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Commentary |

Improving Care at the End of Life

Corita Grudzen, MD, MSHS; Deborah Grady, MD, MPH
Arch Intern Med. 2011;171(13):1202. doi:10.1001/archinternmed.2011.132.
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It is widely assumed that more medical care (ie, more tests and procedures) results in better outcomes and that adequately treating pain and other symptoms brings death closer, but there is mounting evidence to suggest otherwise. In addition to the risk of harm that is inherent in all tests and procedures and the discomfort associated with much end-of-life care, new evidence suggests that treating patients' pain and other symptoms is associated with improvements in physical status and may even lengthen survival.1 In fact, at Mt Sinai School of Medicine, New York, New York, an elderly man with hematemesis who was treated with “comfort measures” fared better than a woman with end-stage renal disease who was treated aggressively. Over the next 5 months, the woman was admitted twice to revise her fistula, once for urosepsis, once for hyperkalemia, and finally, for a high-grade small bowel obstruction. After resection of ischemic bowel, she developed overwhelming sepsis and multiorgan failure. One day before her death, the surgical and intensive care unit team communicated her poor prognosis to the family, and she was given a do-not-resuscitate order and weaned from the ventilator. After transfusion, the elderly man was back to baseline and was discharged the following day. He never returned to the emergency department or the hospital.

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In Public Health CareSystem of W.B , India ,the system of End of Life Care Does Not Exist
Posted on May 10, 2011
Professor Pranab kumar Bhattacharya, MD(cal) FIC Pah(ind.)
Professor and Head, Department of Pathology, Calcutta School of Tropical Medicine; C.R avenue. W.B,,
Conflict of Interest: None Declared
Title-: In The Public Health Care System of W.B , India ,the system of End of life Care and Palliative care does not exist and require efforts focused on increasing the palliative care workforce and providing care options better suited to patient needs Both clinician- and system- level changes are needed to improve care for patients with advanced illness
Over 70% of all deaths, occur in those >60-69 years of ages in India. The epidemiology of human mortality is possibly similar in most of developing countries; cardiovascular diseases, like Heart failures, COPD, chronic Renal failure, Stroke, Diabetes and cancer and other chronic diseases are today one of the many predominant causes of death also seen in Kolkata, West Bengal, then it was in late few decades of 19th century, Total death in West Bengal as recorded by govt. civil registration in 2006[ as collected by first author- unpublished data] was 2,89,321 people. The crude death rate in west Bengal is 6.2 per 1000 adult population (male 6.8 when female5.6) when infant mortality rate is 37% in 2008. The crude death rate in India is7.4 per 1000 populations in 2008 ,when infant mortality rate is 55.A sample registration system in west Bengal by the authors showed in 2008 , 54% death here occurs in age range 60-69 years, when in rural west Bengal percentage of death in that age range was 59% when in urban areas it was 48%. The causes of death in Medical colleges in the year 2006 based on a study of 7500 deaths[ by first author] causes of deaths are like this-: Cerebro vascular and cardiovascular causes- 34%, COPD and Tuberculosis -15%; Respiratory Infections-0 4%; Cancer- 5.22%; Burns- 8% ;Road Traffic Accident -04%; Diabetes-0 4% ;The causes of death in district and subdivisions in rural West Bengal however varied based on 7600 deaths. Cardiovascular death and cerebro vascular causes was- 36 %, poisoning-0 9% ,COPD and Tuberculosis was -10% ;Respiratory infections was-0 7% percent, Burns -06% , Road Traffic Accidents 05%, Cancer- 1.5%, Diabetes -1.52%,. This is an average district and Sub divisional data of West Bengal in 2008, AIDS also accounted for <0.1% of all deaths, although among those age 35–44, it remains however a leading cause of death in Western World . So it is reasonable to plan for dying in the foreseeable future .Since heart failure, chronic obstructive pulmonary disease tuberculosis (COPD), chronic liver failure and hepatities (2.24%), Chronic Renal failure and nephritis ,Nephrotic syndrome (0.5%), cirrhosis(1.07%) Sepsis (0.4%) dementia and many other conditions have a recognizable terminal phases, a systematic approach to end-of-life care may be thus part of all medical specialties and in teaching prograame. Terminally ill patients have a wide variety of advanced diseases, often with multiple symptoms, demanding relief, and require noninvasive therapeutic regimens to be delivered, in flexible care settings. Fundamental to ensuring quality palliative and end -of-life care is thus can be limited with a focus on four broad domains: (1) physical symptoms; (2) psychological symptoms; (3) social needs that include interpersonal relationships, care giving, and economic concerns; and (4) existential or spiritual needs. Questions should aim at elucidating symptoms and discerning sources of suffering and gauging how much these symptoms interfere with the patient's quality of life. Many patients with illness-related sufferings, can also benefit from palliative care settings , regardless of prognosis. Ideally, palliative care should be considered as a part of comprehensive care for all patients who can afford it, as palliative care is very costly. In USA, about 40% Patients dies in Hospital. When the picture is reverse in West Bengal About 70% of patients here die out of the hospital and in home setting. Even those who take a treatment in the hospital.. In Cuba however >70% population die under palliative care in Hospices. .
