How to prolong life and remove pain from terminally ill: palliative medicine in Russia
The theme of death is unpleasant and frightening. But it will always be relevant. We at the Medicine 24/7 Clinic work with death every day. We are a rare medical institution for palliative medicine in Russia. Moreover, we do not just offer hospice services to patients with the last stages of oncological diseases and other fatal diagnoses, but actively fight for the extension of their lives without pain and agonizing symptoms.
In the clinic, one might say, there are no random people - neither among the doctors, nor among the staff. Two thirds of the staff were faced with oncology - they treated relatives, some were treated themselves. Why is it important? A person with a cancer diagnosis is in many ways not like a person with any other disease. He has other reactions to what is happening, a different view of life, medicine, and his own perspectives. Communicating with him, too, must be very different. Those who have gone through this know how to do it right.
Unfortunately, modern effective palliative medicine is still very expensive. In Russia, it is available to those who are willing to spend hundreds of thousands and even millions of rubles to fight the disease to the last and die like human beings. Such a system can only be changed at the state level. This is beyond our power, so we do what we can.
And for this money we can do no less than the clinics of Israel or Germany - we have the same technologies, methods, medicines and excellent specialists. And at the same time, it is still 30-50% cheaper to treat with us than abroad. Ready to illustrate with examples from their daily practice.
Our conscience is calm and for the fact that we do not convince the patient to make a choice in our favor if he has the opportunity to receive a similar service, for example, by quota in the region or for less money from our colleagues.
But it is necessary to take into account that state medicine is “free” for a long time only with great reservations. The same MRI / CT for registration quotas in the budget cancer center will have to be paid, if not 2 months to wait for their free line. And onkopatsyent this time there is never.
Yes, our specialization is extremely difficult and ungrateful - but we see the need to talk about the fact that Russian medicine is not powerless, even in hopeless cases. And, although it sounds unexpectedly, we hear the words of gratitude all the time. From patients who received in our clinic an extra few months of life, and from their relatives.
Therefore, we want to conduct an educational program and clarify this terribly important question: is it necessary to die - is it painful?
For most of its history, Homo sapiens lived an average of 30 years, until it was overtaken by cave lions, enemy troops, or the plague. But over time, people learned to wash their hands before eating and taking birth, came up with the UN and WHO, started a schedule of vaccinations - and the average human lifespan doubled.
Medicine gives more and more reasons to count on longevity. 90 years ago we did not have antibiotics (Fleming discovered penicillin only in 1928). And now we are learning to treat fatal diseases with the help of genome editing.
Leila Richards, the first person from whom lymphoblastic leukemia (cancer of the hematopoietic system) was cured with donor T cells with an altered genome.
Until eternal life is still very far away, but over the past hundred years the list of causes of death has changed a lot.
The distribution of causes of death: in 1900 in the lead pneumonia, tuberculosis, gastrointestinal infections in 2010 - heart disease and cancer
People now do not die from sepsis (blood infection), or tuberculosis, and heart attacks, strokes, diabetes and cancer . Cancer causes every sixth death in the world. At the same time do not die from it instantly. In addition, civilization has given chances for life to people with chronic diseases, severe neurological diagnoses and AIDS. In this regard, medicine is faced with new problems.
There are 40 million people in the worldthat suffer from pain, motor limitations and other severe symptoms, and they cannot be cured. But to help such people is still possible. This is what palliative medicine does .
A palliative (from the French palliatif from the Latin pallium - a veil, a raincoat) is a non-radical solution, a half-measure applied when radical solutions are simply impossible.
Palliative medicine, respectively, is a special branch of medicine, an integral part of the concept of "palliative care." Her tasks do not include complete recovery, since it is impossible. Its goal is to improve the quality of life of patients with a fatal disease, using the achievements of modern science. Palliative medicine can prolong life, reduce pain and painful symptoms.
Palliative medicine works with the following diseases:
In addition, people with renal and hepatic insufficiency, rheumatoid arthritis, dementia, and severe neurological diagnoses such as amyotrophic lateral sclerosis (who was ill with Stephen Hawking) or multiple sclerosis need palliative care.
