About the Author: Dr. Jenifer Jeba S. is a Professor and the Head of the Palliative Care Unit at the Christian Medical College, Vellore. She is also an Honorary Senior Lecturer at the School of Medicine, Cardiff University.
Every year, May 17th is observed as ‘World Hypertension Day’. Hypertension is the most important risk factor for the chronic disease burden in India. One in every third adult is hypertensive according to a nation-wide survey(2015). Poorly controlled hypertension results in end organ damage; ischemic heart disease, heart failure, stroke, peripheral vascular disease and chronic renal failure (figure 1). Sadly 57% and 24% of stroke and coronary artery disease-related deaths, are due to hypertension. The control of hypertension with regular anti-hypertensive treatment to prevent end organ damage and integration of palliative care in those individuals who do developed organ damage is important.
Despite progress in evidence-based treatment for chronic heart failure, stroke and chronic kidney diseases, these conditions are associated with high morbidity and mortality. Affected individuals have high symptom burden both physical and psychological, impacting their quality of life (QoL) adversely. This is often compounded with complex decision-making requiring good communication and family support. Comprehensive management should include chronic disease management, supportive care and palliative care as part of Universal Health Coverage. The provision of Palliative care should not be seen as an alternative to the full range of services that include prevention, treatment and rehabilitation, but, as an important component which is need based with an overall goal to relieve suffering and improve the QoL for patients and their families. The integration of palliative care provision in the management of end organ damage due to hypertension has been endorsed by academic bodies.
Tools like SPICT-LIS could be used in the identification of individuals with palliative care needs. The presence of general indicators of poor or deteriorating health, along with any of the disease specific clinical indicators (Table 1) helps identify individuals with advanced progressive illness. This can then aid in the assessment of unmet supportive and palliative care needs and thereafter plan their care appropriately.
Key components in the care of such individuals should include:
- optimal disease specific treatment
- sensitive and clear communication on expected course of illness, treatment options, preferences, and goals of care
- regular symptom assessment and management
- patient and care-giver empowerment on home-based care
- involvement and co-ordination with appropriate multidisciplinary services
- identification of disease progression, re-visiting goals of care
- identification of end-of-life, and planning care while respecting patient autonomy and promoting dignity
- careful assessment of risk and benefit of any life-prolonging treatment especially if not contributing towards symptom control or QoL
- bereavement support
Primary palliative care should be provided to all patients with end organ damage due to hypertension by the treating physician. Support or networking with specialist palliative care physicians should be considered when faced with complex needs, if possible. To avoid care fragmentation, co-ordination and continuum of care should be planned as many of them may need hospital admissions and care by multidisciplinary teams. To enhance care and promote palliative care integration within comprehensive management, it is important to promote joint educational opportunitieson communication skills and primary palliative care for physicians providing caring for such individuals. Such training should also be incorporated within postgraduate and super-specialty curriculum and training.
As such integration is implemented research gaps especially around challenges in prognostication, identification of individuals with palliative care needs and time of integration, care models, symptom management should be further studied.
Take home messages:
- Early detection and control of hypertension will reduce the morbidity and mortality secondary to end organ damage.
- Integration of palliative care in the comprehensive management of heart failure, stroke and chronic kidney disease can complement care and improve the QoL of patients and their families.
- Systems for identification of individuals with palliative care needs should be introduced in clinical practices which will lead to a holistic assessment and appropriate care delivery.
- Education of physicians, trainees who care for individuals with end organ damage in hypertension in primary palliative care should be a priority.
- Research in different settings to identify appropriate models for such integration and care should be studied.
- Gupta R, Gaur KS. Ram CV. Emerging trends in hypertension epidemiology in India. J Hum Hypertens. 2019; 33, 575–87.
- Ramakrishnan S, Zachariah G, Gupta K, et al. Prevalence of hypertension among Indian adults: Results from the great India blood pressure survey. Indian Heart J. 2019;71:309-13.
- Schmieder RE: End organ damage in hypertension. DtschArztebl Int 2010; 107: 866–73.
- Jaarsma T, Beattie JM, Ryder M, et al. Advanced Heart Failure Study Group of the HFA of the ESC. Palliative care in heart failure: a position statement from the palliative care workshop of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2009;11:433-43.
- Holloway RG, Arnold RM, Creutzfeldt CJ, et al. Palliative and end-of-life care in stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45:1887-916.
- Rao SR, Vallath N, Siddini V, et al. Symptom Management among Patients with Chronic Kidney Disease. Indian J Palliat Care. 2021;27(Suppl 1):S14-S29.
Note: This article is a republication from the Indian Association of Palliative Care‘s June edition Newsletter.
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