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ABSTRACT
Palliative care is the
active total care of patients whose disease is
not responsive to curative treatment. Control
of pain, of other symptoms, and of psychological,
social and spiritual problems is paramount. The
goal of palliative care is achievement in family
practice, of the best possible quality of life
for patients and their families. With the increasing
burden of cancer patients, family physicians in
developed as well as developing countries are
expected to provide the best possible care to
patients with cancer pain. A good understanding
of the available pharmacological and non-pharmacological
options makes the task of caring for such patients
very rewarding and satisfying. Good end-of-life
care requires eliciting a shared understanding
of the patients' values and beliefs. Terminally
ill patients may prefer to be at home during their
last days, spending the rest of time with their
beloved ones and extended family rather than staying
in hospitals.
The existing heath care facilities are more attuned
to caring for acute health problems and they play
only a limited role in the care of the chronically
ill in society. Those who need continued supportive
care spend their lives not in the hospital, but
in the community among their family and neighbours.
Terminally ill patients can experience neurologic,
respiratory, infection-related, digestive, and
musculoskeletal symptoms all at the same time.
Physicians must adopt a systemic vision, a vision
that takes into account the effects that diseases
are having not just on patients but also on patients'
caregivers and loved ones. Family physicians are
the medical professionals best equipped to care
for most terminally ill patients, as their training
imparts the skills and knowledge needed to treat
common problems associated with every system of
the human body.
Key words: Palliative care, Family practice,
End of life care, symptom assessment, continuity
of care
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Introduction
Palliative care describes
comprehensive (physical, psychological, and spiritual),
interdisciplinary services that focus on alleviating
suffering and promoting quality of life for patients
(and their families) facing a life-threatening or terminal
illness.(1) These approaches provide comfort to dying
patients without necessarily modifying the underlying
medical condition. (2) This healthcare modality provides
relief of suffering and improvement in the quality of
life in various illnesses. Palliative treatment may
also be used to alleviate the side effects of curative
treatment, such as relieving the nausea associated with
chemotherapy in cancer patients. The care aims to maintain
dignity of the patient even in death and to sustain
and rehabilitate the individual's family.(3) Family
practice can involve the relief of symptoms such as
pain, shortness of breath, fatigue, constipation, nausea,
loss of appetite and difficulty sleeping, to help patients
gain the strength to carry on with daily life, improve
their ability to tolerate medical treatments, and help
them better understand their choices of care. Overall,
palliative care in family practice offers the patients
the best possible quality of life during their illness.(4)
Role of Family Physician in symptom management:
Primary care professionals have the potential and ability
to provide end of life care for most patients, given
adequate training, resources, and, when needed, specialist
advice. They can readily identify patients from cancer
and chronic disease registers who might benefit from
an early palliative care approach. We could deliver,
simultaneously, active treatment and patient centered
supportive care, through a team with whom many patients
have a valued long term relationship.(5) Palliative
care services need to be extended to patients with non-malignant
conditions who have comparable concerns to, and in some
cases even greater unmet needs, than cancer patients.
(6) General practitioners and community nurses can lead
the way in providing a palliative care approach for
patients with terminal organ failure illness. The first
step in such an approach is for the goals of care to
be discussed and agreed. Management plans are adjusted
accordingly.(7) Effective control of symptoms and maintaining
quality of life are prioritized. Establishing clear
goals can facilitate decision-making regarding treatment.
The main goals of palliative care are to prevent and
relieve suffering and to enable the best quality of
life possible for patients and their families, no matter
what the stage of disease or the need for other treatments.(8)
Physical symptoms and side effects, psychological and
psychiatric issues, and spiritual and existential dimensions
should be assessed and responded to based on the best
available evidence. Continuity of care and communication
among the varied settings involved should be promoted
and facilitated to help achieve these goals and to prevent
feelings of abandonment.(9) Once goals are established,
they can be used to construct advance directives about
the types of care that patients want. Gradual rise in
the prevalence of advance directives over the past decade
will improve their effectiveness, as physicians and
patients become more familiar with them and physicians
become more comfortable using them for assistance in
guiding the care of cognitively impaired adults.(10)
A fundamental goal of palliative care in family practice
is the relief of pain and other symptoms. Successful
approaches to the assessment and management of pain
and some physical and psychological symptoms have been
established in controlled trials.(11) Despite these
advances, under-treatment of symptoms persists in the
majority of patients and settings. Patient assessment
in end-of-life care should include the following: disease
history, physical symptoms, psychological symptoms,
decision-making capacity, information sharing, social
circumstances, spiritual needs, practical needs, and
anticipatory planning for death, have pain that contributes
materially to functional impairment and decreased quality
of life. Pain becomes an especially challenging issue
among patients with cognitive impairment.(12) Pain is
often not identified and tends to be undertreated in
long-term-care facilities and is also common among patients
who require end-of-life care. Relief of suffering begins
with routine and standardized symptom assessment with
use of validated instruments. Effectiveness of Family
Physicians' use of specific communication skills in
enhancing disclosure of the issues of concern to a patient,
decreasing anxiety, assessing depression, and improving
a patient's well-being and the level of the patient's
and the family's satisfaction is a goal of the treatment.(14)
Those communication skills include making eye contact
with patients, asking open-ended questions, responding
to a patient's affect, and demonstrating empathy.(15)
The confluence of enhanced attention to primary care
and palliative care education presents educators with
an opportunity to improve both (as well as patient care)
through integrated teaching. Improvements in palliative
care education will have benefits for dying patients
and their families, but will also extend to the care
of many other primary care patients, including geriatric
patients and those with chronic illnesses, who make
up a large proportion of the adult primary care population.