However, most often the phrase "palliative medicine" is used nevertheless in the context of the treatment of cancer of stage III-IV.
The history of palliative care began in the 6th century, when in Europe they created the first shelters for pilgrims - “hospice”. Throughout the Middle Ages, hospices, almshouses, nursing homes were organized only by church forces. Doctors - treated those who could be saved. Dying medicine is not systematically engaged.
The engraving of the XIII century - the reception of travelers and care for the sick.
The problem is that even today many have not even heard of palliative medicine, or they don’t know that it exists in Russia in principle. And accordingly, the ideas about the process of dying and the last stages of life are still somewhat medieval.
But the institution of palliative medicine is not a synonym for hospice.
People usually enter a hospice in the last 3-6 months of life, and more do not leave it. The task of palliative medicine is just the opposite, to “untie” the patient from the hospital bed, make his life as active as possible until the moment of death, and even delay the end.
The task is not trivial - the symptoms of incurable diseases are usually severe, affecting several body systems at once. To combat them, they use both surgical and pharmacological treatment, psychology, transfusiology, modern medical equipment and experimental techniques. Yes, the whole arsenal of modern medicine is used where there is no hope for a cure. In order to give the terminally ill person the opportunity to complete the work and adequately end his life.
In other words, the older version of the understanding of palliative medicine, solely as a measure to alleviate death-suffering, is being replaced by the concept of extending active life, despite the presence of a fatal disease. At the same time, more and more time is devoted to work not only with the patient himself, but also with his relatives.
The scheme of integration of palliative medicine in the standards of late-life care.
Pain ranging from moderate to acute is experienced in the terminal stages of the disease in 67-80% of palliative patients.
Besides the fact that pain is obviously tormenting - it reduces the criticality of thinking, the patient falls into a depressive state and refuses a prospective treatment. Therefore, the relief (elimination) of the pain syndrome is the most frequent task in palliative medicine.
In our practice, we use the so-called “pain relief ladder” of WHO: a treatment regimen that allows us to gradually move from non-narcotic analgesics to weak and strong opiates. Our doctors are able to work with multimodal anesthesia schemes, so as not to switch to narcotic painkillers ahead of time.
Due to this, pharmacological anesthesia gives a satisfactory result in 90% of our practice cases. In addition, we have some ways to help even those patients who got into the unhappy 10% - more on this below.
However, it is wrong to reduce palliative care only to anesthesia, or to assume that completely incurable (incurable) patients do not need treatment. The treatment options are varied and can significantly improve the quality of life of the patient and increase its duration.
We have gathered about a dozen modern technologies in our clinic to work with it.
Molecular genetic testing
Scope of application: Oncology.
The genetic material of a tumor of a specific patient is investigated using high-throughput sequencing methods (DNA structure determination technique). This gives important information.
First, potentially effective drugs are determined. It happens that treatment according to standard protocols stopped working and the disease began to progress again. In such cases, the results of genetic testing often indicate a drug that is not included in the “gold standard” of treatment for this type of cancer, but may help.
In addition, according to the test results, conclusions can be drawn about the potential resistance of a particular tumor to therapy, to predict relapse and concomitant diseases.
Chemoembolization of tumors.
Scope of application: oncology.
This is a method of local chemotherapy, carried out by endovascular surgery. The operation is carried out through a small puncture in the patient's skin: instruments-catheters, special thin tubes are led to the vessels, and they are led through vessels to the target site. The surgeon monitors the process with x-ray equipment. Spherical microparticles of the drug act in two ways:
Palliative chemotherapy is aimed at reducing the tumor mass or inhibiting the growth of a tumor.
Radiofrequency ablation of metastases controlled by CT (RFA).
Scope of application: oncology.
In cancer, there are cases when pain is not relieved by even strong opiates. But so sick physicians often have the power to help.
RFA is a minimally invasive (non-traumatic) operation that destroys the tumor by high temperature. Relieves a person from intractable pain syndrome and pathological bone fragility caused by metastases. This operation is also done without incisions, through a puncture, and they “aim” and control the process through a multispiral computed tomography apparatus (MSCT).
