Department of Pain and Palliative Medicine: An Overview
The Department of Pain and Palliative Medicine is unique among medical specialties deals with patients who require complete care in terms of physical, psychological, social and spiritual aspects.
The department is involved in clinical, home care, teaching and rehabilitative activities.
Palliative care is delivered by a team of health care professionals which includes -
Doctors to provide specialised palliative care, Nurses to provide specialised nursing care & Social workers to provide psychosocial support and to look into rehabilitation services
The department has an out-patient; an in-patient and a home care service.
The patients groups are:
Cancer – pain, symptom & supportive management.
Non-cancer pain- mainly includes patients with chronic pain (pancreatitis, peripheral vascular disease, low backache, fibromyalgia, myofascial pain syndromes, post-herpetic neuralgia etc.)
Patients with lymphoedema both cancerous and non-cancerous origin.
Chronic, incurable and debilitating diseases like Chronic Obstructive Pulmonary Diseases, Neurological incapacitating conditions, Cerebrovascular accidents, AIDS, untreatable diabetes and end-stage heart, renal & liver diseases.
This is the only Palliative Medicine Department in India, which liaisons with the Intensive Care Unit to provide better end of life care in an attempt to provide ‘Good Death’ in the presence of their loved ones.
Clinical
Out-Patient Department
This includes a team of palliative care physicians, nurses, social workers and office staff. They are qualified and committed. The doctors will see the patient according to first come first serve basis. But if a patient has much difficulty he or she will be seen first. We are aiming at improving quality of life with the available resources.
Patients with Cancer
These patients undergo various investigations and treatments before they reach here and most of their resources would have been utilized during the course of their illness. Even though palliative care starts from the time of diagnosis, due to unawareness on the part of physicians and patients they reach us at a later stage when other medical specialties announces “nothing can be done”. The patient and family feel that the medical system rejected us and they have no idea what to do. They suffer from different symptoms, pain being the most common one. So they are physically, mentally and financially exhausted. It is a tough challenge to provide the optimum care with the available resources at this stage. Nowadays the timely reference from the Dept. of Oncology makes Palliative care available for cancer patients, hand in hand with the disease modifying therapies like Radiotherapy & Chemotherapy. This helps them to cope better with the adverse effects of the aforesaid therapies. We see the patients as human beings rather than looking at them as “cases” or “diagnosis only”.
Patients with Chronic Pain
Patients with chronic pain resemble cancer patients in many aspects even though they have no cancer. They are also worried about the ongoing pain, cause of pain and the uncertainty about it. This is a socioeconomic as well as a personal problem. The pains impact on the person, family and loss of productivity in addition to expensive investigations. They also require a holistic approach, which is practiced by palliative care physicians. Detailed pain history is taken & treated according to the WHO pain ladder. Patients who doesn’t respond to drug therapy are also taken up for interventional procedures.
Lymphoedema Clinic
The patients attending the lymphoedema clinic are mainly referred from oncology, general surgery and reconstructive surgery. We also receive direct references from other hospitals.
Lymphoedema is a notoriously debilitating progressive condition with no known cure.
Worldwide, 140-250 million cases of lymphoedema are estimated to exist, with filariasis being the most common cause.
Because lymphoedema is disfiguring and sometimes painful and disabling, it can create mental, physical, social and sexual problems. Several studies have noted that women who develop lymphoedema after treatment for breast cancer have more mental, physical, and sexual difficulties than women who do not develop lymphoedema. The added stress associated with lymphoedema may interfere with treatment that is often painful, difficult, and time-consuming.
We have three palliative care nurses in the department who are trained in lymphoedema management at the Regional Cancer Center, Trivandrum.
Patients present with mild to severe swelling, often disabling with potentially life-threatening complications. This disease is often first noticed by the patient as an asymmetry or increased circumference of an extremity. As swelling slowly progresses, patients may have difficulty fitting into clothing. Once well established, lymphoedema may cause fatigue related to the size and weight of the extremity, embarrassment in public, and severe impairment of routine activities. Recurrent bacterial or fungal infections are also common.
Majority of patients can be treated successfully with conservative measures.
Skin care, Manual lymph drainage massage, Compression techniques, Lymphoedema exercises, clothing instructions, lifestyle modifications & weight reduction measures are taught to the patient. Compression garments, compression aids, compression bandages, antifungal or antimicrobial therapy etc are prescribed in addition to Intermittent pneumatic pump compression when indicated. Regular follow up is done for all patients.
In-Patient Department
Hospital based management of intractable symptoms (Pain & Palliative)
Patients who cannot be managed on an outpatient basis or home care basis because of uncontrolled symptoms (pain, nausea, vomiting, constipation, intestinal obstruction, breathlessness, insomnia, delirium, convulsions, bedsores etc.) and or progressions of their disease and those who will be benefited by hospitalization will be admitted, managed and discharged based on medical assessment.
It offers in-patient care for patients when control of symptoms is inadequate on home care or OP basis.
Facilities for investigations are available for detailed evaluation.
Apart from oral medications, other routes of medicine delivery like continuous intravenous infusion, continuous subcutaneous infusion and continuous epidural infusion etc. are available for optimum control of symptoms.
The time spent in the hospital is also utilized to empower the family members in various other aspects like skin care, mouth care, bowel care, bed sore care etc, so that these could be continued at home once the symptoms are brought under control.
