Palliative Care Facilities Research Articles

Comprehensive geriatric assessment and palliative care

AbstractThe geriatric vision of palliative care is based on a multidisciplinary, patient‐centered approach, looking for a balance between human dignity and medical treatments with a particular focus on the social and ethical aspects. In order to develop the best care models, there is a rising need for a tighter collaboration of all the involved players (i.e., doctors, nurses, social workers). Indeed, the idea of a fragmented system without considering the patient or his/her family is not at all applicable to older patients with chronic disease. The causes of death, the phase of death changes, and the extend of last period of life could be a long phase characterized by complicated treatment decisions, difficult management of symptoms, multiple psychosocial problems, and complex spiritual distress. Recently, Italian guidelines on Comprehensive Geriatric Assessment (CGA) have been published. However, none of the identified studies on patients in hospice and other palliative care facilities met the criteria for inclusion. These findings underscore the need for further research to determine the potential benefits of a multidimensional approach for patients in hospice and other palliative care settings. Our reflections and suggestions on the CGA use for older persons in palliative care may be a starting point for an open and continuous dialogue with all the operators concerned.

Characterization of Laboratory-Confirmed Creutzfeldt-Jakob Disease From 3 Ontario Tertiary Care Centers Between 2012 and 2022: A Retrospective Cohort Study.

Globally, Creutzfeldt-Jakob disease (CJD) affects one in one million people annually, but there is a paucity of recent Canadian data. This study summarizes epidemiology trends and diagnostic timelines of laboratory-confirmed CJD cases in three tertiary Ontario hospitals. Using laboratory information systems, we identified 30 patients with a laboratory-confirmed CJD diagnosis between 2012 and 2022 at three major tertiary hospitals in Ontario. Retrospective chart reviews were then completed. Patients had a mean of 2.2 hospital visits (SD, 1.2) prior to being admitted for testing. The most common symptom presentations included loss of coordination (63.3%), behavioral changes (60%), progressive mobility loss (53.4%), memory loss (50.0%), and involuntary movements (50.0%). Magnetic resonance imaging findings showed potential CJD in 76.7% of cases, and 56.7% exhibited periodic sharp wave complexes characteristic of CJD on electroencephalogram. The mean duration from symptom onset to microbiologic testing was 91 days (SD, 90.7). End-point quaking-induced conversion (EP-QuIC) testing of cerebrospinal fluid was positive in 90.0% of patients, while 83.3% tested positive for 14-3-3 on enzyme-linked immunosorbent assay. Elevated cerebrospinal fluid 14-3-3 levels significantly correlated with shorter duration from symptom onset to death (R 2 = 0.71, F = 19.55, P = .0022). Post-diagnosis, 46.7% of patients were discharged home, 16.6% were transferred to external palliative care or hospice facilities, and 36.7% died during admission. The mean time from symptom onset to death was 121 days (SD, 120.7), and from diagnosis to death 35 days (SD, 83.9). This study highlights the importance of early CJD consideration and laboratory testing when appropriate neurologic symptoms are present.

Age- and gender-based social inequalities in palliative care for cancer patients: a systematic literature review.

Cancer is a major public health problem worldwide, given its magnitude and growing burden, in addition to the repercussions on health and quality of life. Palliative care can play an important role improving quality of life and it is cost-effective, but some population groups may not benefit from it or benefit less based on age and gender inequalities. The aim of this systematic review was to analyze the available evidence on age- and gender-based social inequalities in access to and use of palliative care in cancer patients. A systematic review was conducted following the PRISMA guidelines. An exhaustive literature research was performed in Pubmed, CINHAL and Embase until November 2022 and were not restricted by language or date of publication. Eligible studies were observational studies analyzing the access and use of palliative care in cancer patients. Fifty-three studies were included in the review. Forty-five analyzed age and 44 analyzed gender inequalities in relation to use of and access to palliative care. Our results show that older people receive poorer quality of care, worst symptom control and less preferences for palliative care. In relation to gender, women have a greater preference for the use of palliative care and generally have more access to basic and specialized palliative care services and palliative care facilities. This review reveals difficulties for older persons and men for access to key elements of palliative care and highlights the need to tackle access barriers for the most vulnerable population groups. Innovative collaborative services based around patient, family and wider community are needed to ensure optimal care.

