Background: The mental health of healthcare workers suffered greatly during the COVID- 19 pandemic. Globally, various preventive and therapeutic strategies were explored. Rajyoga, one of the oldest yogic systems practiced in India for millennia, is accessible to all irrespective of place or time, making it a viable option for promotion of mental wellbeing. Objectives: To assess the feasibility, acceptability, and effectiveness of Rajyoga meditation among healthcare professionals working in hospital settings during the COVID-19 pandemic. Methods: A single-blinded, randomized interventional study was conducted from April 2021 to January 2022. A total of 240 healthcare professionals were recruited through snowball sampling using online Google Forms. Participants were assigned either to a control group receiving online relaxation music or an intervention group practicing Rajyoga meditation online. Pre- and post-intervention anxiety, stress, and well-being were assessed using validated tools: Generalized Anxiety Scale, Corona Anxiety Scale, Perceived Stress Scale, and WHO Wellbeing Index. Findings: High levels of psychological distress were reported: 45.8 % had moderate to severe anxiety, 20.4 % had dysfunctional anxiety related to COVID-19, 6.7 % experienced elevated stress, and 68.7 % reported poor wellbeing. Rajyoga meditation led to significant reductions in anxiety and stress and improvements in well-being. Its effects were comparable to music therapy in relieving COVID-related psychological symptoms. Novelty: The study is distinctive in focusing on healthcare workers and assessing a cost- effective, accessible intervention. Its online format enhances feasibility and adherence to social distancing norms, making it suitable during public health crises.

BACKGROUND:The Palliative Care: Promoting Access and Improvement of the Cancer Experience (PC-PAICE) initiative is a team-based, palliative care (PC) quality improvement (QI) project working to promote high-quality PC in India. As a PC QI initiative, PC-PAICE implementation relied upon building interdisciplinary teams, providing the ideal context for understanding facilitators of team cohesion that compelled clinical, organizational, and administrative team members to work together. There is an opportunity to leverage the intersection between QI implementation and organizational theory to inform and improve implementation science. PURPOSE:As a subaim of a larger implementation evaluation, we aimed to identify facilitators of team cohesion within QI implementation context. METHODOLOGY:A quota sampling approach captured the perspectives of 44 stakeholders across three strata (organizational leaders, clinical leaders, and clinical team members) from all seven sites through a semistructured interview guide informed by the Consolidated Framework for Implementation Research (CFIR). We used a combination of inductive and deductive approaches informed by organizational theory to identify facilitators. RESULT:We identified three facilitators of PC team cohesion: (a) balancing formalization and flexibility around team roles, (b) establishing widespread awareness of the QI project, and (c) prioritizing a nonhierarchical organizational culture. PRACTICE IMPLICATIONS:Leveraging CFIR to analyze PC-PAICE stakeholder interviews created a data set conducive to understanding complex multisite implementation. Layering role and team theory to our implementation analysis helped us identify facilitators of team cohesion across levels within the team (bounded team), beyond the team (teaming), and surrounding the team (culture). These insights demonstrate the value of team and role theories in implementation evaluation efforts.

Background The Palliative Care: Promoting Access and Improvement of the Cancer Experience (PC-PAICE) initiative is a team-based, palliative care (PC) quality improvement (QI) project working to promote high-quality PC in India. As a PC QI initiative, PC-PAICE implementation relied upon building interdisciplinary teams, providing the ideal context for understanding facilitators of team cohesion that compelled clinical, organizational, and administrative team members to work together. There is an opportunity to leverage the intersection between QI implementation and organizational theory to inform and improve implementation science. Purpose As a subaim of a larger implementation evaluation, we aimed to identify facilitators of team cohesion within QI implementation context. Methodology A quota sampling approach captured the perspectives of 44 stakeholders across three strata (organizational leaders, clinical leaders, and clinical team members) from all seven sites through a semistructured interview guide informed by the Consolidated Framework for Implementation Research (CFIR). We used a combination of inductive and deductive approaches informed by organizational theory to identify facilitators. Result We identified three facilitators of PC team cohesion: (a) balancing formalization and flexibility around team roles, (b) establishing widespread awareness of the QI project, and (c) prioritizing a nonhierarchical organizational culture. Practice Implications Leveraging CFIR to analyze PC-PAICE stakeholder interviews created a data set conducive to understanding complex multisite implementation. Layering role and team theory to our implementation analysis helped us identify facilitators of team cohesion across levels within the team (bounded team), beyond the team (teaming), and surrounding the team (culture). These insights demonstrate the value of team and role theories in implementation evaluation efforts.

