Dr Rakesh Roy, Chief Clinical Tutor & Incharge, Dept of Palliative Care, SGCCRI

October 12 marks World Hospice and Palliative Care Day. Dr Rakesh Roy, Chief Clinical Tutor & Incharge, Dept. of Palliative Care, SGCCRI, Kolkata in conversation with Shahid Akhter, ENN, demystifies myths and misconceptions about Palliative Care.

Is palliative care for terminally ill patients only?
Not necessarily. While palliative care certainly includes terminal care, it also includes the care of the patients who may have a long time to live but suffering from life threatening or incurable disease. For example, both in AIDS and slow growing cancers, the patients may have long survival, and palliative care is certainly needed.

Does palliative care start when the disease is declared incurable?
In one word no. Ideally all principals of palliative care must be applied from the time of diagnosis. The patients need for emotional support may be most when the diagnosis is broken to him. Emotional support will also significantly increase the patients compliance to definitive treatment. So it will be best for the patient if modalities of palliative care are applied concurrent with definitive treatment. However the need for palliative care does become more when the disease is declared incurable.

Why is palliative care different?
Palliative care is not only for the patient; it is also for the family. Therefore it does not end even if the patient dies. It includes bereavement support for the family.

Does palliative care apply only to cancer and AIDS patients?
No, it applies to any long standing disease that causes poor quality of life though cancer contributes majority of the palliative care patients. Chronic obstructive pulmonary disease, cardiac or renal disease, chronic pain states, quadriplegia or paraplegia, all may need appropriate application.

What are the components of palliative care and is it available to affluent patients or the poor too can get this care?
Components of palliative care include facilities for outdoor care, inpatient care and domiciliary care. Palliative care is for all. Since this care involves cheap drugs therefore even the poor can afford

Is palliative care available only in cities and what are the barriers to palliative care in India?
Palliative care is available in rural area as well. Through link centres and specialist home care delivery systems the state of Kerala has been able to provide quality palliative care to all corners.
Barriers to Palliative Care include poor drug availability, lack of education and awareness amongst physicians and community and lack of policy at the level of institution and government.

Why is drug a barrier and is Morphine very expensive?
Morphine which is WHO approved for treatment of severe cancer pain is not easily available. India manufactures morphine in few states. However it is a national shame that inspite of being a major morphine exporting country only a handful of patients have access to morphine. No. Contrary to it, Morphine is very cheap.

Is palliative care available only in cities and what are the barriers to palliative care in India?
Palliative care is available in rural area as well. Through link centres and specialist home care delivery systems the state of Kerala has been able to provide quality palliative care to all corners.
Barriers to Palliative Care include poor drug availability, lack of education and awareness amongst physicians and community and lack of policy at the level of institution and government.

Why is drug a barrier and is Morphine very expensive?
Morphine which is WHO approved for treatment of severe cancer pain is not easily available. India manufactures morphine in few states. However it is a national shame that inspite of being a major morphine exporting country only a handful of patients have access to morphine. No. Contrary to it, Morphine is very cheap.

Will the patient on morphine be sedated for the rest of the life?
No, certainly not. If morphine is used to morphine-responsive pain in the right dose, it does not cause sedation in the majority of the cases. In fact the patient can pursue a profession and lead a normal life while on morphine.

According to WHO around 24 million adults require palliative care at the end of life each year. 66 percent of these are over 60 years old. Despite this growing need, 42 percent of countries still have no identified hospice and palliative care service, while 80 percent of people globally lack adequate access to medication for treatment of moderate to severe pain.

Will morphine cause addiction?
No, not if used properly. Medical science has clearly understood in the last few decades, that if morphine is used in doses adequate for pain relief, it does not cause addiction. The fear is totally unfounded. Morphine features in the top tier of WHO analgesic ladder. So people should not think morphine is a banned drug.

Will there be withdrawal symptoms if morphine is stopped abruptly?
That is not correct either. There may be withdrawal symptoms if morphine is withdrawn abruptly from som one who has been on the drug for a long time. But withdrawal symptoms do not mean addiction. We have to distinguish between addiction and physical dependence. In simple term addiction can be described as psychological dependence, manifesting as craving for the drug, steadily increasing quantity of consumption unrelated to disease progress and continued use despite harm.

If morphine is taken for pain now, will it become ineffective later when the pain gets worse?
No, this fear is unfounded too. Morphine can be continued as long as required.

Does oral morphine have side effects?
Morphine causes constipation and nausea, vomiting. However these can be effectively managed. Used with reasonable caution, it is almost impossible to cause respiratory depression with oral morphine. The right dose of morphine is what is needed to relieve the pain. If this dose is exceeded, there are toxic signs like drowsiness, delirium, and myoclonus. These serve as warning signs which prevent further consumption of the drug.

The famous psycho-oncologist Buckman, once said that there was one missing chapter in Harrisons Textbook of Internal Medicine. The missing chapter was What do you do when all the treatment advised in all other chapters fail? Palliative care is that missing chapter. It is about treating the illness rather than the disease

Can palliative care be delivered by any doctor or nurse or is it something to be done only by the specialists?
Palliative care is multi-disciplinary care. Family members, volunteers and professionals all have their role to play. But for anyone to do this optimally, some amount of training is necessary.
Ideally palliative care is something to be incorporated into routine medical practice. For this palliative medicine has to become part of medical and nursing curriculum. For the time being, a short period of training would enable any volunteer, doctor or nurse to practice principles of palliative care. And they have the responsibility to train the family member in caring for the patient.

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