Cross-disciplinary advance care planning in oncology and palliative care amidst a pandemic: a best practice implementation project.

Advance care planning (ACP) ensures that patients receive medical care aligned with their values, goals, and preferences, especially regarding end-of-life decisions in serious chronic illnesses. This project aimed to introduce and promote evidence-based ACP in oncology and palliative care at a midsized hospital near Berlin, Germany, during the COVID-19 pandemic. This project was guided by the JBI Evidence Implementation Framework and used a mixed methods audit cycle. A baseline audit was conducted using qualitative interviews and workshops with representatives from all the health care disciplines involved in oncology and palliative care at the hospital. The findings were compared with eight best practice recommendations. Targeted strategies aimed at the key stakeholders involved in ACP practice were then implemented. Finally, a semi-quantitative questionnaire was used in a follow-up audit with the same participants as in the baseline audit. The baseline audit revealed a high level of familiarity with the concept of ACP. However, there was a lack of a uniformly accepted definition and understanding of ACP among the health care professionals, leading to a lack of coordination in task distribution. The follow-up audit revealed improvements with regard to education and training in ACP (Criterion 1: 50% to 100%) and organizational support to facilitate ACP conversations (Criterion 3: 87.5% to 100%). Other audit criteria compliance rates remained unchanged. Clinical education and team-based process analysis can facilitate ACP implementation across disciplines in oncology and palliative care facilities. However, the project did not succeed in implementing lasting changes in clinical processes and best practice ACP due to the COVID-19 pandemic. Such an endeavor would demand considerable resources and time, both of which were constrained during the pandemic. http://links.lww.com/IJEBH/A236.

General practitioners and palliative care practices: a better knowledge of specific services is still needed

BackgroundFrance allows deep sedation for pain relief, but not for euthanasia. In anticipation of an increase in home-based palliative care, the role of general practitioners is central to the design of outpatient palliative care services. This study aimed to describe the knowledge, attitudes, and practices of general practitioners in mainland France regarding palliative and end of life care.MethodsThis was a national descriptive cross-sectional study within the Sentinelles network. Self-report questionnaires were distributed to general practitioners between November 2020 and November 2021. A descriptive analysis was carried out.ResultsOut of the 123 participating general practitioners, 84% had received academic training in palliative care (n = 104). While a significant majority (69%) expressed comfort in pain management, only a quarter (25%) declared that they were competent at indicating deep and continuous sedation for pain relief. Awareness of outpatient palliative care facilities close to their place of practice such as hospitalization at home was over 97% (n = 117/120). Awareness of hospital facilities, including identified palliative care beds on hospital wards and palliative care units, was lower (75% (n = 59/79) and 86% (n = 86/100), respectively).ConclusionsOur results suggest that French general practitioners are reasonably aware of palliative care resources available. However, there is room for improvement, particularly in understanding hospital-based facilities. Furthermore, a quarter of the general practitioners expressed discomfort with deep and continuous sedation for pain relief, highlighting the need for increased training in this specific aspect of palliative and end of life care.

Implementation of a palliative care service in a tertiary hospital in a developing country: Methods, strategies and results.

e24056 Background: In Rio de Janeiro, only 11 palliative care facilities exist, creating challenges in meeting the complex needs of patients with metastatic cancer. Our study aims to implement a palliative care service within an existing oncology practice. This approach holds promise as a model that could guide similar practices in low- and middle-income countries, offering a blueprint for the implementation of palliative care services on a broader scale. Methods: This descriptive study spans from February to December 2023, involving the monitoring of 176 patients. Eligible patients met criteria such as a FAST scale for dementia syndrome ≥ 7A, stage IV disease, ranking 5 stroke, terminal organic failure, uncontrolled symptoms, or requiring end-of-life care. The PC team, denoted as “Continued Care”, comprises a medical leader, 3 routine doctors, and 1 nurse. Activities undertaken by the team encompass consults requested by internal medicine and intensive care unit (ICU) teams, outpatient care, continuous education, and daily monitoring of patients with advance care plan (ACP). Results: Among 176 patients initially enrolled, outcomes were completed for 171 patients. Remarkably, 80% of those receiving PC assistance had an ACP in place, with 78% opting for exclusive non-invasive support. The overall death rate was 38%. Notably, among patients enrolled in the PC program, the ICU death rate was 31%. Conclusions: Institutional PC policies associated with the integration of a dedicated team into the hospital's routine, and investments in disseminating knowledge about irreversible illness processes and comfort strategies, emerge as a pivotal component in establishing a comprehensive and integrated model of PC services. This approach appears to surpass the effectiveness of traditional consult or sectorized model, emphasizing the importance of an institutionalized and holistic framework for delivering quality PC.

