Pilot Project:
"In regions where the knowledge gap is
wider than the technology gap, we were able to show that the
internet is a readily available tool for the exchange of
knowledge that ultimately benefits the patients."
Pilot project participants
Method
“Happiness has entered my house”
Wife of
patient with metastatic lung cancer comment on the care
provided by the palliative care team.
Long
distance educational support between a Palliative Care
physician in Los Angeles and a multidisciplinary Palliative
Care Team in Mumbai comprised of interactive sessions over
the internet three times a week for two months. Cases were
discussed and treatment plans for new patients and new
symptoms were formulated. The role of the physician in Los
Angeles was not to take over the role of prescribing for the
patients but merely to educate the managing physician in
Mumbai. Follow up of patients who were already receiving
care was discussed as well. When possible, theoretical
discussions and lectures on power point were discussed.
The required equipment for this
exercise was a computer with a microphone, webcam, speakers
and a good Internet connection. The equipment was available
at both locations and no additional investment was required.
A popular and readily available Internet chat room was used
to conduct the sessions. Language was not a barrier since
all communication was in English. There is a time difference
of twelve and a half hours between Los Angeles and Mumbai,
with the Indian time being ahead. Sessions started at 8:00
pm in Los Angeles, which corresponded to 8:30 am the
following day in India. In case there was an urgent
situation, the team in Mumbai could send a text page, which
would initiate a call from the physician in Los Angeles.
The aim was to test this pilot project and to evaluate its
effectiveness and benefits.
Results
“This project started a revolution in the community”
Dr. Sanjay
Pisharodi, Palliative Care Physician, Mumbai, India
The
exercise worked very well from a technical standpoint. The
sessions were held with ease. There were minor technical
difficulties, which involved the relay of voice. This was
easily overcome by reconnecting on the voice mode.
A total of forty-three and a half hours were logged. Each
session was projected to last an hour; however, sessions
lasted one and a half hours on average. There was a
bilateral exchange of thoughts and ideas. In the two months,
eighty-one emails were exchanged. The email correspondences
included follow-ups, treatment strategies, doubts, and
clarifications. In urgent situations, the text messaging
system was used. Four text messages were received with each
prompting an international call to discuss patient symptom
management. The strategy was effective in handling
situations that needed prompt attention.
A total of twenty-six patients were
cared for over a two-month period. Of the twenty-six, twenty
were diagnosed with cancer. Fourteen of the twenty cancer
patients were treated for pain. Thirteen of the fourteen
patients had severe pain on presentation. The other patient
had moderate pain. Opioids were also prescribed for
non-cancer conditions such as severe arthritis and symptoms
such as dyspnea. One stroke patient was able to resume
physical therapy after his pain was controlled. Two patients
declined symptom management.
Of the cancer patients who were
presented with pain, thirteen had previously received
treatment for their cancer and pain at a tertiary care
cancer center. Four patients requested euthanasia on their
first visit due to the severity of their pain. Once
treatment was initiated, all patients were pain free within
a few hours. Patients requesting euthanasia had a drastic
improvement in their quality of life after control of their
symptoms. The average duration of care was approximately
forty days. All but three patients were cared for at home.
The other three were treated in the hospital. All deaths
were peaceful and there was no negative feedback regarding
treatment rendered from the patients or their family
members. Patients were not charged for any of the services
provided. They purchased the medications that were
prescribed.
One patient was pursuing aggressive
care while being followed by the team. Five patients were
followed solely for psychological and emotional support, an
integral part of palliative care service.
A team approach was used with nurses and spiritual care
staff members participating in some of the sessions. Various
aspects of care (the physical, social, psychological and
emotional aspects) were dealt with and discussed.
The second patient was enrolled in the
program twenty days after the first patient. During this
downtime, the internet sessions were utilized to conduct
case-based discussions on pain management. A total of eleven
cases were discussed. There were three power point sessions
pertaining to symptom management. Discussions based on the
EPEC (Education on Palliative and End-of-life-care)
curriculum were also held in these sessions.
“I tell my nurses that
patients with cancer do not have to die in pain. This is how it
should be”
Relative of patient with metastatic cancer. She is a head nurse
at a local hospital.
This exercise was very successful in using technology to narrow
the knowledge gap and assist in training various palliative care
team members. The medical team in India now feels confident in
handling the practical aspects of the art and science of
palliative care. In addition, the program has found immense
support from the local community and has received a letter of
appreciation from the local health forum for the services they
rendered.
The whole project exceeded
our expectations. Most importantly, there were no technical
difficulties. We exceeded the target of caring for twenty
patients in two months. More importantly, we were able to
relieve all of the patients’ symptoms with significant
improvement in their quality of life. The impact on the
patient’s quality of life and their caregivers was the most
important tool in measuring the success of this exercise.
There was measured
improvement in both the objective knowledge of the physician in
India as well as subjective confidence before and after the
project.
At the end of the project, physicians in both locations
indicated an improvement in the overall understanding of the
situation in the other location and also learned of the
challenges, advantages and shortcomings of each system.
Cultural differences in dealing with death and pain were
appreciated. The physicians in India acknowledge an increase
in confidence in managing patients with advanced diseases
and treating various symptoms. Growth in confidence was not
limited to the physical aspect of the patient’s being but
also social, psychological and emotional as well. A
deficiency of palliative care services was very apparent
through this experience.
“We could not believe that patients with such
advanced diseases, especially cancer, could live without
pain and die such a peaceful death.”
Physician
participants in India at the end of the experience.
Impact of project on patients
A young stroke patient was unable to participate in physical
therapy due to pain. Once pain was managed, the patient was
able to do aggressive physical therapy.
For a patient
with severe osteoarthritis, her only wish was to go to a
place of worship to pray. She was unable to do so due to
pain. Once the pain was controlled, she was able to fulfill
her desire.
A patient with metastatic cancer
requested euthanasia upon first consultation by the
palliative care team due to severe pain. Within a few hours,
the pain was controlled with the team being
present. The patient requested a meal with family as she had
not eaten well for a long time.
Conclusion
We propose such exercises can be used very effectively in
the exchange of knowledge. Other fields of medicine may also
benefit from such arrangements. Such a set up might be
beneficial in education at school and college levels, as
well. We hope that our experience will enable a free flow of
knowledge and support between various settings, especially
in the field of medicine where it can ultimately make a
difference at a patient’s bedside.
One can tailor the interactions
based on the needs and availability of the participants.
This does not require a lifelong commitment...unless you
want it to be. Good luck !!
Parag
Bharadwaj, MD, Los Angeles, USA
Sanjay
Pisharodi, MBBS, Mumbai, India
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