COVER SHEET

Reflections on the care of a Patient with Palliative Care Needs

Register Number: 25281902
Date: 15-12-2019
I declare that this is wholly my work, except where acknowledged specifically, as the
published work of others.
Total Word Count: 2116
Word count of Learning Part (step III):1158
 I.INTRODUCTION
I am an Anaesthesiologist, working as a senior resident in Anaesthesiology and critical care
medicine department of a semi government/autonomous superspeciality hospital with a bed
strength of 1000.
My work is providing peri-operative anaesthesia services to patients undergoing various
types of surgeries, including oncological (curative and palliative) surgeries.
I’m also involved in providing intensive care to critically ill patients either from acute/
chronic medical or surgical illnesses.
My work also involves providing anesthesia for diagnostic procedures like MRI scans,
guided biopsies and for therapeutic procedures like cath lab, radiotherapy and guided
procedures.
I’m also involved in providing treatment for chronic pain like giving epidural steroid
injections etc.
II.CASE SUMMARY
DIAGNOSIS:-
Mr.” X’’ was a 67 year old gentleman who suffered from multiple chronic medical illnesses
in the following chronological order1
1.Diabetes Mellitus type 2
2. Lumbar Spinal canal stenosis at multiple levels, L1-L2, L2-L3, L3-L4, L4-L5
3.Chronic Renal Failure(CRF),
4. Hypertension,
5.Coronary artery disease(CAD), and
6.Parkinsons disease(PD).

Case History :-
Mr. X was diagnosed with Diabetes at 45 years age. Since then till the age of 62 he used a
combination of diet control and exercise to regulate his blood sugar levels.
When he was 53 years old he was diagnosed with lumbar canal stenosis and underwent
laminectomy and fusion of L4-L5.
Mr X was 59 years old when he was diagnosed with Chronic Kidney Disease(CKD) and
hypertension induced by CKD. Since then he was started on oral hypoglycaemic agents for
diabetes, medications for CKD and antihypertensive treatment.
He was diagnosed with Coronary Artery Disease(CAD) in 2012 and underwent Coronary
Artery Bypass Grafting(CABG). Post operatively he was put on ventilator and underwent
hemodialysis. Afterwards he recovered and was discharged.
Mr.X was diagnosed with Parkinsons disease in 2015, as he developed walking
difficulty,rigidity, tremor, slurring of speech, and difficulty in eating solid food. He was put
on anti-parkinsonian medication since then.
While his Parkinsons disease progressed over time he became more home bound, requiring
assistance and transport facility for making journeys to hospitals, requiring support of a
walking stick to walk, needed support to go to the bathroom, required food which was
mashed up to aid in swallowing. In the last one year, Mr.X also suffered from chronic
constipation.
In the final stages of his life he had fever and was admitted to ICU for 15 days. During that
stay he was diagnosed with hyponatremia and pleural effusion. He was treated for the same.
After staying for 15 days in ICU he was discharged in a stable condition to home. He
developed mild bed sore between his buttocks and still had chronic constipation.
After coming to home he was fine for 10 more days. He became more dependant on Mrs.X
for his daily activities like bathing, going to bathroom, changing clothes etc. He was unable
to walk by himself without support. After 10 days at home Mr.X gradually developed
breathlessness associated with noisy breathing. Mrs X called me for advice. I advised her to
immediately take him to a hospital.
Mr.X was again admitted in ICU. He was diagnosed to have hyponatremia and respiratory
failure. He was put on oxygen mask for couple of days after which respiratory failure
worsened and the intensivists advised ventilator support. But his family members opted not to
put him on ventilator. At the end of his life he was with his family members in the ICU with
respiratory failure.
Investigations :-
INVESTIGATIONS DONE REASON WHY THE
INVESTIGATIONS WAS DONE
MRI spine To know if his spinal canal stenosis has
progressed and it is causing the difficulty in
walking.

To know his cardiac status.

2D echo

To reveal the cause of fever and to know his

Complete blood count haemoglobin levels.

To see the response to treatment of

hyponatremia
Serum electrolyte levels
Final outcome of patient management :-
Mr.X expired after 10 days of the second admission in to ICU. His death was definitely
expected and anticipated by the family members and the treating doctors.
I involved a neurologist, a neurosurgeon, and a physiotherapist in the care of Mr.X. The
neurologist treated the symptoms of parkinsons disease.
A neurosurgeon was involved to see if his lumbar canal stenosis progressed and if it can be
correctible by surgery to improve his ability to move around independently.
Mr.X’s family members opted not to go ahead with the surgery. Instead they were advised to
undergo physiotherapy for which a physiotherapist’s help was taken.
Even a nurse who helped his family members in giving home care, was appointed.
A couple of days before his death Mr.X has asked for a chaplain to administer his last death
rites. A chaplain helped administer his death rites.
All these physicians, allied health personnel and spiritual associates were very helpful in
making the journey of Mr.X more tolerable and improved his quality of life.

