The plant Cannabis sativa L. has been used as an herbal remedy for centuries and is the most important source of phytocannabinoids. The endocannabinoid system (ECS) consists of receptors, endogenous ligands (endocannabinoids) and metabolizing enzymes, and plays an important role in different physiological and pathological processes. Phytocannabinoids and synthetic cannabinoids can interact with the components of ECS or other cellular pathways and thus affect the development/progression of diseases, including cancer. In cancer patients, cannabinoids have primarily been used as a part of palliative care to alleviate pain, relieve nausea and stimulate appetite. In addition, numerous cell culture and animal studies showed antitumor effects of cannabinoids in various cancer types. Here we reviewed the literature on anticancer effects of plant-derived and synthetic cannabinoids, to better understand their mechanisms of action and role in cancer treatment. We also reviewed the current legislative updates on the use of cannabinoids for medical and therapeutic purposes, primarily in the EU countries. In vitro and in vivo cancer models show that cannabinoids can effectively modulate tumor growth, however, the antitumor effects appear to be largely dependent on cancer type and drug dose/concentration. Understanding how cannabinoids are able to regulate essential cellular processes involved in tumorigenesis, such as progression through the cell cycle, cell proliferation and cell death, as well as the interactions between cannabinoids and the immune system, are crucial for improving existing and developing new therapeutic approaches for cancer patients. The national legislation of the EU Member States defines the legal boundaries of permissible use of cannabinoids for medical and therapeutic purposes, however, these legislative guidelines may not be aligned with the current scientific knowledge.
Palliative care is an appropriate and compassionate response to the needs of patients with life threatening illness. International human rights law establishes palliative care as part of the right to health. But what does this mean in practice? How is palliative care part of the right to health at the country level and in everyday patient experience? This thesis addresses this question with evidence from South Africa. South Africa is important for a number of reasons. The government, despite the country's progressive Constitution (No 108, 1996) which entrenches the right of access to health care has yet to take responsibility for palliative care. Most recently, the South African government co-sponsored the World Health Assembly (2014) resolution on palliative care and thus has a commitment to implementing the resolution. The thesis employs General Comment 14 on the Right to Health to frame the four nested studies that were carried out to address the key research question. General Comment 14 (2000), adopted by the United Nations Committee on Economic, Social and Cultural Right, describes the normative content of the right to health (Article 12 International Covenant on Economic, Social and Cultural Rights) to include four overlapping elements – availability, accessibility acceptability and quality. Aim of the research: to evaluate current provision of palliative care in South Africa in terms of the Human Rights considerations of availability, accessibility and quality. Study One commences the thesis by estimating the need for palliative care in South Africa. Using mortality data for 2010 for conditions determined a priori to require palliative care, approximately 0.52% of the population were estimated to require palliative care, which translates into an average need of 698.5 persons per 100000 or 1 in 143 people every year. While this is a considerable burden, it is also likely to be a significant under-estimate, given limitations to the methods identified in the study. Study Two examines availability of services to meet the need for palliative care. A survey was completed by 131 palliative care organisations between March 2011 and October 2011. Only 3% of services were located within the public sector. The estimated number of patients who received care during the year was 46,347. This is approximately 18% of the need identified earlier in Study One. Availability of morphine, as a marker for palliative care, was found to be dependent on employment of and level of palliative care training of doctors and was especially poorly supplied in the rural areas. Thus, the availability of Palliative Care appears to be limited by health system factors. Study Three investigates access to palliative care in Cape Town, via two pathways 1) referral of patients requiring palliative care and 2) palliative care in their current care settings. A prospective cohort study over six months followed up 162 participants from three groups: 1) patients with metastatic cancer; 2) patients living with HIV with a CD4 count of < 200 cells/mm3 ; and3) patients diagnosed with motor neuron disease (MND). A questionnaire and a validated patient-reported outcome scale, the African Palliative Care Association (APCA) African Palliative Outcome Scale (POS), was administered at first visit. Thereafter participants were followed up telephonically once a month. Few patients (5%)were referred to palliative care services even though a significant number of patients died during the course of the study, indicating a failure to access palliative care when needed. Patient outcomes for people living with HIV improved significantly whereas the majority of patient outcomes in the cancer and MND groups did not