1. Cervical cancer: Where does the care end?
Dr.G.J.Pratheepan MBBS, MD, MRCP(UK), FRCP(Edin)
Consultant Physician
Teaching Hospital, Jaffna
JMA Annual Sessions 2017
Good morning Ladies and gentleman. We have come to the end of symposium. What ever starts should end. The Plane lands, The sun sets…The care ends. Its time to talk about both the Science and the art. I think we also need to ask the question, How does the care end? Obviously we know the care end with the end of the patient. But How the care has been given often gives an important message to the family, friends and the health care team.

2. Palliation in General
Providing quality of life to the terminally ill patient and supporting the carers.
It is about providing comfort to the terminally ill patient and the family and it goes beyond the death of the patient as bereavement support, in a holistic manner addressing all the aspects of the life.
Palliation comes from The Greek word palliare means – to cloak or to mask, which means, even though the actual situation is beyond our control, we help the patient by other means.

3. Palliation in non cancer
Palliation in cancer
Palliation in non cancer
Though palliation was originally provided for cancer patients, now it has become an umbrella term to embrace all needy patients from both cancer and non cancer.

4. JMA 2017 Cancer 49% Non cancer 51%
A demographic study of the medications used in subcutaneous syringe drivers in a palliative care setting – An Australian Experience Pratheepan1 G.J, Jenny Crane2
JMA 2017
Cancer 49% Non cancer 51%

5. 1. Symptom control 2. Advance care planning 3. End of life care
Palliative care
1. Symptom control 2. Advance care planning 3. End of life care

6. Palliation in Cervical cancer
Moving from Cure to symptom control
Chemo radiation
Other measures
Palliative measures are different for local spread and distant spread

7. symptoms Pain is usually the main symptom Other issues : Bleeding
symptomatic pleural effusion
ascites
DVT
urinary fistulas and ureteral obstruction
Uremia from ureteral obstruction
Dyspnea from anemia / pulmonary involvement
Depression / Anxiety

8. Pain Due to regional nerve, muscle and bone infiltration
Need to optimize the patient’s ADL
Exclude oncologic emergencies
Spinal metastasis
Fractures
Opiates are the main stay of pain management

9. Pain Regular opiates - Morphine Long acting preparations
Fentanyl patches
Managing the pain crisis with medications
When there is a constant pain, there should be regular opiates. WHO step ladder, Usually opiates are not combined, except with patches when the same medication is not available.
The breakthrough dose is usually 1/6 of the total dose.
Pain crisis 8 and above. 10mg morphine in 10 ml saline. Iv push. Untill 2/10 pain score, keep naloxone handy.
Oral to parenteral calculation due to the first pass metabolism.

10. Vaginal bleeding Vaginal packing Radiation therapy
Uterine artery embolisation

11. MDT approach Gynecologic oncologist Radiation oncologist
Radiologist / Interventional radiologist
Palliative care physician

12. Advance care planning

13. What is it?
Planning the patient’s future care with the patient’s current situation, according to the patient’s wishes

14. Why is it important? To give peace of mind to the patient and family
To avoid decisions to happen in an emergency
To avoid important decisions to be taken other than the patient.
To provide the best possible care to the patient.
To maintain the autonomy of the patient
To enhance the work satisfaction of the treating team.

15. Terminal discharge
Discharging patients at his/her or the family’s request, for death at home which is likely to occur within the next few hours or a few days

16. Consider...... • Patient’s wishes • Family’s requests • System support
• Medication supply
• Symptom control
• Information requires
• Psychosocial support

17. Patient’s wishes
• Many patient with advanced cancer would prefer to be cared for and to die at home.
(Higginson I J et al1998,2000) (Wilkinson S 2000)

18. Place of death
Up to 70% of palliative care patients wish to be cared for and to die at home

19. Discharge planning Considerations:
Continuous care at home – nursing care
Caregiver coping
Resource available – transport, home care team
Provide medication
Provide information

20. About carers
Anyone who cares, unpaid for a friend or family memberwho due to illness, disability, a mental health problem or an addiction cannot cope without their support.
The carer burden is often very high, especially in a palliative setting.

21. By being a carer Self satisfaction and rewarding Can lead to poverty
Losing recreation
Losing career opportunities
Carer burnout & depression

22. Qualities of a good death
1. Experience as little pain as possible
2. Recognise and resolve interpersonal conflicts
3. Satisfy any remaining wishes that are consistent with their present condition
4. Review their life to find meaning
5. Handing over control to a trusted person
6. Be protected from needless procedures
7. Decide how social and how alert they want to be

23. Everyone dies only once……
Everyone dies only once……. At least half the importance of a birthday celebration needs to be given to the dying patient……

24. THANK YOU