion attempts to provide insight and guide in alleviation of dyspnoea in cancer and interlink the background factors.

Comparative evaluation of characteristics of neuropathic pain and its effect on quality of life in cancer patients in oncology ward and palliative care unit

Sathish Kottaisamy

Postgraduate in Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India.

E-mail: ksathish2023@gmail.com. Mobile: 9566293149

Background: Advancements in cancer therapy have decreased cancer- related mortality. However, the objective of improving quality of life through cancer treatments is compromised by difficulties in management of pain in cancer patients.

Aim: This study attempts to characterise and quantify neuropathic pain in terms of quality of life and determine if treatment of neuropathic pain (NP) can improve the overall quality of life in cancer patients.

Method: The study included a total of 46 cancer patients (Oncology: 26, Palliative:20) and utilised the Self Complete Leeds Assessment of Neuropathic Symptoms and Signs Scale (S-LANSS) Pain Score for NP assessment, Edmonton Symptom Assessment System (ESAS) and Short Form - Brief Pain Inventory (SF-BPI) for assessing pain characteristics, Eastern Cooperative Oncology Group - Performance Status (ECOG-PS) for determining the patient performance and WHO Quality Of Life - BREF (WHOQOL-BREF) for assessing the quality of life.

Results: Based on the S-LANSS score, 57% (15) of the oncology patients and 70% (14) of the palliative unit patients had NP. The non-NP patients were excluded from further analysis. The ESAS (#1), SF-BPI (#5) and ECOG- PS scores were lower and the WHOQOL-BREF scores (especially physical health and psychological) were higher in palliative unit patients than oncology ward patients respectively.

Conclusion and Discussion: Results demonstrate that NP and quality of life has an inverse relationship and that the oncology ward patients are treated inadequately for NP which affects their overall quality of life. Note: Participants are being actively recruited to have 60 patients in each group.

A Tri-speed: A comprehensive approach to overcome suffering in cancer patients amid COVID 19- Through the eyes of a palliative care physician

Wasimul Hoda

Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India.

E-mail: wasu077@gmail.com. Mobile: 8797770602

A pandemic brings enormous suffering through illness, anxiety, stress and death with inevitable financial and social instability. The response to such situation needs taking care of all the sufferings related to it especially in cancer patients. The current situation indicates a major role of supportive care in form of palliative care. Palliation has a key role and considered as an ethical obligation even at the time of pandemic. Delivery and continuity of palliative care for patients with cancer within resource constrained health systems in the context of current COVID-19 pandemic is a major concern and challenge at the same time. Therefore, evidence based subjective approach toward the patient and family members is the need of hour. We propose a comprehensive care model of TRI-SPEED approach that can be useful in providing holistic care during and post COVID 19 pandemic.

Palliative care interface for dying ICU patients availing concession at the Bangalore Baptist Hospital

Stanley C. Macaden

Bangalore Baptist Hospital, Christian Medical Association of India,

Bengaluru, Karnataka, India

E-mail: stancmac@gmail.com. Mobile: 9.19663E+11

Background and Aims: With the aim of improving end-of-life-care an integrated care plan (ICP) for the dying was jointly created by IAPC and ISCCM. IAPC became a member of the international collaborative for best care for the dying person and project India was initiated. The ICP and guidance and care plan for the dying (GCP-D) document of project India was then continued in BBH. A 6 months experience of this palliative care interface in BBH ICUs at 3 different periods is presented.

Methods: Terminally, ill patients admitted to ICU with an acute crisis and not improving by 1^st week are referred for Palliative care and the ICP is begun. Joint patient reviews and counselling with the family were done. Patients were then transferred to the ward or discharged home as appropriate. Data of dying patients who availed concession, were collated and analysed over 6 months periods, pre, immediately post and 1 year, after start of ICP.