BACKGROUND:The population of patients with cancer requiring palliative care (PC) is on the rise in India. Family caregivers will be essential members of the care team in the provision of PC.OBJECTIVE:We aimed to characterize provider perspectives of the challenges that Indian families face in taking on a palliative caregiving role.METHOD:Data for this analysis came from an evaluation of the PC-PAICE project, a series of quality improvement interventions for PC in India. We conducted 44 in-depth semi-structured interviews with organizational leaders and clinical team members at seven geographically and structurally diverse settings. Through thematic content analysis, themes relating to the caregivers' role were identified using a combination of deductive and inductive approaches.RESULT:Contextual challenges to taking up the PC caregiving role included family members' limited knowledge about PC and cancer, the necessity of training for caregiving responsibilities, and cultural preferences for pursuing curative treatments over palliative ones. Some logistical challenges include financial, time, and mental health limitations that family caregivers may encounter when navigating the expectations of taking on the caregiving role. Strategies to facilitate family buy-in for PC provision include adopting a family care model, connecting them to services provided by Non-Governmental Organizations, leveraging volunteers and social workers to foster PC awareness and training, and responding specifically to family's requests.CONCLUSION:Understanding and addressing the various challenges that families face in adopting the caregiver role are essential steps in the provision and expansion of PC in India. Locally initiated quality improvement projects can be a way to address these challenges based on the context.

PURPOSESeven major palliative care (PC) centers in India were mentored through the Palliative Care—Promoting Assessment and Improvement of the Cancer Experience (PC-PAICE) by US and Australian academic institutions to implement a quality improvement (QI) project to improve the accessibility and quality of PC at their respective centers. The objective was to evaluate the experiences of teams in implementing QI methods across diverse geographical settings in India.METHODSA quota sampling approach was used to elicit perspectives of local stakeholders at each site. The Consolidated Framework for Implementation Research informed development of a semistructured interview guide. Analysis leveraged deductive and inductive approaches.RESULTSWe interviewed 44 participants (eight organizational leaders, 12 clinical leaders, and 24 team members) at seven sites and identified five themes. (1) Implementing QI methods enabled QI teams to think analytically to solve a complex problem and to identify resources. (2) Developing a problem statement by identifying specific gaps in patient care fostered team collaboration toward a common goal. (3) Making use of QI tools (eg, A3 process) systematically provided a new, straightforward QI toolkit and improved QI teams' conceptual understanding. (4) Enhancing stakeholder engagement allowed shared understanding of QI team members' roles and processes and shaped interventions tailored to the local context. (5) Designing less subjective processes for patient care such as assessment scales to identify patient's symptomatic needs positively changed work practices and culture.CONCLUSIONEngaging and empowering multiple stakeholders to use QI methods facilitated the expansion and improvement of PC and cancer services in India. PC-PAICE demonstrated an efficient, effective way to apply QI methods in an international context. The impact of PC-PAICE is being magnified by developing a cadre of Indian QI leaders.