improve. Thus, the accessibility of palliative care to patients already in the health system appears to be poor, except when palliative care is integrated into primary care, as is the case for patients with HIV on ARV treatment. Study Four evaluated the quality of care delivered to patients requiring palliative care in accredited hospice and non-hospice non-governmental services in five of the nine provinces of South Africa. A survey was conducted with 459 patient participants and 253 family members who were followed up over a 4-6 week period. Perceptions of quality care were explored through narrative questions and patient-reported outcomes were assessed using the APCA African POS. The results show significant improvement in patient reported outcome measures in both hospice and non-hospice groups, with pain and worry showing the most improvement. Content analysis of the narrative questions identified 5 themes: Quality of Care, Place of care, Staff values and attitudes, Information-sharing and Problems experienced by participants Conclusion: The thesis presents evidence that despite nominal commitment by the state, palliative care is not yet implemented as part of the right to health in South Africa. The need is great but availability of palliative care services is insufficient to meet the need. Access is poor even where palliative care is available but is facilitated by integration of palliative care into primary care services. However, when access is achieved, quality of care is generally good and patient outcomes improve over time with evidence that palliative care values patients as individuals. The study considers concepts relating to dignity and human rights in health as core to both human rights and palliative care. Implications: In South Africa, the planned National Health Insurance Policy lists palliative care as a service in the primary health care setting. In addition, a National Palliative Care Policy has been approved with strategies to integrate palliative care into public health facilities. As General Comment 14 has proved useful for the thesis, for the future, it may also provide a framework to monitor state accountability on the basis of Availability, Accessibility, Acceptability, and Quality of palliative care that can be transferred to other countries.
Abstract Gastric cancer (GC) is a public health issue with high incidence and mortality in Colombia due to tardy diagnosis and barriers to access to curative treatment; this leaves palliative care (PC) as the only option. Our aim is to describe the access barriers to PC perceived by adults with GC, caregivers and physician in Santander, Colombia. A qualitative study was carried out with the analysis of the grounded theory (Strauss and Corbin), through semi-structured interviews, after sampling for convenience we found that the access barriers were: administrative, economic, cultural, knowledge, communication, institutional and geographical; strategies to overcome barriers: screening programs, governmental surveillance, and investment in health. In conclusion, access to PC requires remove barriers to timely and integral access and strengthen health and education policies to facilitate procedures and services that ensure the attention required by the adult with GC.
The western countries often considered as those, which had achieved high cultural level and that are the announcers of liberalism and freedom, have legitimized euthanasia with national law by allowing killing a person for a disease or old age. In Lithuania as in the majority of countries of the Old Continent, the decreasing rate of birth, the obsolescent society and its changing attitude towards life, old age and pain force a liberal society to discuss about various forms of death and particularly euthanasia. As the life pace is running in a breathtaking speed causing many human traumas, which often make a person disabled; the diseases that still remain incurable force us to pay attention to the weak people who need help by providing them not with death but life. In this case the palliative help as an alternative to euthanasia stands for the weak. The problem of the topic rises from the intentions to legalize euthanasia, to prove "the right to die"in the court without submitting any other solutions to such a position. When spreading such the posture covered by mercy, the alternative is found in palliative help and care. Lithuania is the last country in Europe, which legalized palliative help – the tools of life quality improvement of the patient suffering from the dangerous, incurable and progressing disease and his relatives. These tools prevent from torment and palliate them, help to solve other physical, psychosocial and spiritual problems. This topic is particularly relevant to prove that the disease and old age do not destroy the person and therefore it is not allowed to kill him, that not everything that is legal may be moral at the same time, that by regulating the health system it is not allowed to lose the main purpose: to treat a person not to kill him. Research problem – the relevance of legislation protecting human life by encouraging the palliative help with regulating legislation to strengthen the respect to human life and dignified death and by repulsing the spread of euthanasia into the Lithuanian law and health system with the principles of palliative help. Research object – legal regulation of palliative help. Research aim – to analyze the legislation regulating palliative help, to analyze the legislation of the countries that have legalized euthanasia, to submit the main principles and objectives of palliative medicine as contradicting to the principle of stubborn untreatment which becomes an alternative to euthanasia. The thesis aims to reveal the reasons for choosing euthanasia by providing an alternative – palliative help. The right of dieing person to get a full treatment meeting his dignity and the dignified death is an integral field of legal regulation about this medical activity. Objectives of the thesis: 1. To analyze the suicide with the help of a doctor and the legal regulation of euthanasia as well as legal and moral boundaries of evaluation by separating active and passive euthanasia and highlighting the difference of stubborn untreatment. 