The RFA method itself is also used in the treatment of arrhythmias or, for example, varicose veins, but it is used, unfortunately, not so often to make life easier for palliative cancer patients. Read more - in the video.
After getting rid of pain with the help of RFA, patients feel better not only physically, but also psychologically - they start looking at further treatment with optimism.
Implantation of venous infusion port systems.
Scope of application: oncology, AIDS treatment, systemic antibiotic therapy, etc.
Systemic chemotherapy in the treatment of oncological diseases involves the administration of a drug or a combination of drugs with a certain frequency for a long time (6-12 months). Chemotherapeutic drugs damage not only tumor cells, but also healthy tissues, including veins. In order to eliminate complications (phlebitis - inflammation of the veins) from regular injections, put infusion port systems designed for the introduction of drugs into the body.
In addition to chemotherapy, antibiotics and other drugs can be injected through the port, take venous blood for analysis, transfuse blood components, and administer parenteral nutrition (that is, nutrition not through the mouth, but by intravenous mixture). In this capacity, they make life easier for patients with HIV or chronic lung diseases and gastrointestinal tract.
The port is placed under the skin in the upper third of the chest, and a catheter is inserted into the jugular vein. Service life - up to a year.
Diagram of the installation of an infusion port system.
Installation of stents (extenders).
Scope of application: oncology, cardiology.
Requiredwhen vessels, ducts, intestines or esophagus are narrowed due to atherosclerosis or tumor / metastasis. The ability to eat normally, go to the toilet and lead a normal life is returned to patients, the risk of heart attack and stroke decreases (during stenting of blood vessels).
Use of equipment for transfusiology.
Scope of application: oncology, chronic renal and hepatic failure, treatment of any diseases associated with the use of highly toxic pharmaceuticals.
Transfusiology is a branch of medicine that studies the problems of mixing (transfusion) and the interaction of biological fluids and their substitutes. As part of palliative care, she is engaged in the removal of toxic products of tumor breakdown or pharmaceutical preparations. In particular, conduct:
In addition, symptomatic therapy within the framework of palliative care can treat such complications of incurable diseases such as dyspepsia (gastrointestinal dyspepsia), polyserositis (simultaneous inflammation of the membranes of internal cavities, for example, pleura and peritoneum), ascites (accumulation of free fluid in the abdominal cavity), intoxication , nausea and vomiting. A multi-component restorative treatment is carried out to support the functioning of vital organs.
So, patients with a fatal diagnosis, if they have access to high-quality palliative medicine, thanks to her, feel better, they return to the possibility of active life, communication with family and friends, limited work capacity.
Unfortunately, this area of medicine in Russia began to develop quite recently and is not yet very well organized. Looking at the situation from the inside, we believe that to some extent this is due to the special “scrupulousness” of the topic, to the fact that they do not speak about it.
But there are more problems with the fact that Russian doctors are still not always taken to thoroughly introduce the patient in the course of business, to communicate with him a lot. And people often do not even fully understand what is happening to them, how the disease proceeds.
We believe that the doctor should give the patient all the information. With our patients, we are working through all the data on the diagnosis and possible treatment regimens together, literally building a new life for a person for the rest of the term - taking into account the disease. We strive to make the patient with the doctor an effective work team. And we see that this approach gives good results.
Therefore, we in “Medicine 24/7” want as many people as possible to know: even in the most severe cases, doctors are able to help and facilitate a person’s life, and possibly prolong it.
For example, a patient recently agreed to do molecular genetic testing. This helped to select a drug that is not related to its type of tumor in standard therapy protocols - but in this case it worked. Without such an appointment he would have remained 2 weeks, and he lived 4 months. Do not think that this is “not enough” - believe me, for a terminally ill person every day has tremendous significance and meaning.
It happens that people with cancer of stage IV get to us - they were given a conclusion in another medical institution and sent home to die. And we conduct a thorough examination and find out that the diagnosis was made incorrectly, in fact, the stage is only II, and there is a good treatment potential. Such cases are not uncommon.
