A novel and cost-effective way to follow-up adequacy of pain relief, adverse effects, and compliance with analgesics in a palliative care clinic.

INTRODUCTION: A way to assess compliance with analgesics in an outpatient palliative care clinic is essential since often the patient is too ill or weak to come to hospital for weekly follow-ups. A pilot study was conducted using Short Messaging Service via mobile phone as a follow-up tool. CONTEXT: A predominantly outpatient palliative care clinic of a 300 bedded multidisciplinary hospital.
MATERIALS AND METHODS: Sixty patients attending the palliative care clinic were enrolled in the study. Analgesic drugs, co-analgesics, and adjuvants were prescribed on an outpatient basis. If possible, patients were admitted for 1 or 2 days. A simple scoring system was devised and taught to the patients and their attenders. A short message service had to be sent to the author's mobile number. The period was fixed at 2 weeks by which the patients and attenders were familiar with the drugs and pain relief as well. Drowsiness was a worrisome complaint. The mobile number of the patient was called and attender instructed to skip one or two doses of morphine and reassurance given. If required, attender was asked to bring patient to the hospital or come to the hospital for a different prescription as the situation warranted.
RESULTS: Out of 60 patients, 22 were admitted initially for dose titration and all others were outpatients. Three patients were lost to follow-up and one patient died after 7 days. 93% of patients responded promptly. Random survey was done in 10 patients to confirm their SMS response and the results were analyzed.
CONCLUSION: Mobile phones are available with all strata of people. It is easy to train patients to send an SMS. This technology can be used to follow- up palliative care patients and help them comply with their treatment regimen.

INTRODUCTION

Patients with advanced malignancies sometimes come for pain relief as outpatients. A proper interim follow-up to assess the analgesic response is not available till the patient presents back to the outpatient department. A new technique of patient communication was devised in our study to follow-up patients at home using Short Message Service (SMS).

MATERIALS AND METHODS

Sixty patients were enrolled in the study and were prescribed pain killers and adjuvant drugs as per the WHO analgesic ladder. A scoring system was taught to the patients and accompanying persons to send an SMS response.

Patient characteristics

Age group: 18-76 years

Male: 25; female: 35

For details, refer Table 1.

Table 1

Patient characteristics

Sample message

A-3

B-1

C-1

For details, refer Table 2.

Table 2

Scoring systems

They were trained by the author to send an SMS to the mobile number provided.

Messages were received on 1st, 2nd, 3rd, 7th, and 14th days of treatment. Random reconfirmation was done by the author for 10 patients in the study. If drowsiness was received as a numeric response, the patients were contacted telephonically.

It was a general observation that patients with severe, uncontrolled pain were not eating much, had disturbed sleep, and were already constipated. When patients were found to have a Visual Analog Scale (VAS) score of 6 and above at the first visit, they were requested to get admitted for 3-4 days so as to titrate their analgesics. Such patients with a VAS score of 6 or more were started on tablet morphine on day 1 itself along with paracetamol and non-steroidal analgesics. Laxatives were prescribed along with morphine. Effective analgesia was often accompanied by sleepiness, which the patient interpreted as a lack of control, and worried about walking to bathroom alone at night for fear of falling down. Moreover, patients felt that some pain was acceptable and that pain killers were addictive and nephrotoxic. The patients often wanted to decrease the number of drugs in the prescription, willing to accept partial pain relief. Their logic was that they were suffering due to their past “karma” (which often included chronic smoking or alcoholism). Due to all these reasons, drowsiness was focused on more than uncontrolled pain or severe constipation.

RESULTS [TABLE 3]

Out of 60 patients, 22 were admitted initially for dose titration and all others were outpatients. Three patients were lost to follow-up and one patient died after 7 days.

The study was done primarily to assess the use of mobile phone as a communication tool and the response was prompt in 93% of patients (details in master chart). Random survey was done in 10 patients to confirm their SMS response and the results were analyzed. SMS responses were accurate, and few patients were randomly surveyed with a phone call to check the accuracy. This survey showed that patients understood the messaging procedure well. For details, refer Table 3.

Table 3

Data collected through SMS and intervention

DISCUSSION

Pain relief and palliative care forms an integral part of management of advanced malignancies. Palliative care services need to be regularly reviewed and updated for good clinical practice. Patients are considered members of the palliative care team as all treatments are with their consent and in accordance to their wishes. Members of the patients’ family can be considered members as they have an important role in the patients’ overall care, and their opinions should be included. Continued reassessment is a necessity for all patients with advanced disease in whom increasing and new problems are to be expected. This applies as much to psychosocial issues as it does to pain and other physical symptoms.[12] Francis Ho et al. published in BMC an article validating Palliative Performance Scale (PPS). The PPS includes five domains. Using web-based scenarios collected from palliative care experts, PPS scoring was done by participants in the study. They concluded that PPS is an important tool in palliative care.[3] The use of mobile phone as a tool for improving cancer care in a low-resource setting has been explored in Nigeria to follow-up patients and remind them about appointments.[4]

A pilot project was done by the multidisciplinary team at the Cross Cancer in Edmonton using videoconferencing to provide palliative care consultation in rural areas.[5] Follow-up of patients is conventionally done in the outpatient unit. Often, it is the relative who sends the message, keeping the link with the patient open.[6789] We decided to use the mobile phone as a communication tool to follow these patients.[10] Mobile phones are today present with a huge segment of population and today SMS services are available even in regional languages.

This pilot study was carried out to assess if patients can communicate with the clinician and send the correct response for pain relief. Newcastle upon Tyne Hospitals NHS Foundation Trust devised questionnaires to evaluate patient and carer satisfaction. Professor Irene Higginson has copyrighted a Palliative Care Outcome Scale,[11] with pain relief, symptom care, and psychosocial issues highlighted. We have taken only three points, since this is a pilot study, to see what is feasible. We found that 93% of our patients were very prompt in their response. Further, the random verification done by the author was found to be accurate with SMS response in all the patients verified. This helps the clinician to assess the clinical response and the adequacy of drug response.

To the best of our knowledge, mobile phones were used as a communication tool for the first time in our country.