One must remember that when an illness becomes life-threatening, there are many emotionally charged and potentially conflict-creating personable and moments, collectively we call "bad news" situations, in which empathic and effective communication skills are essential. These moments include communicating to the patient and/or family about a terminal diagnosis, the patient's prognosis, any treatment failures, deemphasizing efforts to cure and prolong life while focusing more on symptom management and palliation, advance care planning if possible and affordable, and the patient's way of death. Advance care planning is a process of planning for future medical care in case the patient becomes incapable of making medical decisions. Ideally, such planning would occur before a health care crisis or the terminal phase of an illness. Advance care planning documents are of two broad types. The first includes living wills or instructional directives; these are advisory documents that describe the types of decisions that should direct care. Some are more specific; less specific directives can be general statements of not wanting life-sustaining interventions or forms that describe the values that should guide specific terminal care decisions. But every thing must be after assessing the status of important relationships, financial burdens, care-giving needs, and access to medical care. Common Physical and Psychological Symptoms of Terminally Ill Patients and primary management [As Per Harrison’s Text Book of Medicine. 17th Edition Chapter 11. Palliative and End-of-Life Care] Physical Symptoms 1] Pain- Substantial pain occurs in 36–90% of patients with advanced cancer. 50% had similar levels of pain during the last few days of life. It tends to be localized, aching, throbbing, and cramping. The classic example is bone metastases. Visceral pain is caused by nociceptors in gastrointestinal, respiratory, and other organ systems. It is a deep or colicky type of pain classically associated with pancreatitis, myocardial infarction, or tumor invasion of viscera. Neuropathic pain arises from disordered nerve signals. It is described by patients as burning, electrical, or shock like pain. Classic examples are post-stroke pain, tumor invasion of the brachial plexus, and herpetic neuralgia. Pharmacologic interventions follow the World Health Organization are three -step approach involving non opioid analgesics, mild opioids, and strong opioids, with or without adjuvant. If non opioid analgesics are insufficient, then opioids should be introduced. For continuous pain, opioids should be administered on a regular, around-the-clock basis consistent with their duration of analgesia. The goal is to prevent patients from experiencing pain. Drowsiness, a common side effect of opioids . donepezil may also be helpful for opiate-induced drowsiness, Gabapentin, is now the first-line treatment for neuropathic pain from a variety of causes. One potential side effect to be aware of is confusion and drowsiness, especially in the elderly. 2] Fatigue and weakness More than 90% of terminally ill patients experience fatigue and/or weakness. Fatigue is frequently cited as among the most distressing of symptoms 3] Dyspnea Nearly 75% of dying patients experience dyspnea at some point in their illness. Dyspnea is among the most distressing of physical symptoms and can be even more distressing than pain .When reversible or treatable etiologies are diagnosed, they should be treated. 4]Nausea and vomiting When a single specific cause is not found, many advocate beginning treatment with dopamine antagonists such as haloperidol or prochlorperazine. Prochlorperazine is usually more sedating than haloperidol .For post-chemotherapy and -radiation therapy nausea, one of the 5-HT3 receptor antagonists (ondansetron, granisetron, dolasetron) is recommended. 5] Constipation- is reported in up to 90% of terminally ill patients. If untreated, constipation can cause substantial pain and vomiting and is also associated with confusion and delirium. Constipation can be tackled with physical activity, adequate hydration, and dietary treatments with fiber may be helpful, Fiber is contraindicated in the presence of opioid use. Osmotic laxatives, stool softeners, fluids, and enemas are the mainstays of therapy . When preventing constipation from opioids and other medications, a combination of a laxative and stool softener (such as senna and docusate) should be used. Fecal and urinary incontinence