In-Patient Care for Cancer Patients
This department is also one of the constituents of the Comprehensive Cancer Institute of this hospital.
Along with the primary disease modifying treatment by the Medical, Surgical and or the Radiation Oncologist, we provide supportive care in the form of management of symptoms either related to the disease process or the disease modifying treatment. Counseling for emotional distress and working upon rehabilitation, all form part of providing palliative care to cancer patients and their families. Regular follow up of these patients is done to ascertain that the objectives aimed at achieving- physical, emotional, social and existential (spiritual) comfort, is maintained as realistically as possible.
Terminal Care
For various medical, emotional or social reasons, some families find it difficult to continue caring for their loved ones at home when the terminal stage of an illness is reached. The inpatient service provides terminal care for such patients and measures are taken to keep the patients comfortable in their last period of life. This facility is extended to patients of all specialties within and outside the institution, who are terminally ill.
Pain Relief Services for Non-Cancer Patients
Pain is the most common symptom that brings the patient to the hospital. Pain and Palliative Medicine offers consultation services to in-patients of all specialties within the hospital for management of intractable chronic and acute pains of various etiologies. A comprehensive assessment and evaluation of pain(s) is done and the management strategy recommended. The majority of the pains can be managed with pain medicines alone, while a minority of the pain cases may require hi tech interventions, of which this department is well equipped and is a leader in such services in the country.
Post Surgical Pain Management
This concept has been introduced in this Institution with the objective of providing a pain free surgical experience to our patients. This venture is in line with the goal of achieving a ‘Pain Free Hospital’ status for this institution by 2020.
We work in partnership with the Department of Gastro-surgery for management of postoperative pain. Since the start of this venture two years ago, some significant results have been seen. Post operatively the patient stays pain free, comfortable and satisfied with the overall hospital experience.
· This enables the patients to get mobilized early
· Wound healing is faster
· Patients are able to get back to their normal lives earlier.
· The postoperative hospital stay has been reduced to nearly half
· Ensured better bed utilization and faster turn over.
Other surgical specialties are also showing keen interest in such similar tie-ups. The constraints are awareness among health care professionals & human resources, which are being worked upon.
Home care
The very word home care signifies the services provided at home to the patients and their families, who cannot approach the hospital and avail its service for their treatment.
Objectives are:
· To provide active total care to the patient and family at home.
· To improve quality of life of the patients and their families.
· To set forth a team effort (by empowering the family) in the care of patients.
· To provide rehabilitation opportunities for the patients & relatives.
· To help patients live & die in the highest possible quality at home.
The concept of home care was adopted by AIMS in Jan 2001. It is provided for deserving patients who reside within a radial distance of 35kms from the hospital.
The patient who needs home care service has to register their names. They are assessed using a Performa, which is filled through the interaction with the patient’s caregivers.
On each day, the home care team visits 4 to 7 homes within the same geographical area. A multidisciplinary team consisting of the doctor, nurse, social worker and the co-ordinator visits the patients at home. If patients in one geographical area are less, then two areas are covered at a time.
Minor procedures like ascitic tapping, urinary catheterization & bladder wash, wound debridement, nasogastric intubation, enemas & rectal evacuation, sponge bath, Skin care, Mouth care, Bowel care, Tracheostomy care, intravenous & subcutaneous infusions & injections, Bedsore management, Lymphoedema management, Trigger point injections
The list of the patients and the areas to be covered on each of the days are made prior to the visit. Newer entries are incorporated into the list from time to time.
Areas covered:
North East - Nedumbassery, Desam, Athani up to Angamaly
North – Paravoor, Cherayi
East – Perumbavoor, Kizhakkambalam
West - Vypin, Fort Cochin, Mattancheri
South - Aroor, Thuravoor, Paluruthy
South East - Vaikom, Thalayolaparambu, Kanjiramattom, Thrippunithura
Beneficiaries are:
I.P- Patients who are admitted in the hospital and need no more hospitalized active treatment, can be looked after at home, need continued follow up and those who fall within the range of 35kms from the hospital
O.P- Patients who make visits to the O.P clinic but cannot do so in the future due to declining health condition, who need palliative treatment at home and who fall within the range of 35kms from the hospital.
Referrals from other hospitals that doesn’t have home care facility
Services under Home Care
Medical Intervention- The palliative care team not only looks into the physical care of the patients but gives emphasis on improving their quality of life which is centered around their family also.The patient population seen in home care consists of both cancer and non-cancer patients. The nursing care provided to the patients includes mouth care, skin care, catheterization, tapping, lymphedema measage, pre. Physiotherapy is also provided to the patients by the physiotherapist.
Psychological intervention- Being with the family and their family members and providing emotional support.
Bereavement support- to family members who have lost their loved ones by visiting the family even after the death of the patient and through phone calls.
Social support- Support to the family members is considered important in the total care of the patients .It is provided mainly by rehabilitating the patient and their families.
Rehabilitation is provided in three areas
1) Rehabilitate the patient
2) Rehabilitate the children (educational rehabilitation)
3) Rehabilitate the family members (vocational rehabilitation)
PECULARITIES OF HOME CARE SERVICE
Services in home care are provided free of cost to the poor patients which include free palliative care treatment, free doctor service and free vehicle charge.
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