Background: Prognostic disclosure to patients with advanced cancer facilitates treatment decisions and goals of care discussions. However, the perspectives of patients, families and physicians differ in this regard across different cultures. Non-disclosure of cancer diagnosis or prognosis is commonly observed in family-centric cultures such as India. Aim: To assess the prevalence of and factors associated with cancer patients’ awareness of advanced disease status; and its with quality of life and psychological distress. Methods: Patients for this cross-sectional questionnaire-based survey were recruited from oncology and palliative medicine clinics at a tertiary cancer hospital in India from January 2017 to June 2018. Patients aged ≥ 21 years, aware of cancer diagnosis and receiving oncology treatment for Stage IV solid cancer were included in the study after obtaining written informed consent. Results: Two hundred patients were enrolled, of which 146 (73%) were not aware of the stage of their malignancy and 9 (4.5%) believed that their disease was at stage I, II or III. Those who were aware of their advanced cancer stage had more years of education (9.9 years vs 8.1 years, p = .05) and had poorer spiritual wellbeing in the faith domain (adjusted difference −1.6, 95% confidence interval −3.1 to −0.1, p = .03) compared to those who were unaware. Conclusion: It is recommended that future studies may explore prognostic understanding in Indian patients according to their socio-cultural, spiritual and educational background.

Background and objective Several studies have indicated an escalation in the stress and anxiety levels among all sections of the population at large during the ongoing coronavirus disease 2019 (COVID-19) pandemic. In this challenging environment, meditation or yoga can help in maintaining the quality of life. This pilot study aimed to assess the willingness to practice meditation as a tool to manage anxiety, perceived stress levels, and psychological well-being (quality of life) during the COVID-19 pandemic in India. Materials and methods Bivariate and multivariate logistic regression models were employed to characterize the attitude of healthy Indian adults toward meditation as a stress management tool and its impact on psychological well-being. Primary data of 241 participants were collected using Google Forms circulated via email and social media platforms through the snowball sampling technique. The self-reported data on four different psychosocial scales, viz., for anxiety measurement [the Seven-Item Generalized Anxiety Disorder Scale (GAD-7) and Coronavirus Anxiety Scale (CAS)], for stress measurement [Perceived Stress Scale (PSS)], and to quantify well-being levels [the Five-Item World Health Organization Well-Being Index (WHO-5)], along with those on their perception toward meditation were obtained. Results Our findings suggest that the anxiety and perceived stress scores are lower among those practicing some form of relaxation or meditation than those not practicing it, along with those who already report better psychological well-being and perceived stress. The bivariate results indicated that willingness to meditate among those who were practicing some form of meditation and those not mediating significantly differed based on their age, presence of comorbidities, and GAD and PSS levels. The multivariate logistic regression showed that only those individuals aged 35 years and above and those who have some comorbidity symptoms showed a significant level of willingness to opt for meditation. Conclusions In order to attain proper relief from psychological issues during a pandemic situation such as the current one, a more specific remedial module for meditation procedure needs to be devised as an intervention, and it should be kept in mind that age and comorbidity status also play a significant role with respect to individuals' attitude toward meditation as a tool for psychological relief.

Background: The Palliative Care: Promoting Access in International Cancer Experience initiative (PC-PAICE) partnered with seven regionally diverse Indian palliative care (PC) sites to foster locally initiated quality improvement (QI) projects by training local teams on QI methods. We aimed to identify facilitators of QI team cohesion around team goals. Methodology: A quota sampling approach captured the perspectives of 44 stakeholders across 3 strata (organizational leaders, clinical leaders, and clinical team members) through a semi-structured interview guide informed by the Consolidated Framework for Implementation Research (CFIR). We used a combination of inductive and deductive approaches informed by theory to identify themes. Results: Theme 1: Allow a process to formalize and re-negotiate team roles and coordinate transfer of roles within the interdisciplinary PC team. Theme 2: Foster cross-disciplinary role agreement around shared and bounded QI project goals. Theme 3: Prioritize a non-hierarchical organizational climate of equity and respect for all PC team member involvement and input in the QI project work. Implications: Leveraging CFIR with role and team theories allowed us to identify facilitators of team cohesion, such as promoting a culture of equity and setting clear project goals. These insights demonstrate the value of team and role theories in implementation evaluation.