Results, Discussion and Conclusion: The average length of stay was significantly reduced, also resulting in reduced bill amount for the patient, better turnover of patients and appropriate utilisation of ICU beds. The revenue for hospital also increased significantly. Reduced ICU concessions meant its proper use for other more appropriate patients. Most importantly, early palliative care interface resulted in good death for the patients through appropriate care, shared decision-making and timely support for the family, comforting them in doing the right thing for their loved one.

Asses the knowledge and attitude of all clinical palliative care staffs in uses of narcotics drugs in patients care

Sangeeta Nair

Dy Nursing Superintendent

E-mail: sangeeta.nair@ciplacare.com. Mobile: 9359201599

Background: To provide quality care at the end of life or for chronically sick patients, doctors and nurses must have good knowledge, attitude and practice about palliative care (PC). Purpose of study: The purpose of the study was to know the knowledge and attitude of all clinical palliative care staffs in uses of narcotics drugs in patients care.

Methods: A cross-sectional questioner-based serve study design was carried out using 11 Doctors and 20 nurses working in CPC. The researchers used triangulation in their study method making use of: Palliative care quiz for clinical staffs and practice questions. Questioner is validated internally.

Results: Pre-test taken to assess th knowledge of the clinical staffs After analysing the data training given to both doctors and nurses. Post test conducted and analysis done in which the knowledge of the clinical staff regarding the narcotic drug and its usage has improved.

Discussion and Conclusion: Discussion with all the doctors was conducted on regular basis for prescribing the narcotic drugs and having any fear of its complications. Discuss with the nursing staffs for dispensing and assessing the effects and side effects which will be identified and can be rectified immediately. The clinical palliative care staffs will have the basic knowledge of narcotic usage and effectiveness in clinical palliative care practice.

Unattended supportive care needs and caregiver distress among patients with progressive neurological conditions: An observational study

Alice Thankachan

Department of Onco-anesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India

E-mail: dralicethankachan@gmail.com. Mobile: 9003094520

Background and Aims: According to the Global Burden of disease study group neurological diseases causes 250.7 million disability-adjusted life years (DALYs) 1 which includes approximately 30 million Indians. In this study, I evaluated people debilitated by progressive neurological disorders, their unaddressed needs spanning across numerous domains, identifying those requiring immediate referral to specialised care along with caregiver well-being and their distress which gets usually neglected.

Methods: An observational study was designed for patients and their caregivers presenting to the inpatient unit of Department of Neurosciences at All India Institute of Medical Sciences, New Delhi. Out of the 35 participants who were invited for the study, 30 were included and were assessed using Needs Assessment Tool, Progressive Disease (NAT: PD).

Results: While 66% of patients had some/potential unresolved physical symptoms, 40% required immediate referral to several disciplines including specialist palliative care and occupational therapist for further assessment. The study also inferred a striking 74% caregiver distress caused by patients physical symptoms with 60% of family currently facing problems in interpersonal relationships or functioning.

Discussion and Conclusion: The complicated trajectory of a neurological disorder is often punctuated with cognitive decline, behavioural changes, movement disorders and communication difficulties which warrants an urgent look out for its redressal. In the context of such an extent of distress in patients and caregivers, it is imperative for a shift in the paradigm for integration of palliative care in neurology. Kyu HH Global, regional and national disability-adjusted life-years for 359 diseases and injuries and healthy life expectancy for 195 countries, Lancet, vol. 392 (2018): 1859-1922.

Time to referral of cancer patients to specialist palliative care: A retrospective study

T. Shanthi Prasoona

Palliative Care Unit, Christian Medical College, Vellore, Tamil Nadu, India

E-mail: shanthiprasoona@cmcvellore.ac.in. Mobile: 9994067822

Background and Aims: Early referral and integration of palliative care with standard oncology care have several benefits for patients/carers and reduces inappropriate end-of-life care. In this context, we aimed to study the time of referral of cancer patients to palliative care and their end-of-life.

Methods: A retrospective chart review of palliative care outpatients, who followed up till their death in the year 2020, was done.