2. To define the concept, principles and objectives of palliative help by analyzing the legislation regulating the palliative help. 3. To present the palliative help implementing and complying with them in Lithuania and Europe as fundamental legal principles. 4. To analyze the principles of palliative help as an alternative to euthanasia, the organization of palliative help in regulating legislation. Over twenty years of independence Lithuania that was able to radically change its health system by changing the human conscious, letting in itself more and more freedom has to take proper responsibility for its society and each member particularly that who lost his health, reached an old age and is dieing. When the society is rapidly getting older, the oncological diseases are spreading and changing the perception that health is much more than the absence of the disease, the topic of palliative help is relevant than ever before because it is an alternative to euthanasia.
The western countries often considered as those, which had achieved high cultural level and that are the announcers of liberalism and freedom, have legitimized euthanasia with national law by allowing killing a person for a disease or old age. In Lithuania as in the majority of countries of the Old Continent, the decreasing rate of birth, the obsolescent society and its changing attitude towards life, old age and pain force a liberal society to discuss about various forms of death and particularly euthanasia. As the life pace is running in a breathtaking speed causing many human traumas, which often make a person disabled; the diseases that still remain incurable force us to pay attention to the weak people who need help by providing them not with death but life. In this case the palliative help as an alternative to euthanasia stands for the weak. The problem of the topic rises from the intentions to legalize euthanasia, to prove "the right to die"in the court without submitting any other solutions to such a position. When spreading such the posture covered by mercy, the alternative is found in palliative help and care. Lithuania is the last country in Europe, which legalized palliative help – the tools of life quality improvement of the patient suffering from the dangerous, incurable and progressing disease and his relatives. These tools prevent from torment and palliate them, help to solve other physical, psychosocial and spiritual problems. This topic is particularly relevant to prove that the disease and old age do not destroy the person and therefore it is not allowed to kill him, that not everything that is legal may be moral at the same time, that by regulating the health system it is not allowed to lose the main purpose: to treat a person not to kill him. Research problem – the relevance of legislation protecting human life by encouraging the palliative help with regulating legislation to strengthen the respect to human life and dignified death and by repulsing the spread of euthanasia into the Lithuanian law and health system with the principles of palliative help. Research object – legal regulation of palliative help. Research aim – to analyze the legislation regulating palliative help, to analyze the legislation of the countries that have legalized euthanasia, to submit the main principles and objectives of palliative medicine as contradicting to the principle of stubborn untreatment which becomes an alternative to euthanasia. The thesis aims to reveal the reasons for choosing euthanasia by providing an alternative – palliative help. The right of dieing person to get a full treatment meeting his dignity and the dignified death is an integral field of legal regulation about this medical activity. Objectives of the thesis: 1. To analyze the suicide with the help of a doctor and the legal regulation of euthanasia as well as legal and moral boundaries of evaluation by separating active and passive euthanasia and highlighting the difference of stubborn untreatment. 2. To define the concept, principles and objectives of palliative help by analyzing the legislation regulating the palliative help. 3. To present the palliative help implementing and complying with them in Lithuania and Europe as fundamental legal principles. 4. To analyze the principles of palliative help as an alternative to euthanasia, the organization of palliative help in regulating legislation. Over twenty years of independence Lithuania that was able to radically change its health system by changing the human conscious, letting in itself more and more freedom has to take proper responsibility for its society and each member particularly that who lost his health, reached an old age and is dieing. When the society is rapidly getting older, the oncological diseases are spreading and changing the perception that health is much more than the absence of the disease, the topic of palliative help is relevant than ever before because it is an alternative to euthanasia.