Life-threatening diseases such as cancer trigger spiritual distress in patients. Spirituality affects patients’ quality of life and helps them find peace, hope, meaning, and purpose in life, and to cope with the disease. There has been growing attention toward addressing patients’ spiritual needs at both a global and national level. Although India is a land rich in cultural and spiritual heritage, empirical studies on spirituality have not gained adequate consideration. This chapter provides an understanding of spirituality in an Indian context and makes recommendations for delivering spiritual care to cancer patients in India. In the absence of national protocols or guidelines, a two-tiered approach for spiritual history-taking is suggested. It is crucial to educate and train health care professionals for sensitive communications on matters related to spirituality and for integration of spiritual care into oncological care to provide holistic patient care.

Context. Lack of palliative care (PC) awareness is a barrier to its utilization in developing contexts. Objectives. To identify and understand strategies that changed awareness of the concepts and value of palliative care in a multi-site quality improvement project in India. Methods. The Palliative Care - Promoting Assessment and Improvement of the Cancer Experience (PC-PAICE) evaluation team conducted 44 semi-structured interviews with clinician and organization stakeholders at seven geographically dispersed sites. We used inductive and deductive approaches in this secondary analysis to identify emerging themes. Results. We identified the following strategies to improve awareness of concepts and value of palliative care. Strategy 1: Educate medical trainees, staff, and the community about palliative care and its concepts. Sub-strategies: Participate in community events. Integrate PC concepts into early medical education. Standardize training for practitioners. Strategy 2: Design and disseminate India-pecific research to reinforce awareness of the value of palliative care. Sub-strategies: Publish and use India-specific palliative care research. Strategy 3: Facilitate communication between providers and departments to improve awareness of palliative care services and its concepts. Sub-strategies: Create referral frameworks and network with providers referring to palliative care to change awareness of available services and palliative care concepts. Conclusion. To increase palliative care utilization, program development can include community and provider-focused efforts on awareness of the concepts and value of palliative care. These three strategies held salience across sites representing diverse Indian geographic and cultural settings; as such, they may be applicable to other contexts. Published by Elsevier Inc. on behalf of American Academy of Hospice and Palliative Medicine.

Objectives: Oral cancers have high epidemiologic burden in India, and most oral cancer patients at the All India Institute of Medical Sciences present in advanced stages. Their symptomatic needs are often not adequately addressed and the referrals to palliative medicine clinic are for severe pain or terminal stages. Using quality improvement methods, we aimed to provide early referral to palliative care for advanced oral cancer patients. Materials and Methods: Duration (number of days) between registration at the head-and-neck cancer clinic and referral to palliative medicine clinic at baseline and postinterventions. Interventions: Understanding current perceptions of oncologists for referral to palliative medicine clinic, educating them through departmental meetings, fostering clinician and patient-family awareness through pamphlets, defining process and screening guidelines for referral, including symptom burden charts in head-and-neck cancer clinic notes, soliciting regular feedback from oncologists at review meetings. Results: The number of days for the referral to the palliative medicine clinic decreased from an average of 48 days to 13 days in 6 months. Conclusion: A multicomponent intervention included oncologists and patients and families, education, workflow modification, standardized assessment, documentation, and clinician feedback, and succeeded in improving the timeliness of palliative care referrals of advanced oral cancer patients.

