Pallium India Newsletter: November 2013

From: Pallium India Newsletter <info@xxxxxxxxxxxxxxxx>
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Date: Sat, 30 Nov 2013 22:11:07 +0000

Pallium India
Care Beyond Cure

DEAR FRIENDS,

PEOPLE OF INDIA, LET US NOT FAIL OUR FELLOW HUMAN BEINGS IN PAIN.

The Indian Parliament meets for the third time this year, on the 5th of
December 2013. The long-awaited amendment of the draconian Narcotic Drugs and
Psychotropic Substances (NDPS) Act of India (Lord, what a mouthful!) has been
waiting for action by the Parliament for almost exactly a year. We are trying
hard to reach out to people who matter to make sure that we do not fail in our
duty to our fellow-human beings in pain.

LET US HOPE FOR THE BEST.

ST. JOHNS MEDICAL COLLEGE, BANGALORE, APPOINTS DR. RAJAGOPAL AS VISITING
PROFESSOR
[HTTP://PALLIUMINDIA.ORG/2013/11/ST-JOHNS-MEDICAL-COLLEGE-BANGALORE-APPOINTS-DR-RAJAGOPAL-AS-VISITING-PROFESSOR/]

Pallium India is pleased to announce the appointment of its Chairman,
Dr. M R Rajagopal, as Visiting Professor in Palliative Medicine. St. Johns
Medical College is one of the premier in Medical teaching institutions in the
country, always ranked among one of the top ten of the 350-odd Medical
colleges in the country.

Dr. Rajagopal delivered the Golden Jubilee talk in St. Johns Medical
College Bangalore on 8 November 2013. The title was “Dispelling Myths in
Palliative Care”. While much of the discussion centred around myths surrounding
the spectrum that Palliative care can cover and the obvious questions regarding
opioids, a part of the discussion focussed on the issue of withdrawal or
withholding of life support in the face of futility of treatment.

The audience’s reaction was considerable. Many members of the audience
expressed their own concerns and fears regarding the needless and sometimes
cruel prolongation of life at the cost of quality of life of the patient and
family, in the face of futile treatment.

Dr. Vani Ramkumar, a Professor of Obstetrics and Gynaecology, summed
the discussion up by saying that in all her life, one of the most worthwhile
things that she did was to make sure that her colleague could take another look
at her dying parent before starting of intensive care. Then she took the
colleague for a drive round the campus.

Little things matter a lot. For that doctor’s parent, the intensive
care gave little benefit, and may have induced some suffering. But that one
last look of farewell and the companionship at the time of crisis, were
therapeutic for the doctor.

Pallium India is privileged to be associated with St John’s Medical
College and is grateful to Prof Tarey, Dr Shoba Nair and the erudite audience.
We look forward to working with you.

CONGRATULATIONS, DR. PRIYADARSHINI KULKARNI
[HTTP://PALLIUMINDIA.ORG/2013/11/CONGRATULATIONS-DR-PRIYADARSHINI-KULKARNI/]

Our close associate, Dr. Priyadarshini Kulkarni, who is the Medical
Director of Cipla Palliative Care and Training Centre at Pune is the winner of
this year’s annual award of Cancer Aid and Research Foundation.

CONGRATULATIONS DR. PRIYADARSHINI KULKARNI

NEW TRAINING CENTRE AT JAIPUR
[HTTP://PALLIUMINDIA.ORG/2013/11/NEW-TRAINING-CENTRE-AT-JAIPUR/]

Pallium India is very proud to collaborate with the Palliative Care
Department at Bhagwan Mahaveer Cancer Centre at Jaipur, Rajasthan. North India
desperately needs more training centres. Why should doctors, nurses and others
have to travel to South India for training?

The force behind the training centre is Dr Anjum Joad Khan. She
combines passion, humor, resilience and tenacity of purpose to keep on working
away at the barriers and eventually achieve her objectives. Her first 6 weeks’
course started on 25 November 2013. We are very grateful to Dr Odette Spruyt,
from Melbourne, Australia, who initiated the Hamrahi program which works with
Pallium India to support palliative care programs.
Pallium India-USA is offering to support the program. Thank you Dr Jerina
Kapoor and colleagues.

EMERGENCY MEDICINE – PALLIATIVE MEDICINE INTERPHASE
[HTTP://PALLIUMINDIA.ORG/2013/11/EMERGENCY-MEDICINE-PALLIATIVE-MEDICINE-INTERPHASE/]

Pallium India participated in the International Conference on Emergency
Medicine held at Vythiri Village in Wynad in northern Kerala on 18 November
2013. We discussed three elements of possible inter-phase between emergency
medicine and palliative medicine.