Symptom burden and relief in palliative care units of German Comprehensive Cancer Center and other hospitals

PurposeThe National Hospice and Palliative Registry contains patient data from German hospice and palliative care facilities about symptoms. The aim of the study at hand is to differentiate symptom burden of patients in palliative care units between Comprehensive Cancer Center (CCC) and other hospitals regarding symptom burden and relief of patients in palliative care units.MethodsThe registry analysis provided data of patients in palliative care units (2014–2018). We analyzed characteristic and symptom-related data on 18 symptoms, with considerable symptom-burdened patients (moderate or severe). We followed a cancer (yes/no) and facility-specific descriptive analysis (f, %, μ, Mdn, SD, V, r) using SPSS.ResultsWe evaluated 10,447 patient records (CCC: 4234 pts/non CCC 6,213 pts), 82% with a cancer diagnosis. For cancer patients, the mean age in CCC-affiliated palliative care units was 68 (SD 19–99) years, in others 73 (SD 23–104) years (p < 0.05; V = 0.2). The proportion of patients with significant symptom burden is lower in CCC-affiliated than in other palliative care units. The difference between facilities shows a significant weak effect in pain, vomiting and constipation, depressiveness, anxiety, and tension. The proportion of cases which symptom burden could be alleviated is higher in CCC-affiliated palliative care units with significant weak/medium effect in pain, nausea, vomiting, shortness of breath, constipation, wound care problems, depressiveness, anxiety, tension, confusion, and problems in organizing care.ConclusionWe found differences in symptom burden and symptom relief between CCC-affiliated and other palliative care units. CCCs should continue to feel responsible for sharing knowledge about symptom relief, such as through standard operating procedures and education.

Can We Make More Accurate Prognoses During Last Days of Life?

Background: Life expectancy prediction is important for end-of-life planning. Established methods (Palliative Performance Scale [PPS], Palliative Prognostic Index [PPI]) have been validated for intermediate- to long-term prognoses, but last-weeks-of-life prognosis has not been well studied. Patients admitted to a palliative care facility often have a life expectancy of less than three weeks. Reliable last-weeks-of-life prognostic tools are needed. Objective: To improve short-term survival prediction in terminally ill patients. Method: This prospective study included all patients admitted to a palliative care facility in Montreal, Canada, over one year. PPS and PPI were assessed until patients' death. Seven prognostic clinical signs of impending death (Short-Term Prognosis Signs [SPS]) were documented daily. Results: The analyses included 273 patients (76% cancer). The median survival time for a PPS ≤20% was 2.5 days, while for a PPS ≥50% it was 44.5 days, for a PPI >8 the median survival was 3.5 days and for a PPI ≤4 it was 38.5 days. Receiver operating characteristic curves showed a high accuracy in predicting survival. Median survival after the first occurrence of any SPS was below one week. Conclusions: This study demonstrated that the PPS and PPI perform well between one week and three months extending their usefulness to shorter term survival prediction. SPS items provided survival information during the last week of life. Using SPS along with PPS and PPI during the last weeks of life could enable a more precise short-term survival prediction across various end-of-life diagnoses. The translation of this research into clinical practice could lead to a better adapted treatment, the identification of a most appropriate care setting for patients, and improved communication of prognosis with patients and families.

