Write a short note on terminal care and palliative care.

Definition

Palliative care, as defined by the WHO, is an approach that improves the quality of life of patients and their families facing life-threatening illness, through prevention and relief of suffering by early identification, impeccable assessment and treatment of pain and other physical, psychosocial and spiritual problems.

Terminal care is the component of palliative care delivered in the last days to weeks of life, when the goal shifts entirely from prolonging life to ensuring comfort and dignity in dying.

Principles (WHO)

• Provides relief from pain and other distressing symptoms.
• Affirms life and regards dying as a normal process.
• Neither hastens nor postpones death — this distinguishes palliative care from euthanasia.
• Integrates the psychological and spiritual aspects of care.
• Offers a support system to help patients live as actively as possible until death.
• Supports the family during the illness and in bereavement.
• Uses a multidisciplinary team — physician, nurse, counsellor, physiotherapist, social worker, chaplain.
• Is applicable early in the course of illness, alongside disease-modifying therapy such as chemotherapy — not only at the end.

Symptom Control

Pain — the commonest and most feared symptom. Managed by the WHO analgesic ladder:

• Step 1: non-opioid — paracetamol, NSAIDs, with or without an adjuvant.
• Step 2: weak opioid — tramadol, codeine — with or without non-opioid and adjuvant.
• Step 3: strong opioid — morphine, fentanyl, buprenorphine — with or without non-opioid and adjuvant.

Principles of opioid use: give by mouth, by the clock (regularly, not as required), by the ladder, for the individual, with attention to detail. Prescribe a breakthrough (rescue) dose of about one-sixth of the total daily dose. Always co-prescribe a laxative, since opioid-induced constipation does not develop tolerance. Nausea is common initially and usually settles within a week.

Adjuvants: amitriptyline, gabapentin or pregabalin for neuropathic pain; corticosteroids for raised intracranial pressure and nerve compression; bisphosphonates and radiotherapy for bone metastases.

Communication

Breaking bad news should follow a structured approach such as SPIKES: Setting, Perception, Invitation, Knowledge, Empathy, Summary and strategy. Give information at the patient's pace, allow silence, avoid jargon and false reassurance, and check understanding. Discuss goals of care and advance directives while the patient can participate.

End-of-life Care & Ethics

Recognise dying; stop non-essential drugs and investigations; convert essential medication to the subcutaneous route; anticipate and prescribe in advance for pain, breathlessness, secretions and agitation. Address the family's needs and provide bereavement support.

Ethical principles include autonomy, beneficence, non-maleficence and the doctrine of double effect — a drug given with the intention of relieving suffering is acceptable even if it may incidentally shorten life. Withholding and withdrawing futile treatment is legally and ethically distinct from euthanasia, which remains illegal in India, though the Supreme Court has recognised passive euthanasia and advance directives (living wills) under strict safeguards.