It is important not to succumb to despair and fight to the last.
In the clinic, one might say, there are no random people - neither among the doctors, nor among the staff. Two thirds of the staff were faced with oncology - they treated relatives, some were treated themselves. Why is it important? A person with a cancer diagnosis is in many ways not like a person with any other disease. He has other reactions to what is happening, a different view of life, medicine, and his own perspectives. Communicating with him, too, must be very different. Those who have gone through this know how to do it right.
Unfortunately, modern effective palliative medicine is still very expensive. In Russia, it is available to those who are willing to spend hundreds of thousands and even millions of rubles to fight the disease to the last and die like human beings. Such a system can only be changed at the state level. This is beyond our power, so we do what we can.
And for this money we can do no less than the clinics of Israel or Germany - we have the same technologies, methods, medicines and excellent specialists. And at the same time, it is still 30-50% cheaper to treat with us than abroad. Ready to illustrate with examples from their daily practice.
Our conscience is calm and for the fact that we do not convince the patient to make a choice in our favor if he has the opportunity to receive a similar service, for example, by quota in the region or for less money from our colleagues.
But it is necessary to take into account that state medicine is “free” for a long time only with great reservations. The same MRI / CT for registration quotas in the budget cancer center will have to be paid, if not 2 months to wait for their free line. And onkopatsyent this time there is never.
Yes, our specialization is extremely difficult and ungrateful - but we see the need to talk about the fact that Russian medicine is not powerless, even in hopeless cases. And, although it sounds unexpectedly, we hear the words of gratitude all the time. From patients who received in our clinic an extra few months of life, and from their relatives.
Therefore, we want to conduct an educational program and clarify this terribly important question: is it necessary to die - is it painful?
How humanity lived to palliative care
For most of its history, Homo sapiens lived an average of 30 years, until it was overtaken by cave lions, enemy troops, or the plague. But over time, people learned to wash their hands before eating and taking birth, came up with the UN and WHO, started a schedule of vaccinations - and the average human lifespan doubled.
Medicine gives more and more reasons to count on longevity. 90 years ago we did not have antibiotics (Fleming discovered penicillin only in 1928). And now we are learning to treat fatal diseases with the help of genome editing.
Leila Richards, the first person from whom lymphoblastic leukemia (cancer of the hematopoietic system) was cured with donor T cells with an altered genome.
Until eternal life is still very far away, but over the past hundred years the list of causes of death has changed a lot.
The distribution of causes of death: in 1900 in the lead pneumonia, tuberculosis, gastrointestinal infections in 2010 - heart disease and cancer
People now do not die from sepsis (blood infection), or tuberculosis, and heart attacks, strokes, diabetes and cancer . Cancer causes every sixth death in the world. At the same time do not die from it instantly. In addition, civilization has given chances for life to people with chronic diseases, severe neurological diagnoses and AIDS. In this regard, medicine is faced with new problems.
There are 40 million people in the worldthat suffer from pain, motor limitations and other severe symptoms, and they cannot be cured. But to help such people is still possible. This is what palliative medicine does .
What is palliative medicine and who needs it
A palliative (from the French palliatif from the Latin pallium - a veil, a raincoat) is a non-radical solution, a half-measure applied when radical solutions are simply impossible.
Palliative medicine, respectively, is a special branch of medicine, an integral part of the concept of "palliative care." Her tasks do not include complete recovery, since it is impossible. Its goal is to improve the quality of life of patients with a fatal disease, using the achievements of modern science. Palliative medicine can prolong life, reduce pain and painful symptoms.
Palliative medicine works with the following diseases:
- Cardiovascular diseases (for example, patients with end-stage chronic heart failure) - 38.5%
- Oncological diseases - 34%
- Chronic respiratory diseases (for example, COPD - chronic obstructive pulmonary disease) - 10.3%
- AIDS - 5.7%
- Diabetes - 4.6%
In addition, people with renal and hepatic insufficiency, rheumatoid arthritis, dementia, and severe neurological diagnoses such as amyotrophic lateral sclerosis (who was ill with Stephen Hawking) or multiple sclerosis need palliative care.
