History of Pain and Palliative Clinic

History

Palliative Care had its origins in the 1960s in the UK with the emergence of the hospice movement led by Dame Cicely Saunders. It started with research at St Joseph's Hospice, where Dame Cicely was allowed to experiment by giving regular dosages of drugs to four patients. This apparently simple practice was a novel approach at the time, observed with some scepticism. However, scepticism soon turned to interest as the results showed a marked improvement in the quality of these patients' lives. By the time Dame Cicely left St Joseph's, she had observed and documented over 1,000 cases of patients dying of cancer. Her scrupulous records provide the basis of this fundamental area of research(1).

Dame Cicely's pioneering work was soon followed by others and, in 1963, Professor John Hinton recognized the physical and mental distress of dying in the ward of a London teaching hospital (2). He later developed groundbreaking work on the progression of the awareness and acceptance of dying over time - one of the few longitudinal studies conducted with terminally ill patients and their families (3). His research revealed different patterns of progression, influential factors such as depression and anxiety, and the relationship between patients and their relatives' awareness and acceptance.

In the early 1970s, palliative care in the UK saw its first large-scale epidemiological survey, led by Professor Ann Cartwright and her team (4). Drawing from a random sample of deaths in 1969, she reported the experiences of 785 patients and their families in the last year of life, which would later be compared with those of 639 patients in 1987 (5). In this comparative study, several changes were recognized: increasingly people were dying alone, older and with prolonged and unpleasant symptoms, in institutional and hospital settings, with improved home help though with fewer home visits, and with a greater awareness of the disease and dying.

Current state of knowledge and the challenges ahead

Research on the dying, their families and end-of-life care has continued despite the numerous challenges, mainly in terms of study design and ethical issues (6).

Researchers are faced with a number of complications such as patients experiencing a constellation of symptoms, the difficulty of conducting randomised controlled trials and the thin line between benefit and risk for patients and families.

The volume of research in palliative care has grown dramatically in the last 15 years. Linda George systematically reviewed the literature in 2002 and found 1,000 articles on end-of-life issues, of which approximately 400 were empirical studies (7). Many of these are of excellent quality but improvements in methodology can still be made - grounding studies in conceptual frameworks, for example, carrying out more longitudinal studies and developing high-quality sampling strategies.

There remain important areas in the field of palliative care that have yet to be adequately addressed (8). Under-researched subjects include barriers to accessing palliative care, supportive services, psychosocial and spiritual issues, and the care of special groups such as older people and those from different cultures (9). The challenge for palliative care research is not only to pose important research questions but also to design studies, develop instruments and employ realistic but scientifically sound research designs that will answer those questions (10).

Notwithstanding the development of research into palliative care over the last four decades, the evidence base for much of what is done in clinical practice remains relatively sparse compared with more established medical specialities. This is highlighted by the paucity of data, which slows down the integration of research results into the practice of end-of-life care (8).

Despite being an expanding field, funding is limited and has been largely contingent on the pharmaceutical industry in pursuit of approval for analgesics and other agents to address symptom concerns (10). Worryingly, there is a lack of funding by foundations and government agencies. Only a small share of cancer research funding is devoted to palliative care in the UK - 0.18%, compared to 0.9% in the US (9) - though each death potentially affects the well-being of an average of five other people (11).

