PALLIATIVE CARE

PALLIATIVE CARE

Palliative care is a specialized area of healthcare that focuses on relieving and preventing the suffering of patients. Palliative medicine is appropriate for patients in all disease stages, including those undergoing treatment for curable illnesses and those living with chronic diseases, as well as patients who are nearing the end of life. Palliative medicine utilizes a multidisciplinary approach to patient care, relying on input from physicians, pharmacists, nurses, chaplains, social workers, psychologists, and other allied health professionals in formulating a plan of care to relieve suffering in all areas of a patient's life. This multidisciplinary approach allows the palliative care team to address physical, emotional, spiritual, and social concerns that arise with advanced illness.

Medications and treatments are said to have a palliative effect if they relieve symptoms without having a curative effect on the underlying disease or cause. This can include treating nausea related to chemotherapy or something as simple as morphine to treat a broken leg or aching related to an influenza (flu) infection. Palliative care is specialized medical care for people with serious illnesses. It is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work together with a patient's other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment.

The World Health Organization describes palliative care as "an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual." More generally, however, the term "palliative care" may refer to any care that alleviates symptoms, whether or not there is hope of a cure by other means; thus, palliative treatments may be used to alleviate the side effects of curative treatments, such as relieving the nausea associated with chemotherapy..

The term "palliative care" is increasingly used with regard to diseases other than cancer such as chronic, progressive pulmonary disorders, renal, disease, chronic, heart failure HIV/AIDS, and progressive neurological conditions. In addition, the rapidly growing field of pediatric palliative care has clearly shown the need for services geared specifically for children with serious illness. Although the concept of palliative care is not new, most physicians have traditionally concentrated on trying to cure patients. Treatments for the alleviation of symptoms were viewed as hazardous and seen as inviting addiction and other unwanted side effects. The focus on a patient's quality of life has increased greatly during the past twenty years. In the United States today, 55% of hospitals with more than 100 beds offer a palliative-care program, and nearly one-fifth of community hospitals have palliative-care programs. A relatively recent development is the concept of a dedicated health care team that is entirely geared toward palliative treatment: a palliative-care team.

In the United States, hospice services and palliative care programs share similar goals of providing symptom relief and pain management Non-hospice palliative care is appropriate for anyone with a serious, complex illness, whether they are expected to recover fully, to live with chronic illness for an extended time, or to experience disease progression. In contrast, although hospice care is also palliative, the term hospice applies to care administered in patients with a prognosis of 6 months or less to live

Palliative care:

*provides relief from pain, shortness of breath, nausea, and other distressing symptoms;

*affirms life and regards dying as a normal process;

*intends neither to hasten nor to postpone death;

*integrates the psychological and spiritual aspects of patient care;

*offers a support system to help patients live as actively as possible;

*offers a support system to help the family cope;

*uses a team approach to address the needs of patients and their families;

*will enhance quality of life;

*is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy.

While palliative care may seem to offer a broad range of services, the goals of palliative treatment are concrete: relief from suffering, treatment of pain and other distressing symptoms, psychological and spiritual care, a support system to help the individual live as actively as possible, and a support system to sustain and rehabilitate the individual's family.

Palliative care began in the hospice movement and is now widely used outside of traditional hospice care. Hospices were originally places of rest for travelers in the 4th century. In the 19th century a religious order established hospices for the dying in Ireland and London The modern hospice is a relatively recent concept that originated and gained momentum in the United Kingdom after the founding of St.Christopher’s Hospice in 1967. It was founded by Dame Cicely Saunders, widely regarded as the founder of the modern hospice movement.

The hospice movement has grown dramatically in recent years. In the UK in 2005 there were just under 1700 hospice services consisting of 220 inpatient units for adults with 3156 beds, 33 inpatient units for children with 255 beds, 358 home care services, 104 hospice at home services, 263 day care services, and 293 hospital teams. These services together helped over 250,000 patients in 2003 & 2004. Funding varies from 100% funding by the National Health Service to almost 100% funding by charities, but the service is always free to patients.

Hospice in the United States has grown from a volunteer-led movement to improve care for people dying alone, isolated, or in hospitals, to a significant part of the health care system. In 2005 more than 1.2 million individuals and their families received hospice care. Hospice is the only Medicare benefit that includes pharmaceuticals, medical equipment, twenty-four hour/seven day a week access to care and support for loved ones following a death. Most hospice care is delivered at home. Hospice care is also available to people in home-like hospice residences, nursing homes, assisted living facilities, veterans' facilities, hospitals, and prisons.

The first United States hospital-based palliative care programs began in the late 1980s at a handful of institutions such as the Cleveland Clinic and Medical College of Wisconsin. Since then there has been a dramatic increase in hospital-based palliative care programs, now numbering more than 1400. 80% of US Hospitals with more than 300 beds have a program.