Background-Palliative care is defined by World Health Organization as an approach that improves the quality of life of patients and their families facing the problem associated with life- threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other physical, psychosocial and spiritual problems. This study attempted to assess the knowledge, accessibility and Utilization of palliative care Services to Cervical Cancer and its determinants at Tikur Anbesa Hospital, Ethiopia, Method: This study was a cross-sectional Institution based study of women who had Cervical Cancer in TAH. The study was carried out in Tikur Anbesa Hospital with purposive selection, since it was the only center of palliative care and treatment services in Ethiopia. Data was collected by interviewing the client's using a pretested Amharic version questionnaire. During the survey, 384 women with cervical cancer were interviewed. Data entry was done using Epi Info version 3.5.1 and was exported to SPSS version 21 for analysis. Logistic regression was applied to control confounders. Result: Out of the total clients interviewed, 239(62.2%) respondents who had treatment in Tikur Anbesa Specialized Hospital were knowledgeable about palliative care for cervical cancer. About 86% of client's were in the age 35 years old or older. About Nine out of ten (89.8%) respondents reported problems on accessibility of palliative care services for cervical cancer in Tikur Anbesa hospital. Women's knowledge of care (AOR=26.9), presence of little physical wellbeing to the respondents (AOR=3.1), social wellbeing of the respondents (AOR=1.7); monthly income of the respondents (AOR=0.25) and marital status of the women (AOR=55.4) were statistically significantly associated with respondent's utilization of palliative care services for cervical cancer at Tikur Anbesa Hospital. Conclusion: Among patients with cervical cancer who were interviewed, nearly, more than three women out of five had reported palliative care services from its center at Tikur Anbesa Hospital in the last 12 months of data collection. Recommendation: Community Mobilization through the media, posters and face to face on community health day focusing on palliative care services to cervical cancer must be addressed by Addis Ababa Town administrations and policy makers. Since the center was only TAH, the FDRE government must build another center in Addis or elsewhere in the country so that the problems of resources can be solved.TAH has to fulfill all the facilitations listed and needed for clients with cervical cancer for palliative services based on the standards. Key words: palliative care, cervical cancer, Tikur Anbesa Hospital, Addis Ababa, Ethiopia.
AbstractBackgroundLittle is known about how to involve people with intellectual disabilities in making decisions about treatment and care in their palliative phase. We aimed to reach a consensus about a shared decision‐making (SDM) conversation aid for people with intellectual disabilities, relatives, and healthcare professionals.MethodsIn a Delphi process, an expert panel of 11 people with intellectual disabilities, 14 relatives, and 65 healthcare professionals completed online questionnaires about the relevance and feasibility of a draft conversation aid.ResultsIn Round 1, components were rated as (very) relevant by 70–98% of participants (M = 87%). In Round 2, after amending the aid in response to feedback, relevance ratings were 67–97% (M = 90%) and feasibility ratings 66–86% (M = 77%). The final version consists of four themes: who are you; illness/end‐of‐life; making decisions; and evaluating the decision.ConclusionThe consensus‐based conversation aid is considered sufficiently relevant and feasible to be implemented in practice.
The aim of this study was to investigate current nursing practice related to end-of-life discussions with incurable lung cancer patients and their family caregivers from the perspectives of patients, family caregivers, and nurses in an oncology outpatient clinic. This phenomenological hermeneutic study included nine patients, eight family caregivers, and 11 nurses. Data were collected using participant observation, informal and semi-structured individual or joint interviews with patients and family caregivers, and focus group interviews with nurses. A Ricoeur-inspired approach was used to analyze the data. Three themes were identified: (a) content of end-of-life discussions, (b) timing of end-of-life discussions, and (c) challenges in end-of-life discussions. End-of-life discussions were seldom initiated; when they were, it was often too late. Discussions addressed treatment, place of care, practical/economic concerns, and existential matters. The physical environment at the outpatient clinic, lack of continuity, and nurses' instrumental task workloads and time pressure posed challenges to initiating end-of-life discussions.