The first was in the area of Pain Management, which, sadly, is very
much lacking in any aspect of medical practice in our country.

Second was the area of communication and the need for the emergency
medicine team to keep the patient and the family informed and therefore to
learn the art and science of it.

And thirdly, about the need to have education, guidelines and protocols
for withholding or withdrawing life support in situations of futility of
treatment.

Professor V. S. Mahadevan of Stanford University, USA, who had earlier
delivered a plenary lecture, responded to this from the audience, by agreeing
to the importance of the three elements. He particularly asked a question. Why
is it that most hospitals do not have opioids? When he asks for pain medication
in India, all that he gets are injections of Diclofenac or Tramadol.

This is a very vital question, Dr. Mahadevan. Of course, there are
numerous regulatory barriers to opioid access, which we hope will be removed by
the Indian Parliament in its Winter session in December 2013. But we are sure,
it is not only a question of regulations. All the regulatory barriers that
apply to morphine also apply to Fentanyl, a much more expensive opioid. Why is
it that the more expensive Fentanyl is available in many hospitals in many
formulations while morphine is not?

Those who participated in the discussion on the subject agreed that
closer interaction between emergency medicine and palliative medicine is indeed
necessary. Dr. P.P.Venugopalan and team (who organized this conference and
facilitated this interaction), Pallium India thanks you. And we congratulate
you for taking emergency medicine out into the community and saving many
precious lives.

VISIT BY MR WILLEM SCHOLTEN
[HTTP://PALLIUMINDIA.ORG/2013/11/VISIT-BY-MR-WILLEM-SCHOLTEN/]

Pallium India was privileged to have Mr Willem Scholten visit us in
Trivandrum. Mr Willem Scholten is currently a consultant to WHO. Formerly, he
headed the Essential Medicines program of WHO.

Mr Willem Scholten accompanied our team on home visits and taught in
our “Bruce Davis Training Centre” on several subjects including paediatric pain
guidelines. One of the issues that came up was the new WHO guideline for
paediatric pain management which excludes a step 2. If step 1 is inadequate, it
is recommended that we proceed straight to oral morphine, albeit in tiny doses

This is based on sound reasoning. The step 2 opioid that was
recommended for paediatric pain management was Codeine. Codeine is a pro-drug
of morphine, meaning that it has to be converted to morphine in the body. A
minority of patients are genetically unable to convert Codeine to morphine and
in this group of patients, it would be ineffective. There is absolutely no
possible objection to the use of morphine in tiny doses where you might have
ordinarily considered a step 2 opioid.

There is a practical problem, though. The vast majority of countries in
the developing world do not have access to morphine. Will the abolition of step
2 in children convey the wrong message that it is dangerous to use Codeine when
morphine is unavailable? We would very much like to convey this strong advice
that when morphine is unavailable, of course we must try hard to obtain it. But
till we get it, it is perfectly acceptable to continue to use Codeine for
paediatric pain management when step 1 alone is inadequate.

WORLD INSTITUTE OF PAIN CONGRESS AT KOLKATA AND SPECIAL LECTURE BY MR. DIEDERIK
LOHMAN
[HTTP://PALLIUMINDIA.ORG/2013/11/WORLD-INSTITUTE-OF-PAIN-CONGRESS-AT-KOLKATA-AND-SPECIAL-LECTURE-BY-MR-DIEDERIK-LOHMAN/]

One of the most famous names among global leaders of pain management is
Dr. Prithvi Raj in USA. In 1993, he founded the World Institute of Pain, which
today is a major force in improving pain management globally.

The World Institute of Pain had its world symposium at Kolkata from
14th to 17th November 2013. One of the highlights of the meeting was the Serdar
Erdine lecture by Mr. Diederik Lohman. Mr. Lohman presented the remarkable
findings of the Pain Prevalence Study.

The Pain Prevalence Study, which was conducted very recently under the
leadership of Mr. Diederik Lohman of Human Rights Watch in collaboration with
Pallium India, MNJ Institute of Oncology and the Regional Cancer Centres at
Cuttack, Ahmedabad and Kolkata, has just been completed. The findings are
remarkable. While the final results are yet to be published, it will not come
as a surprise to anyone that the pain burden in any Regional Cancer Centre in
the country is tremendous. The audience listened, enthralled, and expressed its
hope that Parliament does enact the amendment of the Narcotic Regulations of
India.