Other Physical Symptoms that should be also managed in end of life care are Insomnia, Dry mouth, Anorexia, Dizziness, Cough, Itching ,Numbness/tingling in hands/feet
Psychological Symptoms those must be cared for terminally ill are Anxiety Depression Hopelessness Meaninglessness Irritability Impaired concentration Confusion Delirium Loss of libido
The problem in West Bengal provinces of India are , in the public Health Care System, the system does not permit or have not at all conscientious guide line and facility for end of life care management and there are-level constraints on End-of-life care, including bed availability for admissions on this very issue and access to Palliative care–trained clinicians and nurses. The traditional objective of advance care planning has been to have patients make treatment decisions in advance of serious illness so that clinicians can attempt to provide care consistent with their goals. Although advance directives have shown benefit in some cases , they frequently do not affect the quality of end- of-life care or improve clinician and surrogate knowledge of patient preferences . Substantial improvements have been made in advance directives and advance care planning (6, 14–16), but many of these efforts still aim at, and are judged to be successful by, achieving the traditional objective of making advance decisions—an objective that is fundamentally flawed patients’ treatment preferences and values change when their health changes (19, 23–25). At the end of life (26 –One major determinant of changing preferences is adaptability. However, broad values statements, such as wanting to maintain dignity or be free from pain, are often too general to inform individual treatment decisions. we propose that the main objective of advance care planning be to prepare patients and surrogates to participate with clinicians in making the best possible in-the moment facility and decisions. . Our this article and discussions may in future led to efforts focused on increasing the palliative care workforceand providing care options better suited to patient needs Both clinician- and system-level changes areneeded to improve care for patients with advanced illness
Authors of the article(E letter)
*Professor Pranab kumar Bhattacharya- MD(cal) Patho, FIcPath(Ind.),Presently Professor and Head, Department of Pathology, Calcutta School of Tropical Medicine; C.R avenue Kolkata-73. W.B. India and Ex- Additional Professor of Department of Pathology, Institute of Post Graduate Medical Education & Research,244 AJC Bose Road, Kolkata-20, West Bengal, India; *Miss Upasana Bhattacharya- Student, Mahamayatala, Garia, kol-86, only daughter of Prof.P. K Bhattacharya ** Mr. Rupak Bhattacharya-Bsc(cal), Msc(JU), 7/51 Purbapalli, Sodepur, Dist 24 Parganas(north) Kol-110,West Bengal, India **Mr.Ritwik Bhattacharya B.com(cal), **Mr Soumyak Bhattacharya BHM;** Miss Rupsa Bhattacharya of residence7/51 Purbapalli, Sodepur, Dist 24 parganas(north) ,Kolkata- 110,WestBengal, India *** Mrs. Dalia Mukherjee BA (Hons.) Cal, Swamiji Road, South Habra, 24 Parganas(north), West Bengal, India***Miss Oindrila Mukherjee-Student ,Swamiji Road, South Habra, 24 Parganas(north), West Bengal, India****; Mr. Surajit Sarkar BSC, DMLT, Technician, Pathology, Institute of Post Graduate Medical Education & Research,244 a AJC Bose Road, Kolkata-20, West Bengal, India , Kolkata-20 ****Dr. Tridibeshawr Mandal MD(cal) Biochemistry IPGME&R Kol-20; Dr. Hriday Ranjan Das MD(cal) DTM&H (cal) Medical officer Nephrology IPGMER Kol-20

Conflict of Interest: None declared
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