    A 2010 study regarding the availability of palliative care in 120 US cancer center hospitals reported the following: Only 23% of the centers have beds that are dedicated to palliative care; 37% offer inpatient hospice; 75% have a median time of referral to palliative care to the time of death of 30 to 120 days; Research programs, palliative care fellowships, and mandatory rotations for oncology fellows were uncommon The results of a 2010 study in The New England Journal of Medicine showed that lung cancer patients receiving early palliative care experienced less depression, increased quality of life and survived 2.7 months longer than those receiving standard oncologic care Hospital palliative care programs today care for non-terminal patients as well as hospice patients. The Patient Protection and Affordable Care Act-currently being debated by house and senate would seek to expand palliative care in the U.S. The first pan-European centre devoted to improving patient palliative care and end of life care was established in Trondheim, Norway in 2009. The centre is based at NTNU’s Faculty of Medicine and at St. Olavs Hospital/Trondheim University Hospital, and coordinate efforts between groups and individual researchers across Europe, specifically Scotland, England, Italy, Denmark, Germany and Switzerland, along with the USA, Canada and Australia.

In the United States hospice and palliative care represent two different aspects of care with similar philosophy, but with different payment systems and location of services. Palliative care services are most often provided in acute care hospitals organized around an interdisciplinary consultation service with or without an acute inpatient palliative care ward. Palliative care may also be provided in the dying person's home as a "bridge" program between traditional US home care services and hospice care or provided in long-term care facilities. In contrast over 80% of hospice care in the US is provided in a patient's home with the remainder provided to patients residing in long-term care facilities or in free standing hospice residential facilities. In the UK hospice is seen as one part of the specialty of palliative care and no differentiation is made between 'hospice' and 'palliative care'.

In most countries hospice and palliative care is provided by an interdisciplinary team consisting of physicians, registered nurses, nursing assistants, social workers, hospice pharmacists, physiotherapists, occupational therapists, complementary therapists, volunteers, and, most important, the family. The team's focus is to optimize the patient's comfort. Additional members of the team are likely to include certified nursing assistants or home health care aides, volunteers from the community (largely untrained but some being skilled medical personnel), and housekeepers. In the United States, the physician subspecialty of  Hospice and Palliative Medicine was established in 2006, to provide expertise in the care of patients with life-limiting, advanced disease and catastrophic injury; the relief of distressing symptoms; the coordination of interdisciplinary patient and family-centered care in diverse settings; the use of specialized care systems including hospice; the management of the imminently dying patient; and legal and ethical decision making in end-of-life care. Medications used for palliative patients are used differently than standard medications, based on established practices with varying degrees of evidence Examples include the use of antipsychotic medications to treat nausea, anticonvulsants to treat pain, and morphine to treat dyspnea. Routes of administration may differ from acute or chronic care, as many patients lose the ability to swallow. A common alternative route of administration is subcutaneous, as it is less traumatic and less difficult to maintain than intravenous medications. Other routes of administration include sublingual, subcutaneous, intramuscular and transdermal. Medications are often managed at home by family or nursing support.

In the UK palliative care services offer inpatient care, home care, day care, and outpatient services, and work in close partnership with mainstream services. Hospices often house a full range of services and professionals for both pediatric and adult patients. In the US palliative care services can be offered to any patient without restriction to disease or prognosis. Hospice care under the Medicare Hospice Benefit, however, requires that two physicians certify that a patient has less than six months to live if the disease follows its usual course. This does not mean, though, that if a patient is still living after six months in hospice he or she will be discharged from the service. Such restrictions do not exist in other countries such as the UK Caregivers, both family and volunteers, are crucial to the palliative care system. Caregivers and patients often form lasting friendships over the course of care. As a consequence caregivers may find themselves under severe emotional and physical strain. Opportunities for caregiver respite are some of the services hospices provide to promote caregiver well-being. Respite may last a few hours up to several days (the latter being done usually by placing the patient in a  nursing home or in-patient hospice unit for several days).

Because palliative care sees an increasingly wide range of conditions in patients at varying stages of their illness it follows that palliative care teams offer a range of care. This may range from managing the physical symptoms in patients receiving treatment for cancer, to treating depression in patients with advanced disease, to the care of patients in their last days and hours. Much of the work involves helping patients with complex or severe physical, psychological, social, and spiritual problems. In the UK over half of patients are improved sufficiently to return home. Most hospice organizations offer bereavement counseling to the patient's partner or family should he die. In the US board certification for physicians in palliative care was through the American Board of Hospice and Palliative Medicine; recently this was changed to be done through any of 11 different specialty boards through an ABMS-approved procedure. More than 50 fellowship programs provide 1–2 years of specialty training following a primary residency. In the UK palliative care has been a full specialty of medicine since 1989 and training is governed by the same regulations through the Royal College of Physicians as with any other medical specialty.

