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.

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.

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.

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%

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

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

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

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

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.

Vaginal bleeding Vaginal packing Radiation therapy Uterine artery embolisation

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

Advance care planning

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

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.

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

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

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)

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

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

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.

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

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

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……

THANK YOU