The perceptions of palliative care medical practitioners towards oral health: A descriptive qualitative study

Background: Oral health problems are common, but often overlooked, among people receiving palliative care. Aim: To better understand how oral health can be addressed in this population, this study aimed to explore the perceptions of oral health care among medical practitioners who provide palliative care to inform the development of a palliative oral health care program. Design: A descriptive qualitative design was adopted. Setting/participants: A single focus group was conducted with 18 medical practitioners at a palliative care facility in Sydney, Australia. All participants had experience providing palliative care services to clients. The focus group was audio recorded, transcribed and thematically analysed. Results: The results from the inductive thematic analysis identified four themes. The themes highlighted that participants were aware of the oral health needs of people receiving palliative care; however, they also reflected on the complexity in delivering oral health care across the healthcare settings, as well as the challenges around cost, lack of appropriate dental referral pathways, time constraints and limited awareness. Participants also provided recommendations to improve the delivery of oral health care to individuals receiving palliative care. Conclusions: To improve the provision of oral health care in this population, this study highlighted the need for oral health training across the multidisciplinary team, standardised screening assessments and referrals, a collective responsibility across the board and exploring the potential for teledentistry to support oral health care provision.

Pattern, Outcome and Associated Factors of Oncologic Emergencies Among Patients Visiting Saint Paul ‘s Hospital Millennium Medical College Adult Emergency Department: One Year Cross Sectional Study

Introduction: Cancer patients are at high risk of developing a wide range of medicalemergencies.Patients with cancer face unique disease and treatment-related complications that promptfrequent visits to the emergency department (ED), constituting a significant patient andhealth care burden, resulting in more utilization of resources and ED overcrowding, whichmay hamper the administration of quality and focused care.Objective: The study aimed to assess the patterns, outcomes, and associated factors ofoncologic emergencies among patients visiting Saint Paul's Hospital Millennium MedicalCollege adult emergency department from March 1/2021, to April 30/2022.Methods: A retrospective institutional-based cross-sectional study was used. Data wascollected using a standardized data extraction tool by trained data collectors from patientmedical records and health management information system registry books using asystematic sampling method. A total of 173 cancer patients were included. Data wasanalyzed using SPSS version 25.0.Results: A total of 173 cancer patients were included in the study. The mean age of thestudy participants was 53.05 ± 14.801 years. 56.6% were females, and 43.4% were males.The most prevalent primary tumors were those of the gastrointestinal tract (49.7%) andgenitourinary system (19.1%). About 39.9% of the cases had metastasis. Only 39.3% ofcases started cancer treatment. Oncologic emergencies account for 68.8% of the cases. Themost frequently observed oncologic emergencies were structural (Mass effect) in 64.7% ofcases and hematologic emergencies in 34.45%. About 19.3% of patients with oncologicemergencies have died. The commonest cause of death was due to Gastrointestinalmalignancies, seen in 34.6% of the cases. Those with Hematologic Emergencies had a 4.2times risk of death as compared to patients with local mass effects (P value &lt; 0.006).Conclusion: Oncologic emergencies comprised 68.8% of the cases, of which 19.3% resultedin mortality. There should be a well-organized system with chemotherapy, radiotherapy,and palliative care facility service for patients with oncologic emergencies to reduce patientmortality.

Color scheme: Implementation Evidence-Based Design for Palliative Care and Hospice Building

The number of patients suffering from cancer has increased 27.8% per 1000 population from 2013 to 2018 and most of cancer patients come from Jakarta. Based on interviews with health workers and cancer patients, it can be concluded that there are problems in terms of space requirements and space design in current palliative care and hospice care facilities. This study uses a qualitative method. The data used for this study came from interviews as part of the Evidence-based Design (EBD) process, which was then analyzed using coding techniques and precedent analysis to draw conclusions. It was found that color is an element that can influence human health, the preference for color by cancer patients in Indonesia is in line with the color preference for hospice buildings and cancer health facilities in western countries, and it was also found that cancer patients need a communal area, consultation area, therapy area, spiritual area, and in-patient area. Each of these areas requires a different color scheme.

Palliative medicine specialist and general practitioner interactions: national survey

ObjectivesThe purpose of the study was to investigate the collaboration between primary care and palliative care physicians, which is key to providing comprehensive care, and to identify potential difficulties and...

