Palliative Care

Introduction

Palliative care is a multidisciplinary approach that improves the quality of life of patients suffering from life-limiting illnesses. It focuses on pain relief, symptom control, psychological support, and end-of-life care. Unlike curative treatment, palliative care prioritizes comfort and dignity.

Definition of Palliative Care

According to the World Health Organization (WHO):“Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems—physical, psychosocial, and spiritual.”

Key Components

• Symptom Management: Pain, dyspnea, nausea, fatigue.

• Psychosocial Support: Anxiety, depression, grief counseling.

• Ethical Decision-Making: Do-not-resuscitate (DNR) orders, advance directives.

• End-of-Life Care: Comfort measures, dignity therapy.

• Support for Caregivers: Emotional and practical guidance for families.

Indications for Palliative Care

1. Oncological Conditions:

• Metastatic cancers

• Chemotherapy- or radiation-induced symptoms

2. Neurological Disorders:

• Stroke with poor prognosis

• Motor neuron disease (ALS)

• Parkinson’s disease, multiple sclerosis

3. Cardiopulmonary Diseases:

• Advanced heart failure

• Chronic obstructive pulmonary disease (COPD)

4. Renal & Hepatic Failure:

• End-stage renal disease (ESRD) not on dialysis

• Cirrhosis with liver failure

5. Progressive Infectious Diseases:

• HIV/AIDS

• Tuberculosis (end-stage)

6. Geriatric & Frailty Syndromes:

• Dementia (advanced stages)

• Bedridden elderly with multiple comorbidities

Palliative Care vs. Hospice Care

Principles of Palliative Care

1. Holistic Approach: Addresses physical, psychological, social, and spiritual needs.

2. Team-Based Care: Involves doctors, nurses, psychologists, social workers, and chaplains.

3. Patient-Centered Care: Focuses on patient preferences, autonomy, and dignity.

4. Symptom Management: Uses pharmacological and non-pharmacological interventions.

5. Continuity of Care: Supports patients from diagnosis to end-of-life.

6. Family Involvement: Provides counseling and education for caregivers.

Symptom Management in Palliative Care

1. Pain Management

Pain is the most common symptom in palliative care and follows the WHO Pain Ladder:

WHO Analgesic Ladder

• Step 1 (Mild Pain): Paracetamol, NSAIDs

• Step 2 (Moderate Pain): Weak opioids (Tramadol, Codeine) ± Step 1 drugs

• Step 3 (Severe Pain): Strong opioids (Morphine, Fentanyl, Methadone) ± Step 1 drugs

Adjuvant Analgesics

• Neuropathic Pain: Gabapentin, Pregabalin, Amitriptyline

• Bone Pain: Bisphosphonates, Radiotherapy

• Visceral Colic: Hyoscine butylbromide

2. Dyspnea Management

• Opioids (Morphine): Reduces breathlessness perception.

• Oxygen Therapy: If hypoxic.

• Benzodiazepines: Lorazepam, Midazolam for anxiety-induced dyspnea.

3. Nausea and Vomiting

• Metoclopramide: Prokinetic.

• Ondansetron: For chemotherapy-induced nausea.

• Haloperidol: For opioid-induced nausea.

4. Constipation

• Laxatives: Senna, Lactulose.

• Methylnaltrexone: For opioid-induced constipation.

5. Anxiety & Depression

• SSRIs (Sertraline, Fluoxetine): For long-term management.

• Benzodiazepines (Lorazepam, Diazepam): Short-term relief.

• Cognitive Behavioral Therapy (CBT): Psychological support.

6. Delirium & Agitation

• Haloperidol: Preferred for terminal agitation.

• Midazolam: For severe restlessness.

7. End-of-Life Symptoms

• “Death Rattle” (Respiratory Secretions): Glycopyrrolate, Scopolamine.

• Terminal Sedation: Midazolam, Phenobarbital if distressing symptoms.

Ethical and Legal Aspects in Palliative Care

• Informed Consent: Patients must understand their prognosis and options.

• Advance Directives: Legal documents outlining patient’s wishes (e.g., DNR).

• Euthanasia: Intentional act to end life (illegal in most places).

• Palliative Sedation: Sedation to relieve distressing symptoms without hastening death (ethical).

Palliative Care in Special Populations

1. Pediatric Palliative Care

• Pain management: Fentanyl patches, Methadone.

• Play therapy, music therapy for emotional support.

• Parental counseling and bereavement support.

2. Geriatric Palliative Care

• Polypharmacy risk: Simplify medication regimens.

• Cognitive decline: Advanced care planning.

MCQs for Postgraduate Exam

1. Which opioid is preferred for dyspnea in palliative care?

a) Codeine

b) Morphine

c) Tramadol

d) Buprenorphine

Answer: b) Morphine

2. Which medication is NOT an adjuvant analgesic?

a) Amitriptyline

b) Pregabalin

c) Haloperidol

d) Gabapentin

Answer: c) Haloperidol

3. What is the main advantage of fentanyl patches in palliative care?

a) Rapid onset

b) Non-invasive long-term analgesia

c) Less opioid side effects

d) Better nausea control

Answer: b) Non-invasive long-term analgesia

4. Which drug is most effective for opioid-induced constipation?

a) Loperamide

b) Methylnaltrexone

c) Domperidone

d) Ondansetron

Answer: b) Methylnaltrexone