Results: Of the 136 patients, 55% were 40-60 years, male 49% and female 51%. The common malignancies were gastro-intestinal (24%), followed by gynaecological (21%) and head and neck cancer (15%). About 30% were referred early, 36% intermediate and 34% late (>3 months, 1-3 months and <1 month before death, respectively). The median time from referral to death was 2 months. Most patients were referred at disease progression/recurrence (50%). The commonest reason for referral was symptom control (90%). 80% had pain at the time of referral, with 34% needing strong opioids. About 67% had good performance status (ECOG 1 or 2) at time of referral to palliative care. Trigger for referral was visit to emergency department (15%) and hospital admission in (17%). Patients with gynaecological, gastro-intestinal and head and neck malignancies were referred early. In the last month of life 33% of patients had emergency visits, 36% received oncological treatment and 30% died in hospital.

Conclusion: Although nearly one-third of patients referred to palliative care are referred early, there is a great need to educate and advocate early palliative care integration in standard oncology care.

Helping children cope with cancer-benefits of early referral in pediatric oncology

Anuradha Karegar

Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India.

E-mail: anukaregar@gmail.com. Mobile: 9892566156

Introduction: Palliative care principles can be used throughout the trajectory of life limiting illnesses in children, right from before diagnosis to completion of treatment or towards end-of-life care (EOLC) through bereavement. As a newly established palliative and supportive care unit in a pediatric hospital, we conducted a study to assess the benefits of early referrals of children can be seen for the child, family or care-givers.

Methods: This retrospective study included children referred by the haematology-oncology department during the period: May 2019 to January 2021. Children with cancer newly diagnosed or up to a month after were referred for symptom relief, psychological support to the child and caregivers and counselling for adherence to treatment. The study included a review of patient case-notes and feedback from care-givers and children.

Results: About 16.3% (24/147) were early referrals with M: F = 14:10 diagnoses:(37%) ALL; (45%) tumours; (8%) AML; (4%) PNET and retinoblastoma. Referral reasons: (75%) symptom management; (12%) emotional distress; (41%) decision making support: (100%) family counselling for emotional support; (66%) diversion therapies for children to cope and adjust to the hospital environment; (33%) joint sessions with treating team to decide further treatment plan; (54%) managing treatment complications to ensure faster recovery and better adherence and (16%) acceptance of surgery (one amputation and three limb salvage surgeries) 1 family supported for EOLC and bereavement.

Conclusion: Early palliative care referral enables building rapport, leading to better acceptance of active treatment. Caregivers cope better with the journey as they feel supported throughout the disease trajectory.

Low-dose menthol application for neuropathic pain in leprosy or spinal cord injury: A case series from a nepalese hospital

Sunita Bhandari

Green Pastures Hospital, International Nepal Fellowship, Pokhara, Nepal

E-mail: sunita.bhandari@nepal.inf.org. Mobile: 9779805812065

Introduction: Cold-induced analgesia elicited by low-dose menthol application to manage neuropathic pain (NP) is a novel therapy being explored internationally. The previous clinical audits of leprosy and spinal cord injury (SCI) patients in Nepal have highlighted significant burdens of NP impacting sleep, mood and daily function. Previously a small case series reported on the effectiveness of 2% menthol in mustard oil for people suffering NP from various conditions referred to the palliative care service, this follow-up study reports on a larger series.

Materials and Methods: Patients experiencing NP were identified and consented. Twice-daily application of 2% menthol in mustard oil (Leprosy and other) or sunflower oil (SCI) over 6 weeks was assessed using brief pain inventory (BPI) Short Form and Leeds Assessment Neuropathic Symptoms and Signs (LANSS) at: pre-application, 2 h post-application, 2-week and 6-week (where possible). If 2% menthol was inadequate and 5% was substituted.

Results: 175 episodes from 132 (67M, 65F) patients included 105 leprosy-affected (LAP), 8 SCI and 19 other. Overall 2 h 2 weeks 6 weeks any positive response 156/175 (89%), 125/151 (83%), 54/56 (96%) and 35/36 (97%) Clinical response (≥30% reduction worst pain) 77/175 (44%), 28/151 (19%), 42/56 (75%), 29/36 (81%) total relief 5/175(3%). No response 1/175 (0.5%) worse pain 10/175(5%) ten had increased pain at 2 h; two worse across all parameters; eight although some worse scores, also reported improved Worst pain or LANSS scores.