Access to palliative care in patients with advanced cancer of the uterine cervix in the low- and middle-income countries: a systematic review

BackgroundWomen with advanced uterine cervical cancer suffer from a combination of moderate to severe physical, psychological, social, and spiritual distress due to their disease and are in need of palliative care to improve their quality of life. Approximately 85% of the women live in the low- and middle-income countries. Whether these women and their families access palliative care is not known.ObjectivesTo understand the geographic accessibility, availability, financial accessibility, and acceptability of palliative care by patients with advanced cervical cancer and their families.MethodsWe conducted a Systematic review following PRISMA guidelines in CINAHL, Cochrane Central Register of Controlled Trials, MEDLINE, PsychINFO, PubMed and Scopus for the core concepts: palliative care, access, advanced uterine cervical cancer. Eligible articles were published in English, contained original data on experiences of patients and/or caregivers including symptoms management, and discussed available resources, communication, satisfaction, and healthcare utilization.ResultsOverall there was limited access to palliative care with the few available facilities located in cities, far from the rural areas where most women lived. Pervasive poverty was common with poor affordability of healthcare, travelling, accommodation, and subsistence expenses. Misconceptions and poor knowledge of the disease, cultural beliefs and attitudes, and other health system insufficiencies also presented challenges for access.ConclusionConcerted effort should be made to improve availability of palliative care facilities. Health education to address misconceptions and other cognitive barriers that limit access among cervical cancer patients and their families should be urgently undertaken in the LMICs.

Outcomes of Cancer Patients Who Seek Outpatient Visits Despite Post-chemotherapy Decline.

The medical needs of cancer patients are complex and increase with the disease's progression. However, Japan's aging population and increased medical needs have produced challenges like a shortage of hospital beds. Therefore, patients who have completed chemotherapy are recommended home-based care or referred to local palliative care facilities, especially when cancer treatment is no longer a viable option and outpatient visits become unfeasible. However, some patients still strive to continue outpatient visits, which could result in increased pain and possible urgent hospitalization. These patients may spend their final days in the hospital, which may not have been their desired outcome. Therefore, we examined the outcomes of patients who were recommended home-based care. The study population comprised 34 cancer patients undergoing treatment at the Oncology Outpatient Department of Edogawa Hospital who were recommended home-based care owing to their difficulty attending outpatient visits. Data regarding home-based care recommendations were obtained from the lists of medical social welfare interventions and hospitalized patients. Patients were classified based on whether they opted for home-based care and their caregivers' caregiving capacity. Survival was analyzed using the Kaplan-Meier curve and the log-rank test, and the groups were compared using Fisher's exact test. The median interval between the initial consultation with an oncologist and the date of recommendation for home-based care was six and a half months. Home-based care was mostly recommended because of the progression of cachexia (23 cases) and the worsening of symptoms (11 cases). The median survival for the groups with cachexia and worsening symptoms was 25 days and 35 days, respectively. Ten patients refused home-based care. Of them, six refused it because they wished to continue with outpatient visits. Of the home-based care group (24 patients), only one required an emergency room (ER) visit, while four of the non-home-based care group required ER visits. Regarding end-of-life care, 19 from the home-based care group and four from the non-home-based care group received end-of-life care at home. Additionally, one of the two patients who lived alone and two of the six patients whose caregivers were deemed to have insufficient caregiving capacity received end-of-life care at home. Of the remaining 24 patients, 22 received end-of-life care at home. The short survival period of the group with cachexia indicates that it would be beneficial for patients, their family members, and home-based care providers to facilitate earlier referral to home-based care. However, while home-based care is beneficial for patients who wish to spend their final days at home and for their family members, short-term and achievable goals, such as attending the next outpatient visit, may alleviate anxiety in cancer patients and enable them to live their daily lives without constant awareness of death. Additionally, while non-home-based care could lead to extended pain due to the lack of readily accessible medical personnel, ER visits, and hospital-based end-of-life care, home-based care can be mentally and physically strenuous for the primary caregiver. Therefore, comprehensive information about palliative care options should be provided early on during the outpatient visits of cancer patients who wish for home-based care for informed decision-making.

Performing first application (REST API) for adaptive palliative care facility in Alzheimer’s disease

Performing first application (REST API) for adaptive palliative care facility in Alzheimer’s disease

Curative to palliative care transition challenges in the intensive care unit. A narrative review.