III LEARNING OF PALLIATIVE CARE PRINCIPLES AND PRACTICE

Mr.X was a patient with multiple chronic medical illnesses. As an anaesthesiologist and his
relative, I was involved in his healthcare for a long time.
I realised after getting the training in palliative care, that had I done this course earlier, how
much it would have helped Mr.X in managing his health problems and improving his quality
of life.
There were many things that I could have done differently in management of Mr.X :
1. I would have first recognised that Mr.X is a person who needed palliative care due to
his chronic medical illnesses and repeated hospital visits.
2. I would have involved a palliative care specialist, early in the disease course, so that
his chronic medical problems would have been addressed.
3. I would have recognised his problem of chronic constipation as a major problem
which is decreasing the quality of his life and I would have delved deeper in to the
causes leading to constipation, whether he would have benefited from any other
treatment like high fibre diet2, improving mobility and if needed involvement of a
palliative care specialist.
4. Mr.X’s children lived abroad and he lives along with his wife and he is partly
dependent on his wife for his activities of daily life.I would have spoken and
counselled his wife about how she is coping up with the need to give him constant
care that he needs. I would have extended my help as a doctor and as a person trained
in palliative care to Mrs.X in every possible way, physically, emotionally and
spiritually. I would have enquired deeply in to the physical and emotional health of
Mrs.X herself. I would have formed a communication portal to make Mrs.X’s health
condition known to her children who are living abroad.
 5. Towards the end of his life I would have recognised that an ICU admission would
lead to futile treatment and I would not have suggested an ICU admission. I would
have done whatever is necessary to make Mr.X comfortable at his home where he is
used to spend his time. This would have saved him from developing a bedsore and
would have improved the quality of life in his last days.
6. During Mr.X’s second admission in to ICU, first and foremost I would have
recognised that the breathlessness he has might be terminal and I would have done my
best to alleviate his feeling of breathlessness by employing both non pharmacological
and if needed pharmacological methods. Prior to taking training in palliative care I did
not know that opioids could be used to treat intractable dyspnoea3.
7. I would have involved a spiritual associate much early in the course of the hospital
stay. I would have found out about the spiritual needs of Mr.X and Mrs.X and I would
have involved a chaplain much before he voiced his concern for the need of a
chaplain to administer him death rites.
8. And last, I would have provided extended support to the family members in all ways,
physical, emotional and spiritual in their time of grief.
9. I strongly believe that by learning and applying the principles of palliative care I
would have definitely made the journey of Mr.X more comfortable till the end.

PHYSICAL CARE:- I would have provided adequate relief of his physical symptoms like
chronic constipation with the use of laxatives like lactulose syrup or enema if required, bed
sore care by regular position changing along with the use of air/water bed, mobility exercises
with the help of support or by expert physiotherapist, relief of dyspnoea with the use of
morphine or bronchodilators, proper guidance on taking a balanced diet as he was only taking
mashed up diet. As he is suffering from Parkinson disease, a consultation of the neurologist
for any change in medications or its dose would have made a change in the disease
progression. Need for a physiotherapist and a care giver in this aspect might show an
improvement in quality of self care as the patient is concern about inability in daily activities.
PSYCOLOGICAL CARE:- I would have enquired more in to the fears and anxieties faced
by him, whether he is having any depression, as he is dependent on his wife, and I would
have provided psychological support to both Mr.X and Mrs.X and their children as they are
anticipating a prolonged course of ill health and dependency of Mr.X on them.
SPIRITUAL CARE:- Mr.X has expressed his need to administer him death rites by a
chaplain towards the end of his life. I would have discussed his spiritual and emotional needs
with him before hand and would have facilitated him to fulfil all these needs.
ISSUES OF COMMUNICATION WITH PATIENT AND FAMILY:- Mr.X was always
straightforward in his dialogue and he did not hide anything from his caregivers. He was
always bold and ready to face things as they came to him. But Mrs.X seemed tired of all the
constant care and attention Mr.X needed. A counselling with the family members could have
been made to make them understand the nature of the disease and its progression, the care
that needs to be given for it and to think about will. If required, i would explain the need for a
caregiver to meet the required goals of constant care needed for Mr.X
ETHICAL ISSUES:-This case reflection has been done with prior permission from Mrs.X.
There was no breech of the four cardinal principles of medical ethics in care given to Mr.X
CHANGES THAT HAVE OCCURRED AT MY PERSONAL LEVEL:- I learnt to
recognise the patients who are at the end of life phase and I learnt to empathise with them and
their family members. I began treating the symptom of pain very seriously as different
persons perceive pain differently.
CHANGES THAT HAVE OCCURRED AT MY PROFESSIONAL LEVEL AND IN
MY PROFESSIONAL KNOWLEDGE:- I recognised the futile treatments we are giving
to many patients in our ICU when infact what they need is good palliative care. I have learnt
about the 2014, ISCCM and IAPC joint position statement4 on limiting futile treatment. I also
learnt about advance directives often employed in treating critically ill patients.
IV POLICY AND INNOVATIONS IN PRACTICE IN YOUR FIELD WORK BASED
ON THIS CASE REFLECTION:- I have made pain assessment compulsory in all my post
operative patients and I see that pain is treated adequately5. I also started categorising patients
who are in need of palliative care and started applying principles of palliative care in them. I
started counselling of caregivers in patients needing palliative care. Good symptom control is
emphasized to improve quality of life. Futile treatment is recognised early and patients and
family members are counselled regarding continuing the care. These are the innovations I
have introduced in my field of work based on my training in palliative care and this case
reflection.
Essentially I’m practicing “ADD LIFE TO THE DAYS & NOT DAYS TO THE LIFE”2
principle.

V) REFERENCES
1)Mrs X and myself.
2)Text book for certificate course in essentials of palliative care,5th edition ,IAPC.
3) Gebauer S. Palliative Medicine. In: Miller RD, Cohen NH, Eriksson LI, Fleisher LA,
Weiner –Kronish JP, Young WL, editors. Miller’s Anesthesia. 8th ed. Philadelphia:
ElsevierSaunders; 2015. p. 1919-1941.
4) Myatra SN, Salins N, Iyer S, Macaden SC, Divatia JV, Muckaden M, Kulkarni P, Simha S,
Mani RK. End-of-life care policy: An integrated care plan for the dying. Indian J Crit Care
Med 2014;18:615-35.

5)Integrating palliative care and symptom relief in to primary health care, a WHO guide for
planners, implementers and managers.2018