Conclusion: About 2% or 5% menthol for neuropathic pain in various conditions elicited clinically useful pain control with few adverse effects. This therapy is feasible in low-income settings and needs to be evaluated in a randomised controlled trial.

Project ECHO, a pediatric palliative care: impact of telementoring and education series in Nepal

Anisha Lynch-Godrei

The Children’s Hospital of Eastern Ontario Research Institute, Ontario, Canada

E-mail: alynchgodrei@cheo.on.ca. Mobile: 16479890727

Background and Aim: The vast majority (97%) of children needing palliative care live in low- and middle-income countries (LMICs). In Nepal, more than 43 000 children need palliative care, yet access to pediatric palliative care (PPC) is extremely limited. A lack of education for health-care providers (HCPs) has been identified as a significant barrier to ensuring access to PPC in LMICs. Project ECHO (expansion for community healthcare outcomes) is an online training model which provides teaching and support for providers in resource-limited settings. Here, we aim to develop, implement and assess the impacts of a Project ECHO for PPC in the South Asian context.

Methods: Electronic surveys were distributed at baseline, at the end of the program (10 weeks) and after 6 months.

Results: The program consisted of weekly 60 min ECHO sessions conducted weekly (June-August 2020). There were 41 participants who successfully completed the program. Survey respondents included nurses (49%), physicians (39%) and other HCP (12%). The majority (88%) worked at government hospitals and most (55%) cared for 10 or fewer children per month who required palliative care. Scores for comfort and attitudes about palliative care showed improvements after participation in the program, with stronger improvements noted in providing bereavement care and breaking bad news, particularly for physicians.

Discussion and Conclusion: Project ECHO suggests a novel educational model which can be used to build capacity among health-care providers in resource limited settings.

Nepali translation of supportive and palliative care indicators tool-4ALL (SPICT-4ALL)

Sunita Bhandari

Green Pastures Hospital, International Nepal Fellowship, Pokhara, Nepal.

E-mail: sunita.bhandari@nepal.inf.org. Mobile: 9779805812065

Background: SPICT-4ALL, a version of the supportive and palliative care indicators tool, is designed to help non-clinically trained workers identify a person whose health is deteriorating and provide appropriate care. The Nepali translation of SPICT-4ALL is in development.

Methods: A multidisciplinary group (nurses, social and spiritual carers) informed the Nepali SPICT-4ALL development. They examined the English version, explored concepts, suggested equivalent translation and ensured items were understandable and relevant for a Nepali context. The first draft of Nepali SPICT-4ALL was then compiled by a researcher with palliative knowledge and translation experience. The group checked the translation, suggested modifications and agreed the final text. The draft Nepali SPICT- 4ALL was sent to a wider group of hospital professionals and other sites for comment.

Results: While the overall structure and content of the tool were appropriate for Nepali context, some concepts identified were not easily translated often due to ethnolinguistic diversity. Some clinical terms were challenging to find Nepali equivalents, for example medical terms like; 1. Short of breath.

Discussion and Conclusion: Nepali SPICT-4ALL, still in development, will enable non-clinically trained workers including those in rural Nepal with a contextualised tool to support patients and carers in providing care. Remaining work includes reviewing final feedback and checking consistency by English back translation. Nepali SPICT-4ALL will be tested with patients and patient vignettes to see whether further changes are needed.

Assessing the impact of training using the serious illness conversation guide pediatric adaptation (SICG-Peds) on clinician-family communication

Megan Doherty

The Children’s Hospital of Eastern Ontario, Ontario, Canada.

