Department of Family Medicine

Introduction: Among the focal issues of barriers to pain management include the physicians' lack of knowledge about cancer pain and negative attitudes towards opioids. Many physicians and educators attribute this, at least in part, to limited exposure to pain and palliative care education during medical school.

Towards the end of life, physicians face dilemmas of discontinuing life-sustaining treatments or interventions. In some circumstances, these treatments are no longer of benefit, while in others the patient or family no longer want them. The physician plays an essential role in clarifying the goals of medical treatment, defining the care plan, initiating discussions about life-sustaining therapy, educating patients and families, helping them deliberate, making recommendations, and implementing the treatment plan. Communication is key. It should be clarified that when inevitable death is imminent, it is legitimate to refuse or limit forms of treatment that would only secure a precarious and burdensome prolongation of life, for as long as basic humane, compassionate care is not interrupted. Agreement to DNR status does not preclude supportive measures that keep patients free from pain and suffering as possible. Acceptable clinical practice on withdrawing or withholding treatment is based on an understanding of the medical, ethical, cultural, and religious issues. There is a need to individualize care option discussions to illness status, and patient and family preferences, beliefs, values, and cultures. The process of shared decision making between the patient, the family, and the clinicians should continue as goals evolve and change over time.

Physicians are not ethically obligated to deliver care that, in their best professional judgment, will not have a reasonable chance of benefiting their patients. When further intervention to prolong the life of a patient becomes futile, physicians have an obligation to shift the intent of care toward comfort and closure. Withholding or withdrawing life-sustaining therapies is ethical and medically appropriate in these circumstances. Before reviewing specific treatment preferences, it is useful to ask patients about their understanding of the illness and to discuss their values and general goals of care. Attending physicians should feel free to make a referral to the specialist palliative care service if they need assistance in providing specific advice to patients and families struggling with these end-of-life decisions. Terminally-ill patients with decision-making capacity can opt to forego any medical intervention, including artificial nutrition/hydration and cardiopulmonary resuscitation.

Truth-telling and “breaking the bad news” to patients and their families is one of a physician’s most challenging jobs, yet medical education typically offers little formal training for this arduous task. This is especially so as the attitudes and practice of the physicians towards truth-telling are affected by the cultural and ethical norms, and the social milieu where the physicians and their patients live. Without proper training, the discomfort and uncertainty associated with breaking bad news may lead physicians to emotionally disengage from patients. Numerous study results show that patients generally desire frank and empathetic disclosure of a terminal diagnosis or other bad news. Focused training in communication skills and techniques to facilitate breaking bad news has been demonstrated to improve patient satisfaction and physician comfort. Physicians can use the SPIKES strategy both in breaking the bad news or discussing code status.

The 2015 Quality of Death Index ranked the Philippines near the bottom 3 out of 80 countries surveyed.While palliative care service and essential medicines are not easily accessible in the country, the Filipino family provide adequate psychosocial support and provide "informal" palliative care.The deep Christian faith of the Filipino allow them to eventuality accept death with equanimity and calm.The Philippines is not one of the worst places to die after all, according to most Filipinos.

Death, Dying, and Dignity in the Time of the COVID-19 Pandemic WHO Guide Integrating palliative care and symptom relief into responses to humanitarian emergencies and crises. Geneva: World Health Organization; 2018 https://www.who.int/publications-detail/integrating-palliative-care-and-symptom-relief-into-the-response-to-humanitarian-emergencies-and-crises In The Time Of The COVID-19 Pandemic 5 CHALLENGES IN PALLIATIVE CARE AND END OF LIFE ISSUES The first casualty of coronavirus disease (COVID-19) for patients nearing death is human dignity.

Objectives: Perceived cancer-related stigma can affect mental health and potentially treatment choices for patients with cancer. Nevertheless, perceived stigma is not very well understood in Asia. This study investigated across six developing Asian countries: (1) the prevalence of perceived stigma among advanced cancer patients, (2) its risk factors, and (3) its association with patient treatment preferences. Methods: This cross-sectional study recruited patients receiving oncology care across major hospitals in Bangladesh, China, India, Philippines, Sri Lanka and Vietnam. Participants (N = 1358) were adults diagnosed with stage IV metastatic solid cancer who completed self-reported surveys. Multi-variable logistic regression and ordered logit models examined the associations with perceived stigma and variables of interest. Results: Across the countries, 35%, 95% CI [32%, 38%] of patients reported experiencing at least one facet of cancer-related stigma often or always, while 60% [57%, 63%] reported it occurring occasionally. Top-endorsed facets of perceived stigma across the Asian countries suggest a distinct pattern. Having knowingly engaged in health-risk behaviours (OR = 2.03-2.24, 95% CI [1.14-1.19, 3.43-4.41]), unemployment (2.64 [1.67, 4.19]) and body image change (1.57 [1.00, 2.45]) were associated with higher odds of perceived stigma, while time mitigated perceived stigma wileyonlinelibrary.com/journal/pon

Towards the end of life, physicians face dilemmas of discontinuing life-sustaining treatments or interventions. In some circumstances, these treatments are no longer of benefit, while in others the patient or family no longer want them. The physician plays an essential role in clarifying the goals of medical treatment, defining the care plan, initiating discussions about life-sustaining therapy, educating patients and families, helping them deliberate, making recommendations, and implementing the treatment plan. Communication is key. It should be clarified that when inevitable death is imminent, it is legitimate to refuse or limit forms of treatment that would only secure a precarious and burdensome prolongation of life, for as long as basic humane, compassionate care is not interrupted. Agreement to DNR status does not preclude supportive measures that keep patients free from pain and suffering as possible. Acceptable clinical practice on withdrawing or withholding treatment is bas...