1.Explain the need for palliative care capacity in developing regions.2.Identify and compare the barriers for palliative care awareness with previous social awareness campaigns in India.3.Identify the major domains that enhanced awareness of the value of palliative care at cancer facilities in India. Prior studies have described lack of palliative care (PC) awareness as a barrier to PC integration in developing regions. A guiding framework to promote improvements in this sphere is needed. We aimed to 1) identify and understand the factors that changed awareness of the value of PC at cancer facilities in India and 2) propose a solutions toolkit matched to these factors. In an evaluation of the Palliative Care–Promoting Access and International Cancer Experience PC-PAICE project, we interviewed 44 interdisciplinary providers from 7 geographically diverse sites throughout India using semi-structured interview guides. We used a combination of inductive and deductive approaches to identify themes. Theme 1: Provider and Interdepartmental Communication: Oncology providers may lack an orientation to palliative care as a resource that could improve their patient’s quality of life instead of somewhere to refer “when they started dying.” PC providers found that direct communication with referring providers about key palliative concepts, referral frameworks, and patient co-management may improve professional relationships, referral rates, patient-provider communication, and patient retention in specialty clinics. Theme 2: Education: Physicians, medical students, and nurses had limited understanding of palliative care, and there was no “competency-based training” which led to a “dilution” in practice standards. Clinicians created a curriculum and published India-specific research to enhance the value of palliative care as a field of medicine. Theme 3: Provider Knowledge, Attitudes, and Beliefs: Strategies to cultivate “positive attitudes” towards palliative care are needed to overcome common misbeliefs about PC (e.g. “people go there to die”). Minimal exposure and limited understanding of PC hinders program capacity building; identifying those barriers and creating solutions may help improve awareness and access to these resources.

Mentors at seven U.S. and Australian academic institutions initially partnered with seven leading Indian academic palliative care and cancer centers in 2017 to undertake a program combining remote and in-person mentorship, didactic instruction, and project-based learning in quality improvement (QI). From its inception in 2017 to 2020, the Palliative Care—Promoting Accesst and Improvement of the Cancer Experience Program conducted three cohorts for capacity building of 22 Indian palliative care and cancer programs. Indian leadership established a Mumbai QI training hub in 2019 with philanthropic support. In 2020, the project which is now named Enable Quality, Improve Patient care - India (EQuIP-India) focuses on both palliative care and cancer teams. EQuIP-India now leads ongoing Indian national collaboratives and training in QI and is integrated into India's National Cancer Grid. Palliative Care—Promoting Accesst and Improvement of the Cancer Experience demonstrates a feasible model of international collaboration and capacity building in palliative care and cancer QI. It is one of the several networked and blended learning approaches with potential for rapid scaling of evidence-based practices.

•Identify myths about cancer and terminal prognosis that may inhibit the spread of palliative care in India.•Consider strategies to overcome these palliative care myths in India and other developing contexts. Roughly 2% of people have access to palliative pain and symptom management in India. While there are many factors that limit the access to and use of palliative care, this paper aims to identify myths about palliative cancer care and terminal prognosis that may inhibit the adoption and spread of palliative care in India. We use a quota sampling approach to capture the perspectives of local stakeholders from 7 palliative care practice sites throughout India. We collected a total sample of 44 interviews from the following 3 categories (organizational leaders, clinic leaders, and clinical team members) through a semi-structured interview guide. We identified emergent themes using standard qualitative content analysis methods. Myths influencing decision making for palliative care: Theme 1—Cancer is contagious “…cancer is sometimes they[patient]think it is contagious… that is why it affects our [PC] services…” Theme 2—Palliative care is only for patient with cancer “…we are like most organizations in India we are doing mostly cancer palliative care…our training for management of non-cancer palliative care is still very much lacking…” Theme 3—Palliative care is only for end of life “even if you tell a patient that we are referring you to palliative care, they assume that we are actually giving up on actual cancer care..” Theme 4—Quality of life is not relevant when patient has a terminal illness “…probably doctors as well as patients feel that ok we are in the terminal stage why should we need any care kind of a thing…” Theme 5—Managing pain is “giving up.” Myths about what palliative care means and who it is for persist in India and impact perceptions of the appropriateness and acceptability of palliative care.

