Medindia interviewed Dr. Mallika Tiruvadanan, a Palliative Care expert who heads Lakshmi Pain and Palliative Care Clinic, a charitable trust that combines science with compassion to relieve physical symptoms and offer support to patients suffering from prolonged or life-limiting illnesses. An anesthetist who was later drawn to Palliative Care on seeing the distress of patients and their families, Dr. Mallika specialized in this field at the Edith Cowan University, Australia and for the last ten years has been caring for the sick and spearheading the need to start more palliative care centers to care for the suffering millions in India.

What is Palliative Care?

Palliative Care is the total and active care of patients suffering from prolonged or life-limiting illnesses, lending psychosocial and spiritual care and support for the patient and the family to improve their quality of life.

Generally people—sometimes even medical professionals mistakenly think palliative care is important only during the terminal stage. Actually the care starts from the time of diagnosis and ideally it should be a team effort involving patients, their families, doctors, nurses and volunteers geared for "curing sometimes, relieving often and to comfort always."

What drew you into Palliative Care?

My father had severe pain and I took him to the pain clinic at Calicut. There, I saw that about 70 – 80 patients came to the pain and palliative care clinic everyday. Those with advanced cancer with pain and several other symptoms had good relief of pain and supportive treatment. As an anesthetist, I already had interest in the management of chronic pain. Hence, I felt the need to learn and provide pain relief and palliative care back in Chennai. However humane, cordial and kind doctors are, they don’t have the time and the facility to help terminally ill patients cope with pain and other distressing symptoms such as vomiting and diarrhea which are often collateral to the medical treatment. Our clinic is hospital-based and we work along with other specialists.

What is the scope of work you undertake in Palliative Care?

At the basic level we believe in "being" there with the patient, at every point of the illness. In the good old days before the invention of antibiotics and surgical procedures small courtesies such as pulling up a blanket, opening a window to let in fresh air, reading or listening to a patient, asking what he/she needed to be comfortable, massaging painful areas were extended naturally to sick people. Care and communication are sidelined in the hurried frenzy of modern life.

When a patient and the family comes to us weighed down by the challenge of coping with a serious illness, pain and other distressing symptoms, we as palliative care specialists make them comfortable in the environment they prefer—home or hospital. We study the person’s medical history and listen actively as they open up and talk about their physical, emotional, psychological, social, spiritual and financial problems. Unless every issue is addressed our goal of improving the overall quality of the patient’s life will not be realized.

I am ably assisted by Dr. Subathra Muthukumaran, chief nurses Ms Sona and Ms Tamilselvi and a host of other health care workers in our daily activities. Besides, there are many medical professionals and health experts who regularly lend support to the Center’s mission of providing relief and comfort to patients and their families. We also undertake home calls. Currently we are attending to about 25 new patients and review about 80 patients every month.

We discuss treatment plans and options or work hand-in-hand with the doctors who are already treating the patients. We even arrange for chemotherapy or radiotherapy for some patients who cannot afford the same. An increasing number of doctors are referring their patients to us for palliative care and we give the patients hope that something can be done to alleviate their symptoms and mitigate their suffering.

Symptoms such as vomiting, insomnia, constipation and breathlessness can be corrected by appropriate medication or procedures. As for cancer pain which can be a harrowing experience, it can be treated with inexpensive medication by following the WHO guidelines.

Are drugs such as morphine available for your patients when required?

In 1986 WHO declared oral morphine as the drug of choice for cancer pain and it should never be denied to patients who need it. Contrary to popular belief, oral morphine is not addictive and is prescribed worldwide for millions of patients. In fact, a country’s development in palliative care is measured by the increased use of oral morphine in cancer pain treatment. 

However, morphine is classified under narcotics and there are certain restrictions in its procurement. A few years ago when the Indian government came down heavily on the licensing of narcotics, availability of oral morphine was seriously hit and we were left with cancer patients suffering in pain and agony. In the 1990s, the WHO and the International Narcotics Board collaborated with the government of India, which led to the amendment of rules regarding the procurement and supply of morphine for medical purposes.

Currently morphine supply is monitored by the Drug Controller of India and 16 state governments led by Kerala and Tamil Nadu have simplified rules for using oral morphine. Doctors certified by the Indian Association of Palliative Care (IAPC) can get the licence to procure and dispense oral morphine for treating patients’ with severe pain.

Tell us some moving moments while taking care of your patients?

An elderly patient at an advanced stage of cancer who was at our clinic was too ill to move and became restless when his son’s marriage was arranged. He expressed his desire to somehow be there at the marriage hall and the son wanted his father to be there too. So we arranged for his transport in an ambulance with a doctor accompanying him and a nurse alongside holding the IV lines; it was a strange scene. The struggle to transport him to the wedding hall and back seemed nothing in comparison to the joy in his eyes when he witnessed his son’s marriage. Twenty-four hours later he peacefully breathed his last.

Can you share with our readers some difficult cases you’ve handled?

It always centers around pain management and the "difficult pain" is most challenging while dealing with patients. When the mechanism of pain gets complicated it becomes a struggle for the patient and the carers. Sometimes when a patient becomes too ill to swallow medicine, we resort to invasive procedures.