What happens to palliative care in times of mega disaster?

New series: Posters from the 15th World Congress of the European Association for Palliative Care

Poster presentations are an essential cornerstone of every EAPC Congress – this year in Madrid more than 900 posters were on display representing the scientific rigour and commitment of people involved in palliative care from across the world. If you were not able to attend the congress in Madrid, now’s the chance to see some of the posters close up and to enter into discussion with the contributors . . .

Here, Dr Sunita Panta from Nepal explains the background to her poster: ‘Limitations in Chronic Pain Management and Efficacy of Alternative Modalities during Mega Disaster in an Underdeveloped Nation’.

Dr Sunita Panta

Anyone who works in a low-income country with few palliative care services will be acutely aware of the difficulties and challenges that confront us daily, but when your country is also prone to earthquakes, or other natural disasters, the challenge is even greater. My poster describes the unique difficulties and obstacles that we faced when disaster struck our country.

For the past 17 years, I have been working in a tertiary military hospital, Shree Birendra hospital in Kathmandu, Nepal, as an anesthesiologist. Palliative care in my hospital started with pain management for chronically ill patients. Later, with the establishment of an oncology ward, other symptoms such as nausea, vomiting, constipation, loss of appetite, lack of sleep, anxiety, and depression demanded a palliative care approach in the hospital. A pain management clinic was started for outpatients with cancer, prolapsed intervertebral discs, migraine, fibromyalgia and post herpetic neuralgia, based on the World Health Organization pain ladder treatment principles.

Opioids were prescribed supplemented with adjuvants such as acetaminophen and non-steroidal anti-inflammatory drugs with a numeric rating scale of 0-11 as a guide. The clinic was run on a weekly basis but the opioid prescription was limited to five days owing to hospital regulations. Fortunately, we were able to extend the prescription of morphine for a week with proper documentation and later the pain clinic was also extended to twice a week. Oral morphine in tablet and syrup form became the drug of choice for chronic cancer pain. Despite side effects such as nausea, constipation and drowsiness, patients were able to eat well, sleep well and carry out their daily activities, thus improving the quality of life.

The Nepal earthquake in 2015 led to a surge of casualties in my hospital and other negative outcomes. Chronic pain patients were discharged and were deprived of prescribed opioids. The hospital was partially damaged and the acute wards had to be shifted into tents. Because of lack of space and personnel, the pain clinic could not function and continuous aftershocks prevented the patients from coming to the hospital.

Patients resorted to alternative modalities including over the counter drugs, vitamins, herbal medications supplemented by yoga, massage, meditation and traditional remedies such as tiger tattoos to stop the spread of herpes zoster lesions on the body. But most of the alternative methods were less effective than opioids and had more side effects. The pain clinic re-opened two months later but by now we had lost many of our patients and some were reluctant to discontinue their alternative medication and restart the chronic pain therapy.

Nepal is a low-economy disaster-prone country and in dire need of palliative care. During disasters, mass-casualty management policies should have provision for palliative care too. There should be better communication so that patients are informed about other sources of pain management and palliative care treatment. Regional and international medical teams assisting in disasters should come prepared to provide pain management and palliative care along with acute trauma care.

Links and resources

• Read the abstract of ‘Limitations in Chronic Pain Management and Efficacy of Alternative Modalities during Mega Disaster in an Underdeveloped Nation’ (Poster no: P02-388) in the EAPC 2017 Book of Abstracts.
• Contact Dr Sunita Panta by email.
• Read more posts from the Madrid Posters series on the EAPC Blog and other posts relating to the 15th EAPC World Congress in Madrid.
• Read more posts from the Palliative care in Humanitarian Crises series.

10^th EAPC World Research Congress, Bern, Switzerland – 24 to 26 May 2018. Submit your abstract now (closing 15 October 2017.