Qidwai, Waris

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eCommons@AKUDepartment of Family Medicine Medical College, PakistanMarch 2012Care of the dying patient: a neglected issue inPakistani contextWaris QidwaiAga Khan UniversityFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_fam_medPart of the Health Services Administration Commons, and the Health Services ResearchCommonsRecommended CitationQidwai, W. (2012). Care of the dying patient: a neglected issue in Pakistani context. Journal of the College of Physicians and SurgeonsPakistan, 22(3), 133-134.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_fam_med/55Journal of the College of Physicians and Surgeons Pakistan  2012, Vol. 22 (3): 133-134 133Health care in Pakistan is undergoing change and it isappropriate to closely look at and reconsider humaneaspects in clinical practice. In this context, care of thedying patient is an important and highly sacred part of ahealth care provider's responsibilities. Acceptance ofdeath as a reality and culmination of life is not easy forpatient, his or her family and health care providers. Ourhealth care providers are trained to save and prolong lifewith little or no training on how to deal with dying patientand his/her family.The issue of diagnosing dying patients is challenging,since one has to depend on set of evidence basedindicators, which may predict death in hours or days. Itis important to pick-up these indicators which includespatient's becoming bedbound, inability to take fluids andmedicines orally and lack of responsiveness that mayincrease probability of patient's death.1In United Kingdom, one-fourth of the population die ofcancer and half of them suffer needless pain.2 Data isnot available in Pakistan but situation is probably worse.Limited evidence is available to confirm the paucity ofknowledge and skills among health care providers indealing with dying patients and their families.3Certain established evidence based principles ensurethat patients die in peace and with dignity. It ensures thattheir families are well supported during the traumaticperiod and after patient's death during bereavement.4-6Patient's greatest fear is that of suffering fromdistressing symptoms. This fear of suffering can beminimized by ensuring that symptoms are controlled.Pain is the most distressing factor and, therefore,analgesia should be started early and be given regularly,in appropriate dose and with the anticipation of nextwave of pain. Opiates can be used based on patient'sneeds without fear of drug dependency or large dosage.Fear, anxiety, and depression should be addressed asthese factors increase pain perception. Management ofconstipation, cough, dyspnoea, insomnia and vomitingimproves quality of life. Correct uses of the medicationswith written instructions helps, since patients as well asrelatives often forget.Isolation of the patient or his/her family should beavoided. He should be given time to talk of fears andproblems, with consultation based on honesty and truthand avoidance of un-necessary pessimism. A policy of'gentle truth' is generally best as patients have ideaabout their condition and it helps develop trust in treatingphysician.An unhurried approach, based on kindness andempathy is required when caring for dying patients. Acaring touch of a considerate physician is consideredimportant.  Patient's customs and religious belief shouldbe respected. One should not say that nothing can bedone but at the same time false hopes should not begiven. Often, doctor and the family know the disease,diagnosis and prognosis, but hide it from the patient.This is known as “conspiracy of silence”, and should beavoided.Inappropriate therapy in a dying patient adds pain to thedying process. A need for any invasive palliativeprocedure such as gastrostomy should be reviewed forpros and cons and patient's wishes should always berespected.Involvement of family in caring and supporting dyingpatient is crucial. Prognosis and available symptomatictreatment should be explained to family to alleviateconcerns. Family members providing care should besupported and told that they are giving help and supportthat no one else can, which is allowing the patient to diein bed. Care of the family does not end with the death ofthe patient and support of the bereaved is importantresponsibility of the treating physician.Team work is important when looking after dyingpatients. Team should at least comprise of physician,nurse, and physiotherapist etc. among others from along list of professionals. It is important to know theservices available in area of practice including nightnursing.Continuity of patient and family care are important partof care provision for the dying patient and family. It isimportant to ensure that the patient and his/her familyknow that someone will be available round the clock. Itis necessary to visit regularly rather than on request onlyand same doctor and nurse should visit the patient. Thebest drug a patient can be given is the time of doctors,relatives and friends.Fears of a dying patient can be many. Fear of the dyingprocess can be addressed by providing symptom reliefDepartment of Family Medicine, The Aga Khan University, Karachi.Correspondence: Prof. Waris Qidwai, 207/C/2, PECHS,Karachi - 75400.E-mail: waris.qidwai@aku.eduReceived February 02, 2012;  accepted February 22, 2012.Care of The Dying Patient: A Neglected Issue in Pakistani ContextWaris QidwaiEDITORIALand assurance. Fear of the unknown can be addressedby empathetically looking into the spiritual needs. Fearof separation and hardships for the family should bediscussed and addressed. Fear of losing control anddependence on others should be addressed.A doctor's responsibility does not end with death of thepatient and care of the grieving relatives is part of thecare provided to dying patient. Caring for the dyingpatient provides unique opportunity to develop rapportwith family. A visit by the doctor after death of the patientis invaluable, with promise to continue support. Griefreaction varies and a relative showing no reaction maybe heading for a serious emotional grief reaction.Sedatives may help initially but should be prescribed fora short duration only. In patients dying at home, mortalityamong the bereaved is less.It is time that curriculum is updated and we incorporatetraining of medical students and postgraduate traineesin caring for the dying patient. A need exists to haveawareness sessions for the public to educate themabout dying and dying process. All stakeholdersincluding academia and policy makers have to play theirrole and make dying a dignified, humane, and pain-freeprocess in Pakistan for patients and their families.REFERENCES1. Ellershaw J, Ward C. Care of the dying patient: the last hours ordays of life. BMJ 2003; 326:30-4.2. Office of National Statistics. Annual review of the registrargeneral on deaths in England and Wales, 2000 [Internet]. [cited2012 Feb 02]. Available from:  www.statistics.gov.uk/downloads/theme_health/DH1_33/Table17.xls 3. Salahuddin N, Shafqat S, Mapara S, Khan S, Siddiqui S,Manasia R, et al. End of life in the intensive care unit: knowledgeand practice of clinicians from Karachi, Pakistan. Intern Med J2008; 38:307-13.4. Working Party on Clinical Guidelines in Palliative Care.Changing gear: guidelines for managing the last days of life: theresearch evidence. London: National Council for Hospice and SpecialistPalliative Care Services; 1997. 5. Doyle D, Hanks GW, MacDonald N, editors. Oxford book ofpalliative medicine. 2nd ed. New York: Oxford University Press; 1998.6. Morphine in cancer pain: modes of administration. ExpertWorking Group of the European Association for Palliative Care.BMJ 1996; 312:823-6.134 Journal of the College of Physicians and Surgeons Pakistan  2012, Vol. 22 (3): 133-134Waris Qidwail l l l lOl l l l ll l l l lOl l l l l

Care of the dying patient: a neglected issue in Pakistani context

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Care of the dying patient: a neglected issue in Pakistani context

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