•Identify the factors affecting sustainability of quality improvement initiatives from seven diverse palliative care centers in India.•Recognize how these factors impacted the sustainability levels of the locally initiated quality improvement interventions at the seven palliative care centers in India. Quality improvement (QI) in healthcare is a series of methodical actions towards improving system and patient outcomes. Sustainability is the integration of these steps into existing systems continuously over a period of time. The multiple and complex needs of palliative care (PC) patients and the dynamic quality conscious healthcare environment makes it imperative for PC professionals to routinely practice QI activities. To identify the factors impacting sustainability of QI interventions in seven varied and geographically distant Indian PC settings. Data needs for this analysis was obtained from a larger study aimed to assess the implementation of QI interventions for PC in India. Quota sampling represented shareholders perspectives from seven varied and geographically distant settings. A semi-structured interview guide facilitated the conduct of 44 interviews from three categories (organizational leaders, clinic leaders, clinical team members). Qualitative content analysis methods identified emerging themes. Factor 1: Adopting reliable systems and interventions: Implementing evidence-based approaches, employing standard QI tools, designing simple non-resource intensive interventions, streamlining existing systems / processes. Factor 2: Mentorship: Availability of a learning network and access to QI experts, to institutional local mentors and other national PC leaders. Factor 3: Leadership support: Facilitate change management (policies, obtaining team buy-in), allocate resources (personnel, funds, equipment), organize regular sensitization sessions. Factor 4: Committed Teams: Dedicated core team, effective communication with other team members, continuity of teams, project ownership, team support. Factor 5: Periodic monitoring and evaluation: Periodic team meetings, regular measurement of relevant indicators, constant feedback mechanisms. Concentrating on the above mentioned factors empowered and guided the varied PC institutions to sustain delivery of quality PC, as sustainability of QI interventions was a key focus area among shareholders.

BACKGROUND:Quality improvement (QI) methods represent a vehicle for fostering locally initiated innovation cycles. We partnered with palliative care services from seven diverse practice settings in India to foster locally initiated improvement projects.OBJECTIVE:To evaluate the implementation experiences of locally initiated palliative care improvement projects at seven diverse sites and understand the barriers and facilitators of using QI to improve palliative care in India.PARTICIPANTS:We use a quota sampling approach to capture the perspectives of 44 local stakeholders in each of the following three categories (organizational leaders, clinic leaders, and clinical team members) through a semi-structured interview guide informed by the consolidated framework for implementation research (CFIR). We use standard qualitative methods to identify facilitators and barriers to using QI methods in seven diverse palliative care contexts.RESULTS:Across all sites, respondents emphasized the following factors important in the success of quality improvement initiative: leveraging clinic level data, QI methods training, provider buy-in, engaged mentors, committed leadership, team support, interdepartmental coordination, collaborations with other providers, local champions, and having a structure for accountability. Barriers to using QI methods to improve palliative care services included lack of designated staff, high patient volume, resources, patient population geographic constraints, general awareness and acceptance of palliative care, and culture.CONCLUSIONS:Empowering local leaders and medical personnel to champion, design, and iterate using QI methods represents a promising powerful tool to spread palliative care services in developing countries.

•Identify palliative care needs, referral timings and reasons for delay in referral to palliative care clinic for advanced oral cancer patients.•Develop, test and sustain interventions to provide early referral to palliative care clinic for advanced oral cancer patients. Recent literature affirms the benefits of early palliative care in advanced cancer patients. The prevalence of oral cancer is high in India and often patients present at advanced stages at the time of diagnosis. Bleak scope of curative treatment and high symptomatic burden detracts from the quality of life of these patients. The aim of this study was to provide early referral to a palliative care clinic for advanced oral cancer patients. This initiative was carried out at Dr B. R. Ambedkar, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, India in collaboration with quality improvement leaders at Stanford University. A multidisciplinary team consisting of oncologists, surgeons, nurses, administrative staff, palliative care physicians and overseas quality improvement mentors was formed. Using A3 methodology, we applied improvement tools to understand the current situation. A cause and effect analysis revealed absence of referral guidelines and misalignment of what was deemed appropriate early referral as the major factors contributing to the practice of late referral. Our interventions were developing a standard, agreed upon, protocol for providing palliative care referral and consultation, creating awareness through pamphlets, educating oncologists and surgeons through weekly departmental meetings and documenting symptom burden in the medical record. The interventions were sustained by soliciting feedback from oncologists and surgeons during periodic departmental meetings, educating new oncologists and surgeons about referral protocols during their orientation program i.e. once in three months and by auditing patient referral data. Number of days from identification of advanced oral cancer to referral to palliative care clinic decreased from an average of 48 days at baseline to 13 days post-interventions. Early referrals to palliative care clinic are possible using a multidisciplinary team approach focusing on aligning expectations between oncologists, surgeons and palliative care professionals, modifying process maps and standardizing and documenting assessment.