Introduction Among the focal issues of barriers to pain management include the physicians’ lack of knowledge about cancer pain and negative attitudes towards opioids. Many physicians and educators attribute this, at least in part, to limited exposure to pain and palliative care education during medical school. Aim The researcher investigated the medical students’ knowledge about cancer pain and the use of opioid analgesics. Methods The subjects were a sample of 50 students of the University of the Philippines College of Medicine in their integrated clinical clerkship year. Descriptive statistics (frequencies, means, standard deviation, rating scales) were used to determine mean knowledge score and level of confidence with opioid use. The study also identified specific areas where students exhibited good or poor knowledge of opioids. Results Approximately sixty-nine (69%) of the study respondents mentioned that pain management was given to them during their Anesthesiology lectures wh...

Context. To date, little is known about palliative care (PC) awareness and utilization in low-and middle-income countries (LMICs) in Asia. Objectives. This study aimed to investigate PC awareness and its predictors, utilization of PC services, and perceived utilization barriers among advanced cancer patients from select hospitals in Asian LMICs. Methods. This cross-sectional study analyzed data of 759 advanced cancer patients at major hospitals of four LMICs in Asia (i. e., Bangladesh, Philippines, Sri Lanka, and Vietnam). The predictors of PC awareness were investigated using multivariable logistic regression. Results. Overall PC awareness was 30.8% (n = 234). Patients with higher education (OR = 1.0; CI = 1.0,1.1), from upper-middle or high-income households (compared to low-income) (OR = 2.0; CI = 1.2,3.3), awareness of disease severity (OR = 1.5; CI = 1.0,2.2), and higher pain severity (OR = 1.1; CI = 1.0,1.2) had higher odds of PC awareness. Compared to patients who perceived themselves as being very informed about disease trajectory, those who were unsure (OR = 0.5; CI = 0.3,0.8) or uninformed (OR = 0.5; CI = 0.3,0.9) had lower odds of PC awareness. The PC utilization rate was 35.0% (n = 82) among those with PC awareness, and 47.8% (n = 66) among patients recommended PC by a healthcare professional (n = 138). The most cited PC utilization barriers were currently receiving anti-cancer treatment (n = 43; 33.9%), and having insufficient information about PC (n = 41; 32.3%). Conclusion. The low awareness of PC services in these major hospitals in Asian LMICs highlights that more effort may be required to promote the awareness of PC in this region. The efforts should especially focus on those from disadvantaged groups to reduce the gap in PC awareness.

Ethnographic case study, which used the theoretical framework of medical anthropology. Data were collected through semi-structured interviews with family caregivers of patients admitted in the ICU in a private tertiary hospital in the Philippines. RESULTS Identified cultural factors affecting end-of-life decision-making and EOL care include: the patient and family's perspective on death and dying, collective decision-making, perception of pain and request for pain relief, role of religion and faith, and perception regarding hospice and palliative care. When it comes to making end-of-life health care decisions, religion, family and home are powerful influences on many terminally ill Filipino. Advance-directive completion rates among Filipino patients were at 10 percent. "Only God can decide when life ends" or "while there's life there's hope, so we cannot give up on our patient" are a few of the reasons why many seriously ill Filipino patients and their family members tend to balk at approving advance care directives. The Filipino family unity is more and more disrupted by migration. It is becoming increasingly common to conduct family meetings using Face Time or Skype conferencing. It is the children abroad who serve as financier and primary decision-makers. Two out of five Filipino patients' relatives refused to make a 'Do not resuscitate' order when it is initially offered upon admission. Many patients are thus transferred to the ICU and stay there for prolonged periods of time while the family here wait for overseas family members to come home before considering possible withdrawal or withholding of artificial life-support measures. Meantime, the burden of aggressive, heroic measures on the patient begin to outweigh the benefits, and the hospital expenses continue to rise to exorbitant levels. Regarding Lung Cancer 51 year old patient intubated in the ICU: "I don't want to sign that Advance Directives. My mom will improve. She will not die. But if we put it in writing, then that is sort of like we hasten the death. And we need to wait for my father working in Germany to arrive first; he can be the one to decide."-Son, 31 years old Regarding Colon Cancer 60 year old patient intubated in the ICU: "I cannot decide about dad. Let's wait for my brother who is a practicing doctor in the US"-Daughter, 41 years old Regarding 78 year old Stroke patient GCS=3/15 patient intubated in the ICU: "Do everything possible. My mother is a fighter and she wants to live. We didn't discuss her wishes for end of life care because you don't talk about those things. My siblings abroad said they leave it up to me to decide and I think we should fight with her."-Daughter, 45 years old

This study aimed to describe the quality of life (QOL) and psychological distress (anxiety and depression) of Filipino patients with advanced solid cancers and identify sociodemographic and clinical-related factors associated with them. Methods 195 patients with advanced cancer were recruited from a major hospital treating cancer patients in the Philippines. Participants completed self-reported surveys on Quality-of-life (QOL-FACT-G) and psychological distress (HADS-D, HADS-A). Multi-variable OLS regression models were performed where sociodemographic, health history and clinical characteristics were included as predictors. Results The average total FACT-G score was 65.39/108 (Standard deviation (SD) = 13.76), with the physical well-being scale having the lowest scores (M = 14.14/28, SD = 5.92). The two most common symptoms reported were fatigue (88%) and pain (86.5%). Physical symptom burden was significantly negatively associated with QOL and psychological distress. The average HADS-total score was 14.46/21 (SD = 5.77), with 8% with probable anxiety and 27% with probable depression. Participants who reported greater reliance on their spiritual faith for strength in coping with illness reported lower depression scores.