Palliative Care From The Perspective Of An Otorhinolaryngologist In India

Dear Editor,

In Otorhinolaryngology, one of the important categories of patients dealt with by ENT surgeons are head and neck cancer patients. Some patients have cancer at an advanced stage with metastasis, where the chances of survival are minimal. Such patients are candidates for palliative care management. However, palliative care is still much less recognized among the ENT community in India. Although palliative care is included in the postgraduate ENT syllabus as per NMC and NBEMS and the theoretical content is available in standard textbooks of Otorhinolaryngology and Head And Neck Surgery, its practical implementation is rare. There are differences in the palliative care issues specific to head and neck cancers as compared to other types of cancers. Many medical issues affect the quality of life at the end of life. These include communication challenges following laryngectomy or tracheostomy, and difficulties in eating and drinking due to surgery and radiotherapy.¹ Other problems include edematous changes of the face and neck, resulting in both functional and cosmetic consequences and strong-smelling ulcerated wounds leading to social isolation.¹ Many general symptoms occur at the end of life such as pain, anxiety, different types of dyspnea, and acute bleeding.¹ The efficacy and side effects of all therapeutic approaches applied during the last phase of life must be questioned. Considering the patient's wishes is of the highest priority.¹ While addressing a terminally ill head and neck cancer patient open-minded questions must be asked relating to the patient's individual goals.² The open-minded questions should concentrate on the worries of the patient, hopes of the patient, etc. While it is always better to take advice from palliative care providers, training otolaryngologists to develop primary palliative care competencies is equally important for improving outcomes in head and cancer patients.³ In recent years, various steps have been taken worldwide to increase the knowledge of palliative care. Palliative care has recently been included by the American Society for Head and Neck Surgery as a core competency for fellowship.² Educational modalities such as simulation and online training, if integrated into the curriculum, may optimise palliative care.⁴ In many instances it is observed that a head and neck cancer patient may visit an apex oncology setup during the first visit but return to the local ENT doctor in follow-up visits related to palliative care issues. Also, palliative care is still in a developing stage and the number of palliative care specialists is still less. This short-coming can be addressed to some extent in the context of Otorhinolaryngological cancers if ENT surgeons develop basic competencies in palliative care. This will improve end-of-life care and provide satisfaction to the patient and the family.

Given the huge patient load of oral and head and neck cancers in India, training ENT doctors about the basics of palliative care will make a significant impact. In the Indian context of head and neck cancers, Otorhinolaryngology case discussions, journal clubs, and model OSCE should include topics on palliative care. Joint CME can be conducted involving palliative care specialists and ENT surgeons. Tailored courses in palliative care related to head and neck cancer management can be completed online through authorized palliative care centers by otorhinolaryngologists. Palliative care sessions can be planned by the otorhinolaryngologist on specific days of a month at an ENT center receiving a huge load of head and neck cancer cases. An Indian model of Palliative care specific to Otorhinolaryngology must be prepared with guidance from experts in otorhinolaryngology, oncology, and palliative care.

A model case sheet is proposed for basic palliative care management for ENT surgeons in the context of head and neck cancers. (Annexture - 1)

It is concluded that the limitations in basic palliative care management for otorhinolaryngological cancers can be successfully addressed if the topic is practically implemented by the ENT Department in medical colleges and NBEMS-accredited DNB ENT Institutes. Further improvisation and innovations in palliative care history taking, clinical examination, and management can be achieved with inputs from medical students and faculty.

Conflict of Interest

Nil

Source of Funding

Nil 

Annexture - 1

Ent And Head And Neck Oncology Palliative Care Case Sheet

 Name Of The Patient -

  Age -

  Sex -

  Registration No -

  Address -

 Name Of The Family Member /Guardian -

 Date -

 Phone Number -

 Diagnosis -

Treatment Received For Otorhinolaryngological Cancer

• Surgery -                                                          

• Chemotherapy -                                 

• Radiotherapy -                                   

• Any Other Treatment/No Treatment - 

Palliative Care Issues/Complaints

• Swallowing Issues

• Breathing Issues

• Dryness Of Mouth

• Nausea And Vomiting

• Pain

• Psychological Issues

• Anyother

 Palliative Care Centre/Hospice Facility Accesible

Previous Palliative Care Treatment History

Local Examination

• Oral Cavity

• Pharynx And Larynx

• Nose

• Ear

• Any Other

 Details Of Present Palliative Care Treatment Given To The Patient

Satisfaction Level Of The Patient And Family Member /Guardian Through Vas(Visual Analogue Scale) At The End Of Palliative Care Session

Future Directions

• Requires Outpatient/Inpatient Treatment In Hospital Under Otorhinolaryngologist Trained In Palliative Care

• Treatment By An Otorhinolaryngologist Along With A Palliative Care Consultant

• Requires Home Based Palliative Care

• Referal To A Specialised Palliative Care Center

• Any Other