E-mail: megandoherty@hey.com. Mobile: 6137918329

Background and Aims: An essential component of high-quality and patient-cantered care for children with life-limiting conditions is eliciting families values, priorities and goals about their childs future health care. The Serious Illness Conversation Guide pediatric Adaptation (SICG-Peds) provides a standardised approach to communication, which includes patient and caregiver tested language and incorporates best available evidence. We aim to assess the impact of SICG-Peds training workshops on clinicians skills and confidence in leading serious illness conversations with families and to identify barriers to clinician implementation of these communication techniques.

Methods: Clinicians participating in SICG-Peds workshops were surveyed about their knowledge, comfort and attitudes in the management of difficult communication scenarios before and after SICG-Peds workshops (immediately and 6 months). Semi-structured interviews were also conducted with clinicians 6 months after the workshops.

Results: Ninety-four healthcare providers participated in the study. Before the workshop, most participants identified training (54%), mentoring (48%) and a framework for communication (53%) as their most significant learning needs. At 6 month follow-up, 59% of participants reported conducting serious illness conversations with parents at least 4 times. The most common barriers to incorporating SICG-Peds into clinical practice were a lack of adequate time and space, lack of experience and differences in cultural or linguistic backgrounds.

Discussion and Conclusion: SICG-Peds workshops support pediatric clinicians skill and confidence in initiating and leading conversations focused on families values, priorities and goals for their childs health. Future studies exploring the longer-term impacts of serious illness training are needed.

Efficacy of oral or sublingual morphine in children with dyspnoea at the end of life

Ashish Telgote

Revised General Nursing and Midwifery

E-mail: ashyle452@gmail.com. Mobile: 9870623954

Introduction: Children with impaired respiratory or neurological function have dyspnoea at the EOL. Most clinicians are uncomfortable with prescribing morphine (drug of choice) in such cases. We share our experience on morphine in children with dyspnoea at EOL.

Methods: A retrospective descriptive study of children receiving oral/ sublingual morphine for dyspnoea was undertaken at BJ. Wadia Hospital for Children. Palliative care patients records were reviewed (May 2019-Feb 2021). Underlying diagnosis, indication, duration and time to death were recorded.

Results: Eighteen children (12 days-16 years) were included in the study. Diagnoses were cancer-9, neonates-2 and infants-4 with neurological/ congenital/genetic disorders, spinal-muscular-atrophy-2 and ataxia- telangectasia-1. Low-dose morphine (0.1 mg/kg 8 hourly) was started for dyspnoea in 6 opioid-naA've patients and for compassionate extubation in 7. Morphine was given to five patients receiving morphine for pain. Seven children on ventilator were extubated (futility) after morphine and lorazepam. Morphine eased extubation; further oxygen requirement was reduced and children could be managed by low-flow oxygen for 4 h-4 days. Dyspnoea improved in 1 infant with laryngomalacia, O2 was stopped after 3 days of morphine and child survived at home for a week. For other children who were dyspnoeic on BiPAP or O2 by non-rebreathing mask, breathlessness improved in 3, O2 requirement decreased in three patients. A 6-year-old child with lung metastases and pleural effusion survived for 65 days at home on morphine and off-O2, without distress.

Conclusion: Morphine makes children calmer and more relaxed at the EOL, suffering reduces and care-givers are able to see their child peaceful and comfortable.

Coeliac plexus block: The simple knockdown of the complex

Jitendra Pandey

Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India

E-mail: jitenpandey2012@gmail.com. Mobile: 8617322157

Introduction: Carcinoma gallbladder is very much prevalent in the gangetic plane like Patna and we frequently get these patients at our clinic with intractable abdominal pain even with step 3 WHO ladder of pain control. The aim of this case series study is to emphasise the importance of the coeliac plexus block.

Case Description: Prospective non-randomised case series study of eight patients with CA Gall bladder in unresectable stage is conducted at our pain clinic under real life condition from November 2019 to February 2020. They responded inadequately to the combined analgesic therapy and had intolerable side effects contraindicating the further increase in the dose. The patients are selected for the coeliac plexus neurolysis under fluoroscopic guidance under C-arm and paravertebral to T12, the absolute alcohol is injected after confirming the site with the dye Iohexol. The VAS score and QOL SF36 questioners are evaluated in all the eight patients at 2 weeks and 2 months. Primary outcome was the change in intensity. Secondary outcome were the improved quality of life.

