Leading pulmonologist and palliative care physician Dr Rajam K Iyer speaks with Dr Sujeet Rajan on palliative care and also addresses questions and concerns of Seniors Today readers. Dr Noor Gill captures highlights from the Health Live session with Drs Iyer and Rajan
On January 9, 2021, Seniors Today hosted the Weekly Health Live webinar with two leading doctors to speak on, answer questions and address concerns about dealing with chronic illness and rights and comfort of patients and planning the road ahead.
Dr Rajam Iyer is a leading pulmonologist and palliative care physician with the Bhatia and Hinduja Hospitals in Mumbai. She has completed MRCP (UK), DNB, MD and has been a practising pulmonologist for 25 years. Her aim is to provide good quality healthcare in a compassionate manner. She believes that educating patients and their families is the key to improving healthcare in India.
Dr Sujeet Rajan is a leading respiratory physician with the Bombay and Bhatia Hospitals in Mumbai, India.
– Palliative care: The definition of palliative according to the WHO, last revised in 2017, mainly addresses the health-related suffering that the patients and their families undergo when the patient is diagnosed with a chronic illness. It does not just deal with the physical issues, but even the mental, emotional, psychological, financial, spiritual that the patient and their family undergoes during their journey. The idea is to address them as early as possible, acknowledge them and support the patient and their family through the difficult journey.
– Chronic illness: They don’t necessarily have to be something that is incurable. It can also be curable diseases or illnesses that can last for more than 3-4 years for example cancer also fall under the per view of palliative care.
- Health/healthy body, according to the WHO, is not just the mere absence of a disease but the social, emotional, mental and spiritual well-being of the individual.
- Palliative care is something that was practiced many years ago, before there were not as many doctors who had specialized or super specialized and the purpose shifted from care and comfort to cure.
Palliative care aims to bring back compassion into medicine.
Not all illnesses are life-threatening, they can also be life-limiting and that needs to be addressed.
– Patients have autonomy and we need to ask the patients what they want, what is their choice. For the patient to make the choice, they need to be well informed. The rights of the patient start with the doctor’s responsibility to explain the illness to the patient, the trajectory of the disease or the natural progression of the disease so the patient can make an informed choice.
Patients have the right to choose the form of treatment that fits them best and also the right to refuse treatment when they feel that it is not doing them good or does not sit well with them.
– Beneficence of the patient is also important. Do no harm.
The Covid-19 pandemic has brought health, death, life and illness into very sharp focus because a lot of people fell sick at the same time. The best of the healthcare systems such as in America and U.K. did not cope well with it. In such a situation the doctors also go through distress, such as whom to put on the ventilator and whom to not? What are the criteria to decide that? That comes only from having these discussions before, communication and documentation.
Have a frank discussion about this with your doctor, you will be doing yourself and your family a service, you’ll be avoiding the guilt and you’ll be doing the healthcare system a favor because the health care system is overwhelmed right now.
It is very important for you to make this choice. The Supreme Court gives you the right to refuse treatment and also to express what you would like to be done in an emergency situation.
– Making choices for themselves in the case of chronic illness is challenging for the elderly. It is advisable that the senior citizen be accompanied by someone younger, because they will be able to understand and explain it better. It is best to meet with a doctor with someone so that if one doesn’t understand, probably the other will. If some piece of information has fallen away from the patients receptive level, probably can be understood better by the other individual accompanying them.
– Always make your patients recapitulate what you’ve said or explained. You might have said point 1-10, they must have heard from point 1-8, understood 1-5 and might recollect only 1-4. So, this way you can gauge how much your patient understood and if they might need another session which if you don’t have the time for, comes under the role of a family GP or a palliative nurse who can reiterate.
– We often forget that the elderly have a lot of mental issues. The cause of weight loss in elderly is 70% because of depression. We then need to rope in specialists and geriatric psychiatrists. Asking the right questions is important like- who do they live with? If they are sleeping okay? If they are eating well? What was the last meal they prepared?
– This generation of seniors needs to get more tech-savvy because that’s where the future is headed. You need to have a good social life; it helps you live not just longer but even happier.
– Every senior citizen should have an identified GP. In a Covid world, where you can’t just rush to any hospital, you need medical help to come to your doorstep in the form of a family physician. Sometimes specialists are hard to get hold of, and family doctors are trained in symptom management and are well versed with your medical history.
– Palliative care is a team work; it is not a one person job. You need a physician, a caregiver, a physiotherapist a psychologist/psychiatrist, volunteers and so on and so forth depending on the ailment one is suffering with.
– There is an NGO, for caregivers, it’s called “caregiver saathi”. it’s run by Ms Bhavana Issar and it sees into the fact that caregivers to have a place to share their experiences and vent their emotions. There are supports groups for specific disease caregivers. They also have a support for grief and bereavement especially for people who have lost their loved ones to covid-19.
It is not possible to have a solution for everyone but it is good to have someone to reach out to, someone to listen to you.
Caregivers need a big pat on their back. It does take a toll on you but we understand that you do it out of love and concern, so look after yourself well so you can look after them better.
– Chronic illness take a financial toll on the caregiver, in the sense of all the unskilled help they you might need and your medical insurance does not even cover it. But when you compare that to curative treatment, if you do the economics, the suffering that both you and your patient undergo is way less. So, the investment, is not cheap, but if you compare that to the aggressive curative treatment that the patients take for their loved ones even with a poor prognosis is way less.
We have, in our country, 52 million people going below poverty line trying to save their loved ones. That is the amount of health economic burden we are putting on our family and patient trying to save people who have poor outcomes.
– Respite care facilities are also a huge thing that can help you out; to let you live your lives for example go on a vacation or a business trip without compromising the care of your patient or them felling neglected.
– It is extremely important that when you have a patient with a chronic illness, which is either incurable or is progressive, to have these discussions about having an advance directive and having a will, not just a financial will but even the living will.
Ask the wishes of your patient, document it and let your doctor know about them. Palliative care is important even before we reach the end of the road, palliative care plan should made even for when the patient is comfortable.
Continue the treatment that you’re giving, follow your course of management but in tandem keep the supportive care going.
Dr Rajam K Iyer can be reached at rajamk25 [at] hotmail.com