Funding for hospice and palliative care services varies. In the UK and many other countries all palliative care is offered free to the patient and their family, either through the National Health Service (as in the UK) or through charities working in partnership with the local health services. Palliative care services in the US are paid by philanthropy, fee-for service mechanisms, or from direct hospital support while hospice care is provided as Medicare benefit; similar hospice benefits are offered by Medicaid and most private health insurers. Under the Medicare Hospice Benefit (MHB) a patient signs off their Medicare Part A (hospital payment) and enrolls in the MHB with direct care provided by a Medicare certified hospice agency. Under terms of the MHB the Hospice agency is responsible for the Plan of Care and may not bill the patient for services. The hospice agency, together with the patient's primary physician, is responsible for determining the Plan of Care. All costs related to the terminal illness are paid from a per diem rate (~US $126/day) that the hospice agency receives from Medicare - this includes all drugs and equipment, nursing, social service, chaplain visits, and other services deemed appropriate by the hospice agency; Medicare does not pay for custodial care. Patients may elect to withdraw from the MHB and return to Medicare Part A and later re-enroll in hospice.

The first pan-European centre devoted to improving patient palliative care and end of life care was established in Trondheim, Norway in 2009. The centre is based at NTNU’s Faculty of Medicine and at St. Olavs Hospital/Trondheim University Hospital, and coordinate researchers across Europe, specifically Scotland, England, Italy, Denmark, Germany and Switzerland, along ith the USA, Canada and Australi

Institute of Palliative Medicine (IPM) is the leading training institution for palliative care in Asia. An autonomous institution, it is the policy, training & research wing of the World Health Organization Demonstration Project in Palliative Care for the Developing world. It is also the nodal agency for initiating and implementing community based palliative care programme under National Rural Health Mission (Kerala), a Government of India Project.

Institute of Palliative Medicine works closely with local governments in Kerala. IPM is the technical advisor and implementing agency for Pariraksha, the comprehensive home care program by the Local Self Governments in Malappuram District. IPM is the Indian partner for the WHO Collaborating Centre in Oxford. Allotted space within the Medical College Campus itself by the Government of Kerala, Mr. Bruce Davis, founder of the W. Bruce Davis Trust supported the project & helped build this facility. Inaugurated on January 21st, 2003, admission of patients and training programs began by July 14th, 2003.

The Institute of Palliative Medicine (IPM) was constructed to make palliative care available & accessible to all those in need of it. To complete the total care provided by us to all our patients, here patients are admitted to bring difficult symptoms under control or to provide the carers respite care.

Today in modern medicine only about 30-40% diseases are curable; remaining is either chronic or progressive life limiting illness. Patients facing such illness lack quality life, palliative care, relief from pain and other distressing physical symptoms. Alpha brings quality life even to ordinary people. They even provide emotional support, counseling to both patients and their family at their home. They focus on ensuring the best quality of life for the patient till the very end for all kinds of patients. A team of medical professionals came home spend more than an hour at home. They provided first class service for my grandfather, very helpful and much needed counseling for my grandmother and mother. They advised what to talk in front of grandfather and what to avoid in front of him. They even trained my mother for basic nursing services. They gave very good motivation for them and also for the local community to provide emotional and social support to the patient and family. Alpha gave free service and medicines regularly. They visited home every three days and spend more than an hour. In between these days they make phone calls and follow up on patient status. The best part I like about them is that during their visits we offered them tea and snakes but they denied it. They said they don't accept anything for patients home because they don't want to be partial in the service. They are committed to provide same quality service even for the rich and poor patients. So they avoid accepting any gifts or hospitality offered. If we want to pay them for the service they will accept it only after the demise of the patient.

Alpha Pain Care extends its service in Supportive care, long term care, end of life care, chronic pain management, lymph oedema care at their hospital and also at patients home. They also conduct training and education programs for better awareness if illness and enhancing the quality of life of patients. Alpha Pain Care is facilitating pain and palliative care free of cost without any discrimination irrespective of difference in religion, caste, creed and political affiliation throughout Thrissur district in Kerala. Today such facilities are available throughout India. We much impressed by the service and commitment. Welcome to Cinoy's world! I am here to help you and help myself in 'living' a better world. I am Btech(Computing) Engineer from Thompson Rivers University, British Columbia, Canada.I believe, the quality of a person's life is in direct proportion to their commitment to excellence, regardless of their chosen field of endeavor! I am on continous learning and research process in the following arears - People Management, Business Communication, Leadership, Financial Planning, Solution Selling and Philosophy. My vision is to fine tune the human brain to get the best results in all areas.

                                                                     Prof. John Kurakar