However, most often the phrase "palliative medicine" is used nevertheless in the context of the treatment of cancer of stage III-IV.
The history of palliative care began in the 6th century, when in Europe they created the first shelters for pilgrims - “hospice”. Throughout the Middle Ages, hospices, almshouses, nursing homes were organized only by church forces. Doctors - treated those who could be saved. Dying medicine is not systematically engaged.
The engraving of the XIII century - the reception of travelers and care for the sick.
The problem is that even today many have not even heard of palliative medicine, or they don’t know that it exists in Russia in principle. And accordingly, the ideas about the process of dying and the last stages of life are still somewhat medieval.
But the institution of palliative medicine is not a synonym for hospice.
People usually enter a hospice in the last 3-6 months of life, and more do not leave it. The task of palliative medicine is just the opposite, to “untie” the patient from the hospital bed, make his life as active as possible until the moment of death, and even delay the end.
The task is not trivial - the symptoms of incurable diseases are usually severe, affecting several body systems at once. To combat them, they use both surgical and pharmacological treatment, psychology, transfusiology, modern medical equipment and experimental techniques. Yes, the whole arsenal of modern medicine is used where there is no hope for a cure. In order to give the terminally ill person the opportunity to complete the work and adequately end his life.
In other words, the older version of the understanding of palliative medicine, solely as a measure to alleviate death-suffering, is being replaced by the concept of extending active life, despite the presence of a fatal disease. At the same time, more and more time is devoted to work not only with the patient himself, but also with his relatives.
The scheme of integration of palliative medicine in the standards of late-life care.
How today prolong and make life easier for the terminally ill
Pain ranging from moderate to acute is experienced in the terminal stages of the disease in 67-80% of palliative patients.
Besides the fact that pain is obviously tormenting - it reduces the criticality of thinking, the patient falls into a depressive state and refuses a prospective treatment. Therefore, the relief (elimination) of the pain syndrome is the most frequent task in palliative medicine.
In our practice, we use the so-called “pain relief ladder” of WHO: a treatment regimen that allows us to gradually move from non-narcotic analgesics to weak and strong opiates. Our doctors are able to work with multimodal anesthesia schemes, so as not to switch to narcotic painkillers ahead of time.
Due to this, pharmacological anesthesia gives a satisfactory result in 90% of our practice cases. In addition, we have some ways to help even those patients who got into the unhappy 10% - more on this below.
However, it is wrong to reduce palliative care only to anesthesia, or to assume that completely incurable (incurable) patients do not need treatment. The treatment options are varied and can significantly improve the quality of life of the patient and increase its duration.
We have gathered about a dozen modern technologies in our clinic to work with it.
Molecular genetic testing
Scope of application: Oncology.
The genetic material of a tumor of a specific patient is investigated using high-throughput sequencing methods (DNA structure determination technique). This gives important information.
First, potentially effective drugs are determined. It happens that treatment according to standard protocols stopped working and the disease began to progress again. In such cases, the results of genetic testing often indicate a drug that is not included in the “gold standard” of treatment for this type of cancer, but may help.
In addition, according to the test results, conclusions can be drawn about the potential resistance of a particular tumor to therapy, to predict relapse and concomitant diseases.
Chemoembolization of tumors.
Scope of application: oncology.
This is a method of local chemotherapy, carried out by endovascular surgery. The operation is carried out through a small puncture in the patient's skin: instruments-catheters, special thin tubes are led to the vessels, and they are led through vessels to the target site. The surgeon monitors the process with x-ray equipment. Spherical microparticles of the drug act in two ways:
- Like emboli (in fact, traffic jams) - overlap the vessels that feed the malignant neoplasm. The blood flow in the tumor tissues stops.
- At the same time, a chemotherapeutic drug cytostatic (killing cancer cells) accumulated by microspheres is released directly into the tumor tissue, which makes its effect more targeted and reduces the toxic effect of chemotherapy on surrounding healthy tissues.
Palliative chemotherapy is aimed at reducing the tumor mass or inhibiting the growth of a tumor.