Abstract&#x0D; Introduction: The need for high quality palliative care services for critically ill patients and their families remains of high importance.&#x0D; Purpose: This review aims to present the benefits and barriers to implementing palliative care in Intensive Care Units and suggest ways to facilitate the shift from therapeutic to palliative care.&#x0D; Methods: PubMed, Scopus, and Google Scholar databases were searched online. Studies included were eligible for the provision of palliative care in the intensive care unit, published in English from 2012 through 2022.&#x0D; Review: Evidence shows that integrating palliative care impacts the quality of life in intensive care unit and increases rates of use of palliative care facilities. On the other hand decrease length of stay and impacts the cost and the opportunity cost of the intensive care unit. The data suggest that a large subset of intensive care units patients would benefit from palliative care, but palliative care remains underutilized in the ICU setting. Lack of training in palliative care, organizational factors, decisions about end of life, lack of defined criteria for inclusion, and life-saving culture of the intensive care unit are barriers to providing palliative care. Efforts should focus on education, support for effective communication and decision-making, early integration of a palliative approach, redesign of clinical protocols, and reallocation of resources to provide an environment conducive to quality at the end of life.&#x0D; Conclusion: Involving palliative care in critically ill patients has reduced intensive care unit resource use. Nurses need to define their essential management roles within the multidisciplinary critical care team and help develop systems by which these roles can be implemented.

Impact of an outpatient palliative care consultation and symptom clusters in terminal patients at a tertiary care center in Pakistan

BackgroundPatients with terminal diseases may benefit physically and psychosocially from an outpatient palliative care visit. Palliative care services are limited in Pakistan. An improved understanding of the symptom clusters present in our population is needed. The first outpatient palliative care center in Karachi, Pakistan, was established at our tertiary care institution. The primary aim of this study was to evaluate the impact of a palliative care outpatient consultation on symptom burden in patients with a terminal diagnosis. The secondary aim was to analyze the symptom clusters present in our population.MethodsPatients with a terminal diagnosis referred to our outpatient palliative department between August 2020-August 2022 were enrolled. The Edmonton Symptom Assessment Scale (ESAS) questionnaire was administered at the initial visit and the first follow-up visit at one month. Change in symptom burden was assessed using a Wilcoxon signed ranks test. A principal component analysis with varimax rotation was performed on the symptoms reported at the initial visit to evaluate symptom clusters. The palliative performance scale (PPS) was used to measure the performance status of palliative care patients.ResultsAmong the 78 patients included in this study, the average age was 59 ± 16.6 years, 52.6% were males, 99% patients had an oncological diagnosis, and the median duration between two visits was 14 (Q1-Q3: (7.0, 21.0) days. The median PPS level was 60% (Q1-Q3: 50–70). Overall, ESAS scores decreased between the two visits (6.0 (2.8, 11.0), p < 0.001) with statistically significant improvement in pain (5.0 vs. 2.5, p < 0.001), loss of appetite (5.0 vs. 4.0, p = 0.004), depression (2.0 vs. 0.0, p < 0.001), and anxiety (1.5 vs. 0.0, p = 0.032). Based on symptoms at the initial visit, 3 clusters were present in our population. Cluster 1 included anxiety, depression, and wellbeing; cluster 2 included nausea, loss of appetite, tiredness, and shortness of breath; and cluster 3 included drowsiness.ConclusionAn outpatient palliative care visit significantly improved symptom burden in patients with a terminal diagnosis. Patients may benefit from further development of outpatient palliative care facilities to improve the quality of life in terminally ill patients.

Realizing homeliness in palliative care: inpatient and family perspectives on designing the built environment

This article reports 36 in-depth interviews with patients (n = 20) and family members of palliative care patients (n = 16), during an inpatient stay within one of four contemporary palliative care facilities. Interviews were conducted to understand how patients and families felt the built environment supported their experience of palliative care, and the ways that it did not. Over the past decade, a growing body of literature has sought to understand how architectural design can support wellbeing within palliative care settings. Yet, despite evidence that promotes the prioritization of privacy, homeliness, and nature, the sheer complexity of hospital procurement often results in compromises to the successful implementation of best design practice. Here we argue that a deeper understanding of what these environmental affordances mean to patients being treated for a terminal illness, and to their families, may encourage a necessary re-examination of the ease with which these provisions are compromised relative to considerations of risk, cost, or convenience (in building construction and/or maintenance). Importantly, our findings confirm that privacy, homeliness, and nature do not operate in isolation but in accord to shape experiences of palliative care.