 Reference List

Du Boulay S. Cicely Saunders. London : Hodder & Stoughton, 1993.
Hinton J. The physical and mental distress of the dying. Quarterly Journal of Medicine 1963; 32:1-21.
Hinton J. The progress of awareness and acceptance of dying assessed in cancer patients and their caring relatives. Palliative Medicine 13(1):19-35, 1999.
Cartwright A, Hockey L, Anderson JL. Life before death. London ; Boston : Routledge and Kegan Paul, 1973.
Cartwright A. Changes in life and care in the year before death 1969-1987. Journal of Public Health Medicine 13(2):81-7, 1991.
Grande GE, Todd CJ. Why are trials in palliative care so difficult?. [Review] [39 refs]. Palliative Medicine 14(1):69-74, 2000.
George LK. Research design in end-of-life research: state of science.[see comment]. [Review] [98 refs]. Gerontologist 42 Spec No 3:86-98, 2002.
Penrod JD, Morrison RS. Challenges for palliative care research. Journal of Palliative Medicine 7(3):398-402, 2004.
World Health Organization. Palliative care: the solid facts. http://www.euro.who.int . 2004. 24-11-2004.
Ferrell B. Palliative care research: the need to construct paradigms. Journal of Palliative Medicine 7(3):408-10, 2004.
Standing Senate Committee on Social Affairs SaT. Quality End-of-Life Care: The Right of Every Canadian: final report of the subcommittee to update Of Life and Death. 2000. Ottawa, Senate of Canada
 

History of pain and palliative care

Palliative care began in the hospice movement and is now widely used outside of traditional hospice care. Hospices were originally places of rest for travelers in the 4th century. In the 19th century a religious order established hospices for the dying in Ireland and London.

The modern hospice is a relatively recent concept that originated and gained momentum in the United Kingdom after the founding of St. Christopher's Hospice in 1967. It was founded by Dame Cicely Saunders, widely regarded as the founder of the modern hospice movement.

The hospice movement has grown dramatically in recent years. In the UK in 2005 there were just under 1700 hospice services consisting of 220 inpatient units for adults with 3156 beds, 33 inpatient units for children with 255 beds, 358 home care services, 104 hospice at home services, 263 day care services, and 293 hospital teams. These services together helped over 250,000 patients in 2003 & 2004. Funding varies from 100% funding by the National Health Service to almost 100% funding by charities, but the service is always free to patients.

Hospice in the United States has grown from a volunteer-led movement to improve care for people dying alone, isolated, or in hospitals, to a significant part of the health care system. In 2005 more than 1.2 million individuals and their families received hospice care. Hospice is the only Medicare benefit that includes pharmaceuticals, medical equipment, twenty-four hour/seven day a week access to care and support for loved ones following a death. Most hospice care is delivered at home. Hospice care is also available to people in home-like hospice residences, nursing homes, assisted living facilities, veterans' facilities, hospitals, and prisons.

History of palliative care

Palliative care began in the hospice movement and is now widely used outside of traditional hospice care. Hospices were originally places of rest for travellers in the 4th century. In the 19th century a religious order established hospices for the dying in Ireland and London. The modern hospice is a relatively recent concept that originated and gained momentum in the United Kingdom after the founding of St. Christopher's Hospice in 1967. It was founded by Dame Cicely Saunders, widely regarded as the founder of the modern hospice movement.

The hospice movement has grown dramatically in recent years. In the UK in 2005 there were just under 1,700 hospice services consisting of 220 inpatient units for adults with 3,156 beds, 33 inpatient units for children with 255 beds, 358 home care services, 104 hospice at home services, 263 day care services and 293 hospital teams. These services together helped over 250,000 patients in 2003 & 2004. Funding varies from 100% funding by the National Health Service to almost 100% funding by charities, but the service is always free to patients.

Hospice in the United States has grown from a volunteer-led movement to improve care for people dying alone, isolated or in hospitals, to a significant part of the health care system. In 2005 more than 1.2 million persons and their families received hospice care. Hospice is the only Medicare benefit that includes pharmaceuticals, medical equipment, twenty-four hour/seven day a week access to care and support for loved ones following a death. Most hospice care is delivered at home. Hospice care is also available to people in home-like hospice residences, nursing homes, assisted living facilities, veterans' facilities, hospitals and prisons.

