COVID-19 pandemic has taken away focus, resources from cancer patients needing palliative care.

The outbreak of COVID-19 pandemic is impacting the global population in drastic ways and redefining the global health scenario. If the resources are diverted to manageCOVID-19, patients with other life-limiting conditions such as cancer can be pushed out of their healthcare settings with reduced access to healthcare. To mitigate the impact of the pandemic on cancer patients, health systems should focus on the strategies how to strengthen palliative care services. Copyright:

Introduction

The COVID-19 pandemic has generated unprecedented challenges to global health systems. The pandemic is expected to push many countries into historic contraction of per capita income.[1] It has both short-term and long-term impacts on health systems—including access to resources, disruption of services, and increased financial pressure. Many countries are facing a shortage of healthcare resources including a shortage of trained professionals, hospital beds, life-supporting instruments, and medicines.[2] Furthermore, COVID-19 poses a higher risk of mortality for patients with severe life-limiting diseases such as advanced cancers.[3]

Cancer patients need frequent hospital visits and uninterrupted healthcare. The diagnosis and management of cancer are time-sensitive and are likely to be substantially affected by these interruptions.[4] When the healthcare system is overwhelmed with COVID-19 patients and the resources are limited, cancer patients have limited access to the healthcare system and are able to avail supportive treatment only. Moreover, there are also several resource limitations and restrictions to access standard cancer care due to robust measures taken by governments to control infections in cancer hospitals.[5] There is growing recognition of palliative care as an integral aspect of cancer care, with the ability to provide uninterrupted services and improve the quality of life. It will also prevent unnecessary hospital admissions and the use of health services during pandemics.

Indian Scenario

In India, every year more than 1.3 million new cancer cases are reported and this is likely to increase in the next 5 to 10 years due to delay in diagnosis and treatment owing to the pandemic.[6] The pandemic has substantially affected cancer care across the globe and has had a significant impact on the delivery of oncology services in India. There are many reasons behind this crisis.

Most of the government cancer care facilities are located in major cities and people from rural areas have to travel a long distance for their treatment and follow-up. The national lockdown adversely affected the access to cancer care for those who are terminally ill. Social distancing, travel restrictions, and financial issues impose problems on many households. Clinical services also curtailed for many cancer centers and some centers were shut down due to COVID-19 cases. For example, Delhi State Cancer Institute was forced to shut down due to COVID-19 outbreak among the staff. During the lockdown period, Tata Memorial Hospital, Mumbai, continued to offer its services for cancer patients, but the hospital also modified its protocols to defer surgeries, and chemotherapy regimens to minimize the chances of complications.[7]

Due to ongoing pandemic, screening programs and campaigns for early detection of cancers were also reduced. The delay in detection and initiation of treatment of new cases are also likely to increase the future cancer burden in India. The delays in treatment might also shift a lot of patients from the curative to the palliative stage. Both scenarios might have a negative impact on cancer patients’ “long-term survival and prognosis.” In these situations, palliative care is one of the options to provide uninterrupted services to cancer patients. But a country like India that can thrive on primary healthcare and preventive medicine is surprisingly unable to effectively address the needs to invest in palliative care.[8] So, it is medically and ethically necessary that palliative care must be provided in the community, as part of primary health care. We conducted research based on in-depth interviews among randomly selected 30 cancer patients under palliative care in Kerala and Goa in the mildest of the second wave. The study also underlines the importance of focusing on immediate strategies for the effective implementation of palliative care services during pandemic. The study results states that the severity of COVID-19 pandemic has resulted in limited provision of palliative care services throughout the country. Many palliative care centers were converted to COVID-19 care centers. Physicians and nurses who were trained in palliative care have often been deployed to deliver emergency care for people with COVID-19. Citing an example, the study states that the state of Goa witnessed over 80% reduction in in-patients’ admissions while patients’ appointments for chemotherapy and surgeries were postponed given the risk of potential infections. At the same time, we observed that many critically ill patients were not admitted to cancer care facilities and hence progressed into a serious stage. The study added that patients with dyspnea, severe pain, and in the final stage with metastasis were side-lined from the general health system and taken to palliative centers at the last moments. Instead of admissions outpatients visits, home care, and follow-up through phone calls were given priority in Kerala. In addition to emergency home care visits, ASHA workers and palliative care volunteers were supported to get medicines and devices like nasogastric tubes, catheters, etc., for bedridden patients. The study also says that in the context of resource constraints priority has to be given to the interventions aimed at saving lives over palliating discomfort among seriously ill patients and their families.

Conclusion

The current situation of the pandemic, with dramatic increase in deaths associated with corona infection, has underscored the importance of palliative care, especially among people who are terminally ill. In India, it is estimated that 5.4 million people a year need palliative care but less than 2% were receiving it.[78] The Quality of Death which is a measure of end-of-life care has been the lowest across the Indian subcontinent as compared with many other countries. Palliative care is accepted as a cost-effective intervention to improve the quality of life for the terminally ill. Available evidence also indicates that primary care clinicians or family medicine specialists with basic training in palliative care and with the support of simple, safe, effective, and inexpensive medicines and equipment can respond effectively to the palliative care needs of a majority of patients.[9]

As health systems become strained under the pandemic, providing safe and effective palliative care, for patients with life-limiting illness becomes vital but extremely difficult. There is an immediate need for healthcare provider education on palliative care principles and how to triage patients when resources are scarce. Basic palliative care training for all medical and nursing students has been the recommendation of the palliative care community for a long time. Furthermore, in many countries, including India, palliative training module is not included in the medical curriculum. Palliative training modules can be included in the continuous medical education training for doctors (CME) so that the doctors working in public/private sector will be benefited through the training. COVID-19 has impelled us to rethink and insist on capacity building among healthcare professionals and awareness creation and volunteering at community level.

Governments must urgently recognize the role of palliative care during the pandemic and ensure these services should be integrated into the mainstream of healthcare system in a creative way.[10] It is essential to focus on designing immediate strategies for effective implementation of palliative care for terminally ill during COVID-19. It is equally important to plan for long-term strategies beyond the pandemic to strengthen the palliative care services to deal with future disasters.

Key messages

COVID-19 pandemic has taken away the sources form cancer patients who needs continuum of care

Primary care clinicians/family physicians with basic palliative training can effectively manage the palliative care needs of the majority of patients.

Governments must urgently recognize the role of palliative care and should be integrated into the healthcare system

Ethical approval

Institutional approval obtained from CER, Goa Institute of Management and informed consent obtained from all participants before interviews.

Financial support and sponsorship

This Commentary is based on the study supported by Center for Excellence in Research (CER), Goa Institute of Management, Sanqulim, Goa.

Conflicts of interest

There are no conflicts of interest.