Skin lesions on a man's face and scalp

An 87-year-old male patient was admitted to our Clinic for diagnostic evaluation and treatment of extensive, confluent erythematous-livid areas that affected almost the entire skin of his face, scalp, and neck Figure (1). The patient also showed left eyelid ectropion and a palpable subcutaneous, painless nodule in the left mandibular region the size of an apple that bled easily. The patient had been treated for undiagnosed erythematous papules on his left cheek 2 years before and reported that his condition had dramatically worsened over the last few weeks. The patient was otherwise healthy and was only being treated for hypertension and hyperlipemia. Multiple computed tomography (CT) scans were performed which showed an extensive disease affecting the skin and subcutaneous tissue of almost the entire face, scalp and neck, with occasional involvement of muscle tissue as well. Numerous secondarily altered lymph nodes of the neck and multiple tumour infiltrates in the liver were also seen. A skin biopsy from the scalp was performed Figure (2). Histopathology showed a tumoral lesion composed of irregular, anastomosing vascular spaces and an increased number of surrounding endothelial cells with hyperchromatic, atypical nuclei. The clinical and pathological features corresponded to a typical presentation of angiosarcoma (AS). The patient had an inoperable disseminated disease and palliative chemotherapy with paclitaxel was initiated. After three cycles of therapy, the patient's general condition worsened, and was admitted to a palliative care facility. cAS is a rare vascular malignant tumour that has a high risk of both local and distant metastatic dissemination despite aggressive therapy. It is classified into primary AS that occurs sporadically, usually in the scalp or face, and secondary AS that is most often related to a history of radiation treatment and chronic lymphedema.1 This malignant tumour resembles a “spreading bruise” that varies from blue to red in colour. The diagnosis of cAS is often delayed due to its subtle initial clinical appearance as it is often mistaken for an ecchymosis or haematoma, especially in elderly patients on anticoagulants. Most patients are asymptomatic although some may present with bleeding, oedema, and/or ulceration. Diagnosis is based on clinical examination and histopathological and immunohistochemical analysis. The extent of the disease may be assessed with magnetic resonance imaging or CT.1, 2 AS represents less than 0.1% of all head and neck malignancies but is associated with the highest rate of lymphatic dissemination among all head and neck soft tissue sarcomas.3, 4 AS shows aggressive behaviour and carries a poor prognosis, thus early diagnosis is crucial. The optimal treatment is surgery followed by wide-field radiotherapy. Clear surgical margins are of paramount importance and correlate with better outcome, but the disease is often so extensive at the time of diagnosis that it is not possible to excise.5, 6 Despite inconsistent data regarding chemotherapy, this is usually employed for patients with metastatic or inoperable disease. Doxorubicin-based regimens are most recommended, but recent use of paclitaxel has shown better efficacy compared with doxorubicin.6, 7 Though involvement of the face and scalp is common in cAS, the extent of disease in our case was striking. AS should be considered in the differential diagnosis of violaceous or ecchymotic lesions on the head or scalp in the elderly. All authors contributed to the manuscript conception, design, and writing. All authors read and approved the final manuscript. The authors have not declared a specific grant from any funding agency in the public, commercial or not-for-profit sectors. The authors declare no conflict of interest. This article did not require the approval of the Ethics committee. The patient in this manuscript has given written informed consent to the publication of his case details. Due to privacy and ethical concerns, neither the data nor the source of the data can be made available.

The Future of Palliative Treatment in India: A Review.

The rapid dynamics of the world bring about changes in all aspects of the life of human beings. These dynamics hence call for the need for research and development in the field of the betterment of the life of a human. Palliative care for the patient in need is a field that drastically affects human life and can provide an ethical and more humanitarian way to live. The main objective of this article is to examine the Indian system of palliative care's organizational structure, roles, and applicability in India. By reading various research articles on the internet, mainly PubMed and Google Scholar, we collected enough information on the palliative care facilities in India. After going through the research articles and thorough discussion, it comes to the knowledge that India's existing palliative care facilities are lacking behind the rest of the world. However, some states have better approaches and facilities, but overall research suggests the need for more development in the field of palliative care even more. India needs a systematic approach to improving palliative care. These improvements include increasing the workforce, better application of policies, good political support, and educating health care workers and patients requiring palliative treatment.