The first United States hospital-based palliative care programs began in the late 1980s at a handful of institutions such as the Cleveland Clinic and Medical College of Wisconsin. Since then there has been a dramatic increase in hospital-based palliative care programs, now numbering more than 1,400. 80% of US hospitals with more than 300 beds have a program.[2]

A 2009 study regarding the availability of palliative care in 120 US cancer center hospitals reported the following: Only 23% of the centers have beds that are dedicated to palliative care; 37% offer inpatient hospice; 75% have a median time of referral to palliative care to the time of death of 30 to 120 days; research programs, palliative care fellowships, and mandatory rotations for oncology fellows were uncommon.[8]

The results of a 2010 study in The New England Journal of Medicine showed that lung cancer patients receiving early palliative care experienced less depression, increased quality of life and survived 2.7 months longer than those receiving standard oncologic care.[9]

Hospital palliative care programs today care for non-terminal patients as well as hospice patients. The Patient Protection and Affordable Care Act currently being debated by house and senate would seek to expand palliative care in the U.S.

The first pan-European centre devoted to improving patient palliative care and end-of-life care was established in Trondheim, Norway in 2009. The centre is based at NTNU's Faculty of Medicine and at St. Olav's Hospital/Trondheim University Hospital and coordinates efforts between groups and individual researchers across Europe, specifically Scotland, England, Italy, Denmark, Germany and Switzerland, along with the USA, Canada and Australia.

Palliative care

Palliative care (from Latin palliare, to cloak) is an area of healthcare that focuses on relieving and preventing the suffering of patients. Unlike hospice care, palliative medicine is appropriate for patients in all disease stages, including those undergoing treatment for curable illnesses and those living with chronic diseases, as well as patients who are nearing the end of life. Palliative medicine utilizes a multidisciplinary approach to patient care, relying on input from physicians, pharmacists, nurses, chaplains, social workers, psychologists and other allied health professionals in formulating a plan of care to relieve suffering in all areas of a patient's life. This multidisciplinary approach allows the palliative care team to address physical, emotional, spiritual and social concerns that arise with advanced illness.

Medications and treatments are said to have a palliative effect if they relieve symptoms without having a curative effect on the underlying disease or cause. This can include treating nausea related to chemotherapy or something as simple as morphine to treat the pain of broken leg or ibuprofen to treat aching related to an influenza (flu) infection.

Although the concept of palliative care is not new, most physicians have traditionally concentrated on trying to cure patients. Treatments for the alleviation of symptoms were viewed as hazardous and seen as inviting addiction and other unwanted side effects.[1]

The focus on a patient's quality of life has increased greatly during the past twenty years. In the United States today, 55% of hospitals with more than 100 beds offer a palliative-care program,[2] and nearly one-fifth of community hospitals have palliative-care programs.[3] A relatively recent development is the palliative-care team, a dedicated health care team that is entirely geared toward palliative treatment.

HARTAL

Hartal
Not to be confused with Paul Hartal.
Hartal (Bengali: হরতাল hôrtal, Hindi: हड़ताल haṛtāl, Urdu: ہڑتال‎ haṛtāl, Malayalam: ഹര്‍ത്താല്‍, Tamil: ஹர்த்தால்) is a term in many South Asian languages for strike action, first used during the Indian Independence Movement. It is mass protest often involving a total shutdown of workplaces, offices, shops, courts of law as a form of civil disobedience. In addition to being a general strike, it involves the voluntary closing of schools and places of business. It is a mode of appealing to the sympathies of a government to change an unpopular or unacceptable decision.[1] The term comes from Gujarati (હડતાળ haḍtāḷ or હડતાલ haḍtāl), signifying the closing down of shops and warehouses with the object of realizing a demand. Mahatma Gandhi, who hailed from Gujarat, used the term to refer to his anti-British general strikes, effectively institutionalizing the term. The contemporary origins of such a form of public protest dates back to the British colonial rule in India. Repressive actions infringing on human rights by the colonial British Government and princely states against countrywide peaceful movement for ending British rule in India often triggered such localized public protest.

Hartals are still common in Bangladesh,[2] Pakistan, India, and in northern and eastern Sri Lanka, where it is often used to refer specifically to the 1953 Hartal of Ceylon. In Malaysia, the word was used to refer to various general strikes in the 1940s, 50s and 60s, such as the All-Malaya Hartal of 1947 and the Penang Hartal of 1967.

Another variant which is common in Hindi-speaking regions is the bhukh hartal which translates as hunger strike.

