Say no to pain

Palliative care is a specialised branch that deals with the treatment of terminally ill patients, by giving symptom relief and also psychological and emotional support, says DR. MALLIKA TIRUVADANAN.

"We can cure physical diseases with medicine but the only cure for loneliness, despair and helplessness is love. There are many in this world dying for a piece of bread but there are many more dying for a little love."

Mother Teresa

CANCER continues to be a killer disease in spite of much research being done in the field. Approximately one million people are affected by it every year in India. Diagnosis at an early stage may ensure a good chance of a cure or at least a reasonable level of clearance of the disease. Unfortunately only a few come under this category, as early detection is the exception rather than the rule in our country. Thus more than two-thirds of cancer patients are seen at a stage well past that of curative treatment. They undergo many distressing symptoms of which pain is the most common. Ironically, it is more often for relief that they come to the doctor.

The pain can be excruciating. Left untreated it leads to a state of demoralisation and depression affecting quality of life. Needless to say the family too undergoes agony. At this point it may seem that there is little that can be done. The verdict that is usually given when curative treatment is not possible is "nothing more can be done". At this stage, society often associates the word "cancer" with suffering. This is not true anymore as there are ways and means to treat pain associated with cancer.

Certainly attempts to "cure" a patient at this stage are not only impractical but are a drain financially. Surgery, radiotherapy and chemotherapy do have definite roles to play in treatment. But at an advanced stage of the disease there may be little benefit. Such treatment is often expensive, with distressing side-effects that can sometimes be worse than the disease. In short, such treatment should not be offered purely because "there is nothing else to be done" but only with the clear objective of giving the patient quality of life.

Medical care ranges from complete cure to symptom relief. At the end of life, the latter gains importance, as preserving life becomes increasingly impossible. Palliative care medicine is a specialised branch of medicine dealing with the treatment of terminally ill patients by giving symptom relief and also psychological and emotional support.

Pain is the most common symptom. It is defined as "an unpleasant physical and emotional experience associated with tissue damage". Or, "pain is what the patient says hurts". It is how that particular individual feels. This emotional aspect has got to be given importance during treatment. When diagnosis is complete, one can imagine the mental turmoil the patient will face. "How long am I going to live?", "How will my family cope after I die?", "Will I be able to witness my child's marriage?", "Why is God punishing me?", are some of the questions. Besides, emotions such as anger and depression and other unpleasant symptoms - like vomiting, constipation insomnia and loneliness - can aggravate pain. On the other hand, love, companionship, understanding, relief of other symptoms or, just listening to their grief can actually help to bring down the intensity of pain and make it more tolerable. Therefore, one must understand that pain in cancer is not only physical but also influenced by emotional, psychological and even spiritual factors. This is what we call "total pain". If all these factors are not taken into consideration and only the physical aspect is dealt with, the patient is likely to come back with unrelieved pain in spite of the medication given.

The principles of pain relief in cancer are:

* To make a full assessment of the cause of pain, as most patients experience more than one pain.

* To take into account the psychological, social, and spiritual aspects of suffering without isolating them from the physical aspect.

Analgesic drugs (painkillers) are the mainstay of treatment and the patient is instructed to have them whenever he experiences pain. This is wrong as the pain recurs when the effect of the tablet wears off, and this is most distressing to the patient.

Cancer pain is continuous in nature (chronic), because of the persistence of noxious stimulus produced by the growing cancer cells. Thus the aim is to prevent pain rather than treat it. With this aim in mind, drugs are given at regular intervals and in a stepwise pattern in accordance with World Health Organisation (WHO) guidelines. Mild analgesics are started first and as severity increases, stronger analgesics are given, with morphine at the top of the list. In short, to make it effective and convenient for the patient, drugs are given orally. The choice of the drug and dosage is based on the severity of pain and not the stage of the disease.

More than 80 per cent of cancer pain can be controlled with this regimen. For the rest who do not respond to this, other methods are available.

* In those who cannot swallow, like in oral cancer, medications can be injected at regular intervals via syringe infusion pumps that can be plastered to the body.

* The nerves responsible for carrying the pain can be blocked at different levels. Numbing medicines (local anaesthetic solutions), nerve destroying solutions (neurolytics) and morphine and morphine-like drugs are used. A fine tubing can be inserted close to the spinal cord and the solution injected through the other end every few days, manually or via a computerised "pump" implanted under the skin. This can remain for months together producing a prolonged pain free state. In the case of cancer of the stomach or pancreas, a cluster of nerves, "plexus", can be injected with these solutions.

* Skin patches are available now. These look like "Band-aid" strips and release the painkiller in a sustained manner.

* Non-drug methods used along with drug regimen are electrical nerve stimulation at the skin level, relaxation and music therapy, physiotherapy and occupational therapy.

The word "palliative" is derived from the Latin word "pallium" which means a cloak or a cover. Thus palliative care "covers" the patient with not only symptom relief but also with compassion. As no sophisticated expensive equipment is needed, one may call it "high-touch low-tech" care. It is more difficult to treat patients with illness than those whose disease is curable. Professionals trained in this field can render treatment that is individualised and sensitive. It is unrealistic to expect one professional or individual to impart this kind of care. Thus palliative care is the active total care of the patients and their families by a multiprofessional team when the patient's disease is no longer responsive to curative treatment and whose life expectancy is relatively short.

The goals are:

* Relief for patients from pain and other distressing symptoms.

* Psychological and spiritual care for patients.

* To provide a support system to help patients live as actively and creatively as possible.

* To support and help families cope during patients' illness and in bereavement.

Well established abroad

It is pathetic to note that in India, less than three per cent of cancer pain is effectively treated. This is because palliative care medicine is still in the nascent stage while it is well established in the developed countries. There are more than 200 palliative care centres in the United Kingdom.

Palliative care can be given in a hospital, a hospice or at home. A hospice is not a "death house" as many people might think, but one which combines the expertise of a hospital and the love of a home. Palliative care centres (or hospices) are quite active with inpatient and outpatient facilities. Home care is also undertaken. Day care facilities bring patients and families close to each other.

Provisions are made for the former to develop and use their skills like painting, embroidery or craft work, to the maximum. General practitioners and specialists can practise palliative care. Basic training is all that is needed. At all hospitals where cancer (the disease) is being treated, palliative care (of the patient) must be provided. This is not difficult and can be done with existing facilities and practised by doctors without compromising on their respective specialities. It is heart- rending to note that there are instances where pain medication alone is given to these patients without hearing them out.

There are a few centres in Chennai doing active work in this field but we need many more throughout the State and country to cover our million cancer patients.

Palliative care is to prevent "last days" becoming "lost days" by offering appropriate care.

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