Palliative care for stroke patients: Experience at Pain and Palliative Care Society, Thrissur
– Dr. E. Divakaran, Thrissur
Cerebrovascular accidents occur as an acute catastrophe suddenly changing the life course of an individual. Prevention, early diagnosis, and urgent initial management is important for reducing both the morbidity and mortality in these cases. Fora majority of the patients, the care will have to be continued into palliative care and physiotherapy, which can improve their activities of daily living and which will thereby improve the quality of life of these patients and their families.
The following is a brief account of our experience with providing palliative care for stroke patients brought to the Pain and Palliative Care Society, Thrissur.
On an average, we register 50 to 60 stroke patients a year. By the time they reach our center, many of them will have lost the useful time when physiotherapy could benefit them. Generally, this category of patients belongs to the older age group with a mean age of 70 years. Palliative care for these patients consists of explaining the prognosis and in the setting of realistic goals, symptom management, prevention and management of pressure sores, helping them in feeding, and in other activities of daily living along with psycho-social support. Home visits to these patients provide an opportunity to guide them in making the environment of the home friendly to the stroke patients. Even though we may not be able to improve the functional capacity of these patients, we are able to improve the quality of life of these patients and their families.
The other category belongs to a comparatively younger age group with a mean age of 60 years. The life of these patients can be improved with effective palliative care interventions including physiotherapy. Discussion of prognosis is a routine activity at our center. A physiatrist identifies those stroke patients who will benefit from structured physiotherapy. The usual physiotherapy procedures we follow include:
- Passive exercise
- Proprioceptive neuro-facilitatory techniques
- Motor relearning program
- Constrained induced thumb
- Mirror therapy
- Gait training
- Occupational therapy for improving the Activities of Daily Living (step climbing etc.)
The improvement is measured and documented using the Functional Independence measure and Functional Assessment Measure in Brain Injury.
Case study 1: A 59-year-old gentleman had Middle Cerebral Artery hemorrhage with lacunar infarct of basal ganglia and bilateral frontal lobe atrophy. He was treated by fronto-temporal decompression and when he was brought to us, he was totally bedridden. The initial FIMS Score was 18. After 6 months of physiotherapy his FIMS Score improved to 80. Now, he can walk with the support of a tripod.
Case study 2: A stroke patient aged 51 years, non-compliant with antihypertensive treatment, was brought to our clinic from abroad with pontine and brain stem hemorrhage. He was in an unresponsive condition with tracheostomy, supplemental oxygen, and a feeding gastrostomy. He was in a state of locked-in syndrome. The management of this patient highlights the importance of proper neurological assessment and the importance of discussing the implications of the disease with the primary care givers. Even though the diagnosis of locked-in syndrome was made at the initial care facility (abroad), the family was not informed about the implications of this locked-in syndrome. They were treating the patient as though he was a comatose patient. We explained to his wife that he was aware of his surroundings and that he understood whatever was being spoken and that the only problem was that he could not respond. We reassured the patient that we have understood his condition and that we will identify some means to communicate with him. We told his wife about the book ‘The Diving Bell and the Butterfly’ by Jean-Dominque Bauby. Since then, she tried communicating with her husband and has now achieved partial success in communicating with her husband.
The lessons we learned from these two cases can be summarized as follows:
- The great majority of patients suffering from stroke were having either uncontrolled diabetes or hypertension, or both. There is a need to create awareness among the public regarding the importance of drug compliance in managing Diabetes and hypertension.
- Early intervention in stroke patients is rewarding
- Physiotherapy and occupational therapy can improve the functional capacity of stroke patients to a considerable degree.
- Palliative care should be offered to all stroke patients.
About the Author: Dr E Divakaran is the Founder Secretary of Pain and Palliative Care society at Thrissur from 1997 to 2002. He is currently the Director and Faculty at Institute of Palliative Care Thrissur from 2002 onwards and Faculty at Institute of Palliative Medicine, Calicut from 2003 onwards.