Discussion: After neurolysis, patients experienced a significant decrease in pain as shown by the VAS score, decreased opiate demand with improvement in quality of life as evident from the questioners. Hence, this be used as an additional treatment to the conventional pain control in these patients. So let’s beat the heat of solar plexus

Lessons learnt from supervising an academic training program in palliative medicine - A narrative review

Rahul D. Arora

Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India

E-mail: xerxes85@ymail.com. Mobile: 9810785246

Background: A senior resident-led academic program consisting of three sessions per week (Journal club, seminar and case presentation) was introduced with an aim to involve stakeholders in the discussion on the purview of postgraduate training.

Methods: This review discusses format, composition and future directions.

Results: About 37.4% of Journal club articles discussed core topics from Internal medicine (13.6 %), medical oncology (4.5 %) and supportive oncology (13.6 %). Systematic reviews and meta-analysis (38.1 %), randomised control trials (23.8 %), case report (14.2 %), Delphi study, cost-effectiveness analysis, survey, mixed-methods study and n-of-one trials (4.7 % each) were discussed. Journal club discussions included articles themed upon management of chemotherapy- related adverse effects (emesis, febrile neutropenia and peripheral neuropathy), symptom management in chronic renal, neurological disease and advanced cancer, discussion of nomenclature at end of life. Topics included under general palliative medicine, end of life care, palliative pharmacotherapy and general medicine were covered in the seminar. 13 assignments covering topics in general palliative medicine, specialist palliative medicine, clinical examination in general medicine and medical oncology were sent through mail.

Conclusion: Lack of administrative recognition, co-existence of a parallel academic program and lack of faculty participation were identified as factors that may have led to discontinuation.

Overview of training as a palliative medicine resident

Rahul D. Arora

Fellow in Training, Palliative Medicine, Kidwai Memorial Institute of

Oncology, Bengaluru, Karnataka, India

E-mail: xerxes85@ymail.com. Mobile: 9810785246

Background: Training as a senior resident (3-year tenure) involves postings in various medical specialties.

Methods: This document provides an overview of place of posting, duties and salient features.

Results: Postings in Psychiatry, Pulmonary Medicine, Physical medicine and rehabilitation, Emergency Medicine, Medical Oncology, Geriatric Medicine and Neurology, two Non-governmental organisations providing adult and pediatric palliative care services and National Cancer Institute were included as part of training. A total of 16 months were spent outside the parent department. Specific learning objectives included an exploration of the scope of palliation along with measures to seek closer interdisciplinary coordination. A total of 12 surveys were disseminated during my tenure. Postings involved participation in ward rounds, patient review and academic training activities. Participation in the disease management group in Medical oncology and National Cancer Institute provided an opportunity to evaluate and plan the management of early as well as advanced cancer patients in consultation with oncologists.

Conclusion: Integration of a representative from Palliative medicine in the screening stage following registration is a significant step forward for the discipline. This endeavor represents a novel resident-cantered initiative that places the trainee at the centre of intertwined symbiotic medical specialties. Its inherent potential to challenge the existing view on the purview of training represents an interesting opportunity ripe with multiple prospects.

Importance of addressing and relieving spiritual pain: A case report

Archana Vajjala

MNJ Institute of Oncology and Regional Cancer Centre, Hyderabad, Telangana, India

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

Introduction: Addressing and relieving spiritual pain is an important and essential component of palliative care. Its real and comes from hidden areas of a person’s life that cannot be rated on a pain scale making it challenging to diagnose, affecting the quality of life. It often surfaces during the course of a serious illness emphasising its importance and need to understand and address it.

Case Description: A 39-year-old gentleman with a history of HIV infection on ART, diagnosed with Plasmoblastic lymphoma presented with complaints of severe pain and distress unresponsive to different types of pain medications. This patient was suffering from spiritual pain after being diagnosed with life limiting illness affecting his quality of life.

