Dr M R Rajaagopalan | Photo: Prasiit Sthapit
Manipal: Dr. MR Rajagopal, MD, MNAMS is the Chairman of Pallium India, a charitable trust established to promote and fight for the needs of the millions of Indians in dire need of hospice and palliative care. He is the frontrunner of the Palliative care movement in India. He also serves in the position of Professor of Pain and Palliative Medicine at the Sree Uthradom Thirunal Academy of Medical Sciences, Trivandrum. He was in Manipal to attend Palliative Care – 2008, a continuing medical education (CME) on palliative medicine and care held between April 24 and 27.
Q: What is palliative care all about?
A: Quality of life. The last half a century has been spent by the medical fraternity searching for cures to diseases and somewhere in this race for cures, the individual has been forgotten. A cure is not always possible. Palliative care is about increasing the quality of life of a patient in pain – physical and psychological.
Q: How is it different from hospice care?
A: For all practical purposes, it is the same. A hospice is a place where palliative care is given to in-house patients but the care is the same that palliative patients get anywhere else. In the United States of America, there is a difference between the two terms, but that is only because the insurance agencies there demand such definitions.
Q: What is the EPEC project?
A: The Education in Palliative and End-of-Life Care project was started in the USA as an initiative of Northwestern University to educate all healthcare professionals on the essential clinical competencies in palliative care. EPEC is now in India. We took two years, from 2005 to 2007 to develop a curriculum that would suit India culturally and pharmacologically. 2007 marks the beginning of phase two of the project in India where we press for its inclusion in educational medical programmes. EPEC-India aims to give structure to the education of nurses, doctors and para-medical professionals so as to include palliative care into their learning.
Q: The International Atomic Energy Agency (IAEA) has started Programme of Action for Cancer Therapy (PACT) which also talks of palliative care for cancer patients. Are most patients, who need palliation, cancer patients?
A: Well, no. It is just that the other diseases are not brought to notice. If you take cancer as a group of diseases, then it is larger than any other such group, so the patients in this category are more. For example, the institute where I am working has 48 per cent of its cases pertaining to cancer. 52 per cent compose all other diseases. We started the Trivandrum Institute of Palliative Services in 2006 with the aim of reaching out to as many patients needy of such care.
Q: Palliative medicine uses opioids like morphine. Isn’t the administration of these drugs a balance between relief and hastening death?
A: No. I’m glad you brought this up. Palliative medicine rarely hastens death. Quite on the contrary, in some cases, it extends life. A man falls from a coconut tree and is paralysed waist below. Instead of leaving him on the bed to later develop pressure sores, palliative medicine relieves his pain, allows him to stand up using aid and make a living for himself. I know a bank manager and an advocate who are working due to palliation. Without palliative care, they would have been in pain and unproductive. I know of an engineer-turned-builder who worked till five days before his death because of palliative medicine. We make lives productive.
Q: But aren’t there issues of addiction and subsequent withdrawal symptoms?
A: There is a question of dependability. Users of oral morphine in a medical sense may develop a physical dependence; which is quite difference from psychological dependence. In fact, in a study that we conducted two years back in Calicut, we found that of the 1,723 patients who used oral morphine at home in their daily lives none developed any substance addiction. We advocate the use of opioids because of the insignificant risk of physical dependence attached to it, as opposed to the significant risk of psychological risk when consumed non-medically. It is safe.
Q: Especially in India, where procurement of morphine is not easy, is there a need for policy change?
A: The scene is bettering in India. This five year plan had a budgetary allocation for the National Cancer Control Programme (NCCP). On the 15th of this month (April 15, ‘08), the government of Kerela embedded Palliative care in its mainstream medicine.
More change is expected to come. The Indian Association of Palliative Care (IAPC) recently moved to Supreme Court in a Public Interest Litigation (PIL) pressing for realistic narcotic regulation, the inclusion of palliative medicine as a part of mainstream medicine and its inclusion in the curriculum for medical professionals. Since 1997, 13 states have simplified their drug regulation policies thanks to efforts from various quarters.
Q: How must the family and the society play a role in the care of patients?
A: When I said quality at life in the beginning of the interview, I meant the quality of life of the patient and his/her family. The palliative solution to any problem has to be in participation with the patients’ families and the community. Palliation addresses not only the physical ailing of a patient, but also his social and psychological pain – emotional, spiritual or moral. The family of the patient must support him/her.
If there is one place where palliative medicine has failed in India, it is in the society. That is the biggest weakness because the advocacy of palliation has to be universal, not just restricted to medical professionals. We need the help of social workers, who form a large chunk of society, the Press and other media to spread awareness about palliative care in our country.
Q: How was your experience at Palliative Care – ’08?
A: It was a particularly good one. The best CME I have attended so far, no doubting that. It was vibrant and had active interaction among all the delegates. I’m glad that Manipal University has taken the initiative toward encouraging Palliative care among its students and working professionals.
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Sub-edited by Ruchika Sharma |