The burden of cancer disproportionately affects low- and middle-income countries. Low 5-year survival figures for children with cancer in low-income countries are due to late presentation at diagnosis, treatment abandonment, absence of sophisticated multidisciplinary care, and lack of adequate resources. The reasons for late presentation are partly due to limited awareness of cancer symptoms, high treatment costs, and facility-level barriers to timely access to treatment. Given the systemic challenges, the regional need for palliative oncology care for children care is high. Despite the enormity of the need for palliative oncology for children with cancer in Africa, its level of development remains poor. This paper presents the evidence on the status of palliative oncology care for children in sub-Saharan Africa. METHODS: This review provides an overview of the current status of palliative oncology care for children in sub-Saharan Africa, using the WHO building blocks for health systems strengthening as reference points, before proposing a forward-looking prioritized agenda for its development. RESULTS: We noted that survival rates for children with cancer remain much poorer in Africa compared with developed countries and palliative oncology care resources are scant. Our results also show low coverage for palliative oncology care services for children, lack of a critical mass of health workers with the skills to deliver the care, a lack of robust documentation of the burden of cancer, widespread lack of access to essential controlled medicines, limited funding from government and limited coverage for palliative oncology care in most cancer control plans. CONCLUSION: This review highlights priority areas for action that align to the WHO health system building blocks for strengthening health systems.
Hospice care is designed to help individuals with pain, physical and psychological, that arises during the advanced stage of a disease so that the patient can face their impending death with dignity. Through the hospice lens, the patient is viewed as an entity that needs both medical and non-medical care, which differentiates hospices from other forms of care available. However, despite hospice care having been integrated into the medical sphere and its widespread availability to patients, it has begun to be met with social reluctance and fear. This article is a review of theories, concepts, and research in the context of the social construct of cancer, palliative treatment, and hospice care. The texts analyzed in this article have been selected to show both the time-changing approach to the issues discussed, as well as the indication of threads that are characteristic of the USA and Europe, including Poland. The aim of the article is to reflect on the social stigmatization of hospice care, changes in the identity of patients, especially the transition from oncological treatment to palliative and hospice care, and thus draw attention to the patient experience before the impending death.
AbstractAimsTo determine the Oral Health Assessment Tool (OHAT) critical score in palliative care patients and the optimal timing for predicting mortality using time‐dependent receiver operating characteristic (ROC) curves.Methods and ResultsA retrospective observational study was conducted on 176 patients treated by the palliative care team of our medical center between April 2017 and March 2020. Oral health was assessed using the OHAT. Prediction accuracy was evaluated using the area under the curve (AUC) analysis, sensitivity, and specificity, using time‐dependent ROC curves. Overall survival (OS) was compared using Kaplan‐Meier curves with the log‐rank test; hazard ratios (HRs) adjusted for covariates were calculated using a Cox proportional hazard model. A OHAT score of 6 was shown to best predict 21‐day OS (AUC 0.681, sensitivity 42.2%, specificity 80.0%). The median OS was significantly shorter in patients with total OHAT scores ≥6 than in patients with scores < 6 (21 days vs. 43 days, p = .017). For individual OHAT items, the unhealthy status of the lips and tongue was associated with decreased OS (HR = 1.91; 95% confidence interval [CI], 1.19–3.05 and adjusted HR = 1.48; 95% CI, 1.00–2.20).ConclusionPredicting disease prognosis based on patient oral health can enable clinicians to provide timely treatment.
