Preoperative Palliative Care: A Conceptual Framework
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What is the surgery? Asked the preanaesthetic checkup (PAC) doctor. Surgery! I don’t know -replied Mani (name changed) in a whispered voice which was more like a whim with an element of surprise to it. When did you come to know of Cancer? While mindlessly turning the pages of his file, the doctor (D) asked again. Cancer! Do I have one? This time, the element of surprise overwhelmed the agony in Mani's voice. What do you know then? Being tired of monotonicity of doing the same odd task of filling the pink papers asked an irritated D. That I have pain – this was the first time that D had raised his head since morning to glance who is sitting across. A mere look at Mani with tears rolling down his eyes, teeth biting his lips, and him being leaning forward with arms tightly clenched around his tummy jolted D. Him being responsible but just overworked; D soon came to realization where he went wrong. That very moment, the doctor–patient boundary vanquished and was replaced by a human bond filled with compassion.
Tens of thousands of patient like Mani diagnosed with cancer and scheduled for one or the other mutilating surgery present to PAC clinics worldwide every day. With the focus of contemporary medicine being disease-specific rather than illness-specific, lack of training and acute shortage of specialist palliative care physicians, patient's suffering and agony remains largely unheard. The plethora of preoperative investigations and diagnostic procedures lend an egoistic hand to only intensify this burden of pain. Mani's narrative raises many pertinent questions. Pain is one of the most common symptoms with which a patient presents to the healthcare facility and has been declared as the fifth vital sign then why pain scales are not a routine component of PAC sheets just like any other vital parameter? Isn’t the pain an important component of anesthesiology training and evaluation? Definitely yes, but what is required is to broaden the horizons and think where lies the actual burden of pain, introduce the concept of total pain and that the psychological or spiritual dimensions may be equal or in certain cases, the dominant component of pain. A comprehensive pain history will help in identifying patients already on opioids and deciding in advance, the choice and route of postoperative analgesia which can be challenging in such patients. Isn’t a comprehensive history taking constitutes an important component of PAC? Why is that communication skills are not being taught to us? Had it been so then Mani would have been spared from the plight of a disastrous “breaking the bad news.” It is we only who have to answer all these questions as we are the system makers as well as the system changers. However, we do not have to stop at that. The ideal situation of inclusion of the basics of palliative care, symptom management limited not only to pain, ethical decision-making being incorporated into our training though seems distant but also not unreachable. What is required is the will and the motivation. Who say that a preanaesthetic clinic cannot be converted into a combined preanaesthetic and palliative care clinic? The PAC clinic by broadening its horizon may serve a novel role in evaluating as well as managing their various disease-specific, patient-specific, and stage-specific palliative care needs. The use of easy to administer, comprehensive questionnaires such as condensed memorial symptom assessment scale and brief pain inventory serve as an effective screening tools. Such a co-allocation and incorporation of palliative care into the existing services will ensure the best possible quality of life of the patients and a relief to the meager palliative care services currently available in developing countries such as India.
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