Case Discussion: This case report emphasises on the importance of addressing and relieving the spiritual pain which can have a significant impact on improving patient’s quality of life and the manner in which they would cope with illness and healing. Spiritual pain is deeply personal and sometimes all it requires is active listening and the feeling of being present with them in their confusion and distress providing comfort and support. Delivering effective Spiritual care is an art that requires learning a set of skills and integration into a treatment plan using multidisciplinary approach and teamwork. Everyone perceives spirituality differently and relates to it in their own way. Hence, patients preferences, values and beliefs should be respected. Theres no one size fits all approach to spirituality so it’s important to learn spiritual care skills to address it accordingly and relieve suffering.

Methadone versus morphine for neuropathic pain management in cancer cervix: A randomised controlled trial

Adumala Aruna

ESIC Medical College Hospital, Sanathnagar, Telangana, India.

E-mail: raruna73@gmail.com. Mobile: 8885011345

Background: In India, cervical cancer is considered to be the most common cancer among women contributing to approximately 29% of all cancers in women. Pain is one of the most distressing and intractable symptoms in patients with cancer. In patients diagnosed with cervical cancer various pain medications have been used for pain relief with efficacy still not satisfied, especially for neuropathic pain and very few studies have investigated this. Evidence has identified a number of advantages for methadone over other opioids for treatment of neuropathic cancer pain. It was hypothesised that Methadone with its different mechanisms of actions at μ, Î' opioid receptors, NMDA activity and reuptake of monoamines is a good option.

Aim: The primary objective was to determine whether Methadone is superior versus non inferior to Morphine as an analgesic the treatment of cervical cancer related neuropathic pain.

Methods: A double-blinded RCT comparing Methadone to IR Morphine.

Results: A study design was conducted at two pain centres over a period of 12W and a total of 85 participants were recruited of which five withdrew, six died and 74 patients completed the study.

Discussion: All participants showed a mean reduction in pain intensity compared to pre-treatment. Early onset of good pain relief is noted in patients with Methadone compared to Morphine based on NRS (for Morphine from 8.0 to 4.38 and Methadone 8.0 to 3.0) with no added co-analgesics.

Conclusion: Based on our study results, Methadone produced superior analgesic effect compared to Morphine for neuropathic pain relief as first- line opioid with good tolerability

Gastric adenocarcinoma in a 14-year-old boy

Dr Swati

Department of Radiation Oncology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India

E-mail: drswati1471992@gmail.com. Mobile: 9786474358.

Introduction: Gastric adenocarcinoma is usually seen in adults and is rare in teenagers. However, it presents with advanced disease and metastasis at the time of diagnosis in young patients.

Case Description: A 14-year-old non-smoker teenager presented to outpatient department complaining of 45 days history of vomiting and constipation. On palpating the abdomen, hard lump of 20 x 15 cm with irregular surface was felt in the right and left hypochondrium, epigastrium and extending to umbilicus. Contrast-enhanced computed tomography of abdomen showed concentric asymmetrical enhancing thickening (maximum thickness-17 mm) in body and pyloroantral region of stomach with multiple enlarged, necrotic perigastric and peripancreatic lymphadenopathy (largest one measuring 16 mm in short axis diameter). Liver was also enlarged in size with multiple well-defined heterogeneously enhancing soft tissue mass lesions in both lobes of liver (largest measuring 33 x 32 mm in segment 7 of right lobe) Her2-neu overexpression was present.

Discussion: Gastric adenocarcinoma is rare in young patients but the incidence is showing a rising trend worldwide. For this reason, reporting these types of cases will help in better understanding in framing guidelines for treating gastric adenocarcinoma in teenagers. Children presenting with GI symptoms such as hematemesis, abdominal distension or mass are often misdiagnosed by treating physicians. These patients should be evaluated for gastric cancer with radiographic and endoscopic studies to avoid any delay in diagnosis. In this case, patient quickly progressed to fourth stage of cancer within 2 months.