BACKGROUND: Palliative care is well suited to support patients hospitalized with COVID-19, but integration into care has been variable and generally poor. AIM: To understand barriers and facilitators of palliative care integration for hospitalized patients with COVID-19. METHODS: Internists, Intensivists and palliative care physicians completed semi-structured interviews about their experiences providing care to patients with COVID-19. Results were analysed using thematic analysis. RESULTS: Twenty-three physicians (13 specialist palliative care, five intensivists, five general internists) were interviewed; mean ± SD age was 42 ± 11 years and 61% were female. Six thematic categories were described including: patient and family factors, palliative care knowledge, primary provider factors, COVID-19 specific factors, palliative care service factors, and leadership and culture factors. Patient and family factors included patient prognosis, characteristics that implied prognosis (i.e., age, etc.), and goals of care. Palliative care knowledge included confidence in primary palliative care skills, misperception that COVID-19 is not a 'palliative diagnosis', and the need to choose quantity or quality of life in COVID-19 management. Primary provider factors included available time, attitude, and reimbursement. COVID-19 specific factors were COVID-19 as an impetus to act, uncertain illness trajectory, treatments and outcomes, and infection control measures. Palliative care service factors were accessibility, adaptability, and previous successful relationships. Leadership and culture factors included government-mandated support, presence at COVID planning tables, and institutional and unit culture. CONCLUSION: The study findings highlight the need for leadership support for formal integrated models of palliative care for patients with COVID-19, a palliative care role in pandemic planning, and educational initiatives with primary palliative care providers.
ABSTRACTLeukocyte adhesion defect I is a rare disorder (1:1,000,000) caused by diminished expression of CD‐18 β2 integrins on leukocytes leading to abnormal adhesion, migration, and chemotaxis. Clinical manifestations include delayed separation of umbilical cord, omphalitis, recurrent severe infections, impaired wound healing, persistent oral ulcers, and severe periodontitis in primary and permanent dentition.A 5‐year‐old girl, second‐born child to parents with consanguinity, presented with pain and mobility of lower teeth. There was history of recurrent infections and multiple hospital admissions with CD18 level‐3% and frame shift mutation in ITGB2, on 21q22.3. There were scars on hands and feet. Oral examination revealed multiple missing teeth and periodontitis in primary dentition. Oral prophylaxis and palliative treatments were performed with periodic follow‐ups.Interdisciplinary care is ubiquitous for patients with immune deficiencies. Early consultation with pediatric dentists and exploration of medical history is essential for diagnosis and treatment of rare diseases.
Through historical division of roots in the field of medicine, care and cure became positioned at opposite extremes. In this article, we merge conceptual framings with empirical data to consider how the dialectic between caring and curing shaped understandings during the spring 2020 wave of COVID-19 infections. We utilised interviews obtained from healthcare clinicians of a medical centre who volunteered in New York City during the surge of 2020. In the analysis, we reflect upon examples to illustrate how the unpredictability of COVID-19 temporarily deconstructed hierarchical boundaries between caretakers and highlight the benefits of incorporating palliative care measures in COVID-19 treatment.
Our research concerns the conditions of acceptance of different ways to treat pain in palliative care by health professionals and laypeople. Two ways are studied: the use of analgesic, including strong opioids ; implementation of sedation. Our research is based on the Functional Theory of Cognition by Norman Anderson (1981). On the study on the use of analgesics : 192 participants rated the degree of acceptability of each of the 56 proposed scenarios, resulting from the combination of four factors: « decision-making process », « request of the person to be relieved of his pain », « pain level, expressed through digital pain scale », « decision of the physician in terms of painkiller prescription ». For the study of sedation : 192 people judged the acceptability of the 48 proposed scenarios. They are the result of four factors combination: « request for sedation », « type of sedation », « life expectancy », « decision-making process ». In the study on the use of painkillers, especially strong opioids, it appears that only three of the manipulated factors played a role in the acceptability of the doctor's decision. The result by ascending order of the factors is: « pain level », « decision » and « decision-making process ». The less influential factor, since having no significant effect, is the factor « request ». The analysis in clusters also allowed us to discriminate 6 groups of participants, each with their own political judgment. Regarding the study on sedation, we also find that three of the four manipulated factors had influenced the judgment of acceptability. In ascending order, these factors are « request », « type of sedation » and « decision-making process ». The « life expectancy » factor had no significant effect. The analysis in clusters enabled us to distinguish 4 classes of participants, coming together according to their political judgment. The acceptability of the various means used to relieve pain in later life is largely influenced by the factors involved in the scenarios. ; Notre recherche ...