•Learn how physicians in specific countries provide palliative care to their patient populations, often with limited resources.•Recognize specific cultural and political challenges to developing palliative care clinical, educational and research programs.•Describe roles of different health care providers practicing palliative care and how they meet the needs of their local populations. Please join AAHPM's International Scholars for a panel discussion. Each scholar will present for 10-15 minutes on the state of the practice of palliative care in their home country, with an emphasis on the roles of physicians, nurses, and other healthcare providers; the status of education and research in the field; and the unique challenges facing patients and providers. There will be time allotted after each presentation to field questions and dialogue from the audience. Prepare to be educated and inspired by these accomplished individuals who are leading and advancing the field of hospice and palliative medicine in their countries of origin.

Head-and-neck cancers (HNCs) are significant in India. Poverty, illiteracy, lack of access to healthcare, and poor treatment infrastructure pose a major challenge in the management of these cancers. The majority of these patients present with advanced stage and are not amenable to curative treatment. The majority have the potential to benefit from palliative care (PC) interventions. Our experience has been that usually the referrals from HNC clinic for PC are at the end-of-life or terminal stage. Unfortunately, in the state of intractable suffering, it is difficult for patients to understand and fully benefit from the role of PC. Developing an effective working relationship and communication between the PC service and referring surgeons or oncologists is a key to foster more timely, appropriate referral, as both patients and clinicians often misunderstand or fail to recognize the role of PC. In preparation for a quality improvement project to improve access to PC for HNC patients at the All India Institute of Medical Sciences, we reviewed the needs, challenges, conceptual models, and potential of early integration of PC in advanced HNC patients.

Indian Journal of Palliative Care ¦ Volume 24 ¦ Issue 2 ¦ April-June 2018 208 of the disease with adherence. However, non-adherence increased with increase in duration of treatment (mean treatment duration of 4.63 versus 7.23 months (p < 0.04) for adherent and non-adherent respectively). Of the patients prescribed morphine, 62.16% (46/74) were non-adherent and 4.05% (3/74) were misdosing. Of note was the finding that 93.48% patients non-adherent to prescribed morphine had mild pain on treatment. However, 60.56% (43/71) of patients prescribed tramadol were compliant and of the non-adherent patients, 70% had mild pain. Only 9.46% (7/74), and 8.45% (6/71) of patients taking morphine and tramadol respectively, took prescribed SOS doses. 35.43% (45/127) patients taking paracetamol were non-adherent and 12.6% (16/127) were misdosing. The most common reason for non-adherence was found to be satisfactory pain control (33%), and that for misdosing was overlapping of prescription from different departments (9.03%) and misunderstanding prescribed doses (9.03%). Conclusion: Pain is a symptom, very well and only appreciated by the patient, unlike objectively measurable entities or signs in other chronic diseases. This different character demands different treatment. A patient in severe pain will demand analgesics and forget or avoid the same when it is tolerable, as deciphered through this study. Thus pain prescriptions should be flexible, informing the patients of which drugs to increase and also which to decrease in case of increased or reduced pain respectively to match the dynamic character of pain. Also, proper patient education and interdepartmental prescription vigilance finds importance in preventing the patient from harmful misdosing while undergoing multidisciplinary management.