The word is also used in humorous sense to mean abstaining from work.

Hartal is mostly common in Bangladesh these days, as for two opposition parties. Hartal has brought the general people as many awful consequences. As to see from reality, two opposition parties fighting for their own powers, resulting a dreadful consequence to ordinary people. On the contrary, Hartal is fun for school-going students, since they tend to get a free holiday for a little rest from the load of study.

MUHARRAM

Muharram
For use as a given name, see Muharrem.
Islamic Calendar

Muharram
Safar
Rabi' al-awwal
Rabi' al-thani
Jumada al-awwal
Jumada al-thani
Rajab
Sha'aban
Ramadan
Shawwal
Dhu al-Qi'dah
Dhu al-Hijjah

A procession of Shia Muslims in Bhopal.
Muharram (Arabic: المحرّم) is the first month of the Islamic calendar. It is one of the four sacred months of the year.[1] Since the Islamic calendar is a lunar calendar, Muharram moves from year to year when compared with the Gregorian calendar.

The word "Muharram" means "Forbidden" and is derived from the word harām, meaning "sinful". It is held to be the most sacred of all the months, excluding Ramadan. Some Muslims fast during these days. The tenth day of Muharram is the Day of Ashura, which to Shia Muslims is part of the Mourning of Muharram.

Azadari procession carried out by Shia Muslims in Indian city of Hardoi on the Day of Ashura.
Some Muslims fast during this day, because it is recorded in the hadith[2] that Musa (Moses) and his people obtained a victory over the Egyptian Pharaoh on the 10th day of Muharram; accordingly Muhammad asked Muslims to fast on this day that is Ashura and on a day before that is 9th (called Tasu`a).

Fasting differs among the Muslim groupings; mainstream Shia Muslims stop eating and drinking during sunlight hours and do not eat until late afternoon. Sunni Muslims also fast during Muharram for the first ten days of Muharram, or just the tenth day, or on both the ninth and tenth days; the exact term depends on the individual. Shia Muslims do so to replicate the sufferings of Hussein ibn Ali on the Day of Ashura.

Muharram and Ashura
Main article: Mourning of Muharram

Shia Muslims in Dar es Salaam, Tanzania in a Hussainia as part of the commemoration of Muharram

Shia Muslim children in Amroha, India on camels in front of Azakhana as part of the procession commemorating events on & after Day of Ashura
Muharram is a month of remembrance & Modern Shia Meditation that is often considered synonymous with the event of Ashura. Ashura, which literally means the "Tenth" in Arabic, refers to the tenth day of Muharram. It is well-known because of historical significance and mourning for the martyrdom of Hussein ibn Ali, the grandson of Muhammad.[3]

Shias begin mourning from the first night of Muharram and continue for ten nights, climaxing on the 10th of Muharram, known as the Day of Ashura. The last few days up until and including the Day of Ashura are the most important because these were the days in which Hussein and his family and followers (consisting of 72 people, including women, children and elderly people) were killed by the army of Yazid I at the Battle of Karbala on his orders. Surviving members of Hussein's family and those of his followers were taken captive, marched to Damascus, and imprisoned there.

Muharram is also observed by Dawoodi Bohras in the same way as Shias.They practice prayers on the sayings of the present dawah of Bohras, Mohammed Burhanuddin. On the tenth day of Muharrum, they pray for Hussein till the magrib . When the pray ends, Hussein is considered martyr by Yazid. It is also close to the day of resurrection because it said in a book that this world will one day come to an end on Friday 10th of Muharram.[citation needed]]]

With the sighting of the new moon the Islamic New Year is ushered in. The first month, Muharram is one of the four sacred months that [Allah] has mentioned in the Quran.

Timing
The Islamic calendar is a lunar calendar, and months begin when the first crescent of a new moon is sighted. Since the Islamic lunar calendar year is 11 to 12 days shorter than the solar year, Muharram migrates throughout the solar years. The estimated start and end dates for Muharram are as follows (based on the Umm al-Qura calendar of Saudi Arabia:[4])