In addition, caring for the dying, and teaching others
to carry out this task, can be an important vehicle
for personal and professional growth and development
for both students and their teachers.(16)
Pain Relief:
Pain is often the most distressing symptom in patients
with cancer and if not managed appropriately, may destroy
the patient's existence with demoralizing effects on
relatives.(17) Each complaint of pain is valid and unique
with respect to its quality, intensity, duration, cause,
radiation, relieving and exacerbating factors. Clinicians
should document and be aware of outcomes of pain therapy.
It is helpful to think of pain-related outcomes as primarily
measured in two ways: decreased pain intensity and improvement
in psychosocial functioning.(18) Using rating scales
of pain intensity at its worst and on average and using
pain interference scales can help clinicians monitor
outcomes. Inadequate pain assessment prevents optimal
treatment in palliative care.(19) The content of pain
assessment tools might limit their usefulness for proper
pain assessment.(20) The medical community needs to
strengthen clinical competency and specialty skills
in order to ensure quality care at the end of life.
To that end, representatives promised to work within
their individual societies toward developing clinical
methods, tools, or guidelines to meet those needs.
Family Physician in Hospice/Community Resources:
Utility of health services is still inadequate in most
parts of developing countries. Lack of resources, illiteracy,
poverty, lack of awareness about the types of available
healthcare facilities among people developing palliative-care
services is a major challenge in this part of the world.(21)
Home-based palliative care significantly increases patient
satisfaction while reducing use of medical services
and costs of medical care at the end of life. This cost
saving value of home-based palliative care should result
in more end of life care taking place at the patient's
home.(22)
Hospice care always provides palliative care. However,
it is focused on terminally ill patients, people who
no longer seek treatments to cure them and who are expected
to live for about six months or less. The Family Physician
plays a vital role there too as physicians have a way
to align themselves with the patient, use their medical
expertise, and build a rich therapeutic relationship
over time. Palliation done by family physicians in the
community and hospices includes maintain regular contact,
be available, have knowledge of community resources
and covered services.
The primary care physician enhances quality of life,
and may also positively influence the course of illness
in conjunction with other therapies that are intended
to prolong life, such as chemotherapy or radiation therapy,
and includes those investigations needed to better understand
and manage distressing clinical complications. Family
practice also has opportunity for research-based evidence
on end of life care provision locally, nationally and
internationally through primary research studies and
reviews that can disseminate results in order to make
a practical and academic impact to establish appropriate
programs of education and training, as well as consultancy
services. They can work in partnership with key organizations
and individuals as a 'community effort' for the global
improvement of end of life care. Clinical studies, particularly
on the management of pain and other symptoms, understanding
the needs of family and planning interventions to support
them, are the prime goals. Family physicians are in
a good position to provide public education and awareness
of end of life issues as well as developing research
plans across the lifespan in chronic illness and end
of life care, from childhood to old age. (23) Family
practitioners can be a link to provide access to palliative
care and hospice care and respect the physician's professional
responsibility to discontinue some treatments when appropriate,
with consideration for both patient and family preferences.(24)
Such a program should be part of an overall strategy
to give people greater choice in their place of care
and death, and to provide training for health and social
care staff to help care for people at the end of their
lives. It aims to reduce the number of emergency admissions
to acute care for those who wish to die at home, and
reduce the number of patients transferred from care
homes to acute care in the last week of their life.(25,26)
Future Role of Family Physicians:
Family Physicians have a vital and active role to play
in providing care, support and solace in the final stages
of the illness and in guiding the patient and relatives
through a complicated and frightening process. The autonomy
of patients must be protected regardless of their level
of cognitive and/or physical incapacity. Their inability
to make certain care decisions should be assessed at
the outset, however. For patients who are no longer
able to make decisions, their previously expressed wishes
regarding end-of-life care should be respected. For
patients who are vulnerable (e.g. frail, elderly) but
who are still able to make decisions for themselves,
must be involved in decisions about their own care.
Recruitment of dedicated and committed volunteers is
not an easy task, but they are there in every community.
We should mobilize and provide basic training and give
them support. Maintaining a continuing education program
is another task. The volunteers value the friendship
and kinship they experience through their association
with palliative care.
Our health educational system needs to be updated regularly;
the information about palliative care to be made more
generally available and the popular sources of information
like newspapers and television should be used to disseminate
information on palliative care on a large scale. This
will also improve the utility of palliative care services,
provided by us, among the people.(6,21)
Care at the end of life focuses on making patients comfortable.
They still receive medicines and treatments to control
pain and other symptoms. Some patients choose to die
at home. Others enter a hospital or a hospice; either
way, services are available to help patients and their
families deal with the issues surrounding death. Suffering
is best relieved by using a team to approach to the
many elements involved in end-of-life care.
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