Thank you, Dr. Prithvi Raj and colleagues, and thank you, Dr. Gautam
Das, organizing secretary of the conference. Pallium India was privileged to be
a part of it. And thank you Mr. Diederik Lohman and Human Rights Watch for all
that you are doing for this country.

PALLIUM INDIA’S VISIT TO CFHI
[HTTP://PALLIUMINDIA.ORG/2013/11/PALLIUM-INDIAS-VISIT-TO-CFHI/]

The chairman of Pallium India Dr. M.R.Rajagopal and volunteer Sunshine
Mugrabi were privileged to visit the offices of Child Family Health
International (CFHI) in San Francisco, an organization created by Dr. Evaleen
Jones when she was a medical student. We spent time with the director Dr.
Jessica Evert and the team. It was a good exercise to review the program in all
its aspects. Currently, four palliative care professionals from CFHI are with
us in Trivandrum, going through their one month attachment.

From one of the previous batches, two participants, Ms. Lindsay Brahm and Ms.
Mary Macy Jacob (Alex) wrote narratives on their experience in Trivandrum which
were published in an indexed journal – the Journal of Pain and Palliative Care
Pharmacotherapy. In the picture you see Alex in our Pediatric Palliative Care
clinic. Here are the abstracts, with the citation.

WHEN TWO WORLDS MEET: Lyndsey M Brahm
_Journal of Pain & Palliative Care Pharmacotherapy. 2012;26:278–279._ "

The author is one of four American premedical students traveled to
India to spend a month with Pallium India ( palliumindia.org
[http://palliumindia.org] ) to learn about palliative care at Trivandrum
Institute of Palliative Sciences, in the south Indian state of Kerala. The
program was arranged by Child Family Health International ( cfhi.org
[http://cfhi.org] ). They attended classroom sessions and joined the palliative
care team during home visits and hospital consultations. They learned not just
what palliative care is, but also how to understand and adapt to another
culture. It was shocking to learn that all health care expenses are often
out-of-pocket for most of the developing world and to see the extent of the
suffering involved in life-limiting diseases. The students saw how the medical
professional could adopt a basic and simple approach to medicine, acting as a
mix of scientist, humanist, and spiritualist. She concludes that we in the
United States too seem to be learning the value of such an approach and to make
better use of available resources to improve the quality of life of those who
are suffering."

THROUGH THE EYES OF CHILD: REFLECTIONS ON MY MOTHER’S DEATH FROM
CANCER. Mary A. Macy
_Journal of Pain & Palliative Care Pharmacotherapy. 2013;27:176–178._ "

Before being exposed to palliative care, I had lived through 15 years
of emotional suffering, beginning with my mother’s relapse of leukemia. My
mother died 12 years ago; however, the suffering did not end there. Palliative
care helped me find meaning and purpose in my suffering. During her illness I
received no explanations about what was happening to my mother, and I felt
utter emotional loneliness. I received no help in coping with the uncertainties
of my mother’s life with cancer or of her dying process. The experience left me
sad and angry.

Sheltering a child from truth does not lessen fear or alleviate pain;
it only causes feelings of confusion, anger, embarrassment and shame.

You can also read Alex’s blog on her visit here
[http://alexmacycfhipalliumindia.wordpress.com/] ."

PARTING SHOT

IAPCON 2014 [HTTP://IAPCON2014.IN/]

It is not too late to register for the 21st International Conference of
Indian Association of Palliative Care. The event is from 14th to 16th February,
2014 at KIMS, Kusabhadra Campus, KIIT, Bhubaneswar. For more details and to
register, please visit the official website: http://iapcon2014.in/

Tel No : +91 671 2304035
Email: iapcon2014@xxxxxxxxx, ahrccpc@xxxxxxxxx

AND IAPCON THE YEAR AFTER.

The 22nd International Conference of Indian Association of Palliative
Care is to be held at Hyderabad
[http://palliumindia.org/2013/10/22nd-international-conference-of-indian-association-of-palliative-care/]
, from 13 -15 February 2015.

The Conference Secretariat:
Room No 34, Department of Palliative care,
MNJ Institute of Oncology and RCC
Red hills, Hyderabad, Andhra Pradesh, India-500004
Email: mnj.palliative@xxxxxxxxx
Phone: 91 40 23397000, 91 9177238901

Pallium India Newsletter: November 2013

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