Changing the paradigm
Palliative care (from the Latin palliare, “to cloak”), as used in cancer management, is any treatment that aims to reduce the severity of disease symptoms, instead of trying to delay the progression of the disease or offering a cure. Many definitions of palliative care exist. The WHO defines it as: “… an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” The very essence of palliative care is thus improving the quality of life for people facing serious, complex illness. This then begs the question: Why are palliative care teams not involved earlier on the management of patients undergoing treatment for cancer? Areas that have been found to enhance the patients’ ability to cope with the diagnosis of cancer and its treatment include adequate pain management, proper nutritional advice and support, and psychosocial support. The goal of palliative care warrants that this supportive care is made available to all patients from the outset of their journey through cancer treatment. Comprehensive pain management begins with identifying the origin and nature of pain and treating each one specifically. This may range from simple OTC medication to opioid-containing drugs that deliver around the clock relief. Consideration must be given to break-through pain relief, and supplemental analgesia should be made available for this. Common side-effects, such as nausea and constipation, must be prevented; and fear regarding addiction and tolerance to opioid analgesics should be addressed with both the patient and family from the beginning. Coanalgesics (antidepressants, anticonvulsants, and corticosteroids), and behavioural and cognitive therapies may help optimise, and individualise pain management. Another avenue that should be explored is procedure-orientated pain control, especially when pain is poorly managed by pharmacologic means, or is associated with intolerable side-effects. Options include radiofrequency ablation, chemical neurolysis, and cryoanalgesia. These interventions may assist in upper abdominal visceral pain, pelvic pain, vertebral body metastases, and perineal pain. A second sphere where palliative care teams can play an important role is in the awareness of malnutrition from the burden of cancer and side-effects from chemotherapy. This impacts on a patient’s performance status, quality of life, and paradoxically, on treatment response. These care teams are able to provide education that will ensure a patient is able to prevent weight loss and maintain an ideal protein status, be it through the use of supplements or intravenous feeds. And lastly, the issue of psychosocial distress is one of the most unrecognised and untreated aspects of cancer management. Thankfully this can be addressed with the help of palliative care teams. A review of nearly 5000 patients at the Johns Hopkins Oncology Centre revealed that as many as 35% of cancer sufferers experience anxiety, depression and adjustment disorders. These may be prevented or alleviated by emotional support and information, together with an exploration of their fears about disease progression, psychosocial difficulties, and even addressing fears of death. These are just some of the few important aspects in cancer management where palliative care teams are able to provide a valuable support to patients. Perhaps it is time that the misconception that palliative care exists only in ‘the end of days’ needs to be put to rest. To palliate is to cloak, to cloak the compounding issues of an already undesirable diagnosis to ensure that quality of life is always at the forefront of every patient’s management.
By Dr Jason Naicker