In most of the world, the majority of cancer patients are in advanced stages of cancer when first seen by a medical professional. For them, the only realistic treatment option is pain relief and palliative care. Effective approaches to palliative care are available to improve the quality of life for cancer patients.

The WHO ladder for cancer pain is a relatively inexpensive yet effective method for relieving cancer pain in about 90% of patients.

WHO’s pain ladder

WHO has developed a three-step “ladder” for cancer pain relief.

If pain occurs, there should be prompt oral administration of drugs in the following order: nonopioids (aspirin and Paracetamol); then, as necessary, mild opioids (codeine); then strong opioids such as morphine, until the patient is free of pain. To calm fears and anxiety, additional drugs – “adjuvants” – should be used. To maintain freedom from pain, drugs should be given “by the clock”, that is every 3-6 hours, rather than “on-demand” This three-step approach of administering the right drug in the right dose at the right time is inexpensive and 80-90% effective. Surgical intervention on appropriate nerves may provide further pain relief if drugs are not wholly effective.

Is Palliative care terminal care?

No. It is not only terminal care or only for dying. Palliative care emphasizes the quality of life of the patient and the treatment required to maintain as normal and positive a life as possible, irrespective of the number of years of life left and whether or not eventual cure is possible. Palliative care is “high-touch” care with special need for personal involvement and understanding.

What is palliative care? Is it just tender loving care?

In life-threatening (and generally prolonged) illness like cancer, AIDS etc, quality of life is decreased by.

• Physical problems like pain, nausea and vomiting, breathlessness, fungating ulcers and so on
• Psychological problems like depression, anger or denial in response to the illness, emotional isolation etc
• Social problems like financial burden induced by loss of employment, cost of treatment, social isolation etc.
• Spiritual pain (Why me? Why did God do this to me? Or what is the point of my being alive?)

Palliative care is the active total care of the person with such problems. The aim of treatment is improvement of quality of life. The disease process is actively addressed. For example, if it is amenable to surgery, chemotherapy or radiotherapy, these measures are pursued provided they can improve quality of life. Pain and other symptoms are actively treated. At the same time, the emotional, social and spiritual problems are attended to.

When does palliative care start? When the disease is declared incurable?

In one word, no
In answer to question 1, we saw the various problems that adversely affect the quality of life. We can easily see that all these problems would exist at the time of diagnosis as well as all through the phase of treatment, whether it is radiotherapy, chemotherapy or surgery. Hence ideally, all principles of palliative care must be applied from the time of diagnosis. The patients’ need for emotional support may be most when the diagnosis is broken to him. Emotional support will also significantly increase the patient’s compliance to definitive treatment. So it will be best for the patient if modalities of palliative care are applied concurrently with definitive treatment. However, the need for palliative care does become more when the disease is declared incurable.

Some people continue to follow the old WHO definition and say that the term palliative care applies only to the incurable. They may then follow a different terminology and use the term supportive care to describe the active total care that is given during definitive treatment. The terminology matters little. What really matters is that you consider the patient as a whole and address all domains of the patients’ problems, whether or not the disease is curable.

Palliative care is not only for the patient; it is also for the family. Therefore it does not end even if the patient dies. It includes bereavement support for the family.

And all this applies only to cancer and AIDS?

No. It applies to any long-standing disease that causes poor quality of life. Cardiac or renal disease, chronic pain states, quadriplegia or paraplegia, all maybe need an appropriate application of the same principles. Some people use the term long term care (LTC) to describe this.

And it includes rehabilitation of the patient and the family.

Is not morphine what is used for pain relief??

Morphine is only one of the drugs that are used to relieve pain. Morphine does not work in all pains. Only about two-thirds of all pains can be adequately treated with morphine. It is important that the type of pain is identified and the appropriate drugs are used. And morphine is seldom used alone. It is combined with other appropriate painkillers depending on the type of pain. If morphine is used in pains that are not morphine-responsive, it will only make the patient sedated and cause side effects.

Will the patient on morphine be sedated for the rest of life?

No, certainly not. If morphine is used in morphine-responsive pain in the right dose, it does not cause sedation in the majority of cases. In fact the patient can often pursue a profession and lead a normal life while on morphine.

Will morphine not cause addiction?

No, not if used properly. Medical science has clearly understood in the last few decades, that if morphine is used in doses adequate for pain relief, it does not cause addiction. The fear is totally unfounded.

What about pains that do not respond to morphine?

About one-third of all pains fail to respond to morphine. Most neuropathic pains, for example, are only partially responsive to morphine. Assessment of the type of pain and evaluation of opioid sensitivity is, therefore, key to proper management of pain. Most of these pains can be adequately treated if we use the right combination of non-opioid analgesics and adjuvant drugs. Of course, to do this some training in evaluation of pain and management is necessary.