Radiofrequency ablation of metastases controlled by CT (RFA).
Scope of application: oncology.
In cancer, there are cases when pain is not relieved by even strong opiates. But so sick physicians often have the power to help.
RFA is a minimally invasive (non-traumatic) operation that destroys the tumor by high temperature. Relieves a person from intractable pain syndrome and pathological bone fragility caused by metastases. This operation is also done without incisions, through a puncture, and they “aim” and control the process through a multispiral computed tomography apparatus (MSCT).
The RFA method itself is also used in the treatment of arrhythmias or, for example, varicose veins, but it is used, unfortunately, not so often to make life easier for palliative cancer patients. Read more - in the video.
After getting rid of pain with the help of RFA, patients feel better not only physically, but also psychologically - they start looking at further treatment with optimism.
Implantation of venous infusion port systems.
Scope of application: oncology, AIDS treatment, systemic antibiotic therapy, etc.
Systemic chemotherapy in the treatment of oncological diseases involves the administration of a drug or a combination of drugs with a certain frequency for a long time (6-12 months). Chemotherapeutic drugs damage not only tumor cells, but also healthy tissues, including veins. In order to eliminate complications (phlebitis - inflammation of the veins) from regular injections, put infusion port systems designed for the introduction of drugs into the body.
In addition to chemotherapy, antibiotics and other drugs can be injected through the port, take venous blood for analysis, transfuse blood components, and administer parenteral nutrition (that is, nutrition not through the mouth, but by intravenous mixture). In this capacity, they make life easier for patients with HIV or chronic lung diseases and gastrointestinal tract.
The port is placed under the skin in the upper third of the chest, and a catheter is inserted into the jugular vein. Service life - up to a year.
Diagram of the installation of an infusion port system.
Installation of stents (extenders).
Scope of application: oncology, cardiology.
Requiredwhen vessels, ducts, intestines or esophagus are narrowed due to atherosclerosis or tumor / metastasis. The ability to eat normally, go to the toilet and lead a normal life is returned to patients, the risk of heart attack and stroke decreases (during stenting of blood vessels).
Use of equipment for transfusiology.
Scope of application: oncology, chronic renal and hepatic failure, treatment of any diseases associated with the use of highly toxic pharmaceuticals.
Transfusiology is a branch of medicine that studies the problems of mixing (transfusion) and the interaction of biological fluids and their substitutes. As part of palliative care, she is engaged in the removal of toxic products of tumor breakdown or pharmaceutical preparations. In particular, conduct:
- Continuous and cascade plasmapheresis - filtration and purification of blood plasma from a toxic agent.
- Hemodialysis - when the kidneys of the patient do not cope with the work, the “artificial kidney” is connected.
- Mars therapy. If necessary, the patient will be connected to the MARS (Molecular Adsorbent Recirculating System) apparatus, which will temporarily replace the human liver.
In addition, symptomatic therapy within the framework of palliative care can treat such complications of incurable diseases such as dyspepsia (gastrointestinal dyspepsia), polyserositis (simultaneous inflammation of the membranes of internal cavities, for example, pleura and peritoneum), ascites (accumulation of free fluid in the abdominal cavity), intoxication , nausea and vomiting. A multi-component restorative treatment is carried out to support the functioning of vital organs.
So, patients with a fatal diagnosis, if they have access to high-quality palliative medicine, thanks to her, feel better, they return to the possibility of active life, communication with family and friends, limited work capacity.
Unfortunately, this area of medicine in Russia began to develop quite recently and is not yet very well organized. Looking at the situation from the inside, we believe that to some extent this is due to the special “scrupulousness” of the topic, to the fact that they do not speak about it.
But there are more problems with the fact that Russian doctors are still not always taken to thoroughly introduce the patient in the course of business, to communicate with him a lot. And people often do not even fully understand what is happening to them, how the disease proceeds.
We believe that the doctor should give the patient all the information. With our patients, we are working through all the data on the diagnosis and possible treatment regimens together, literally building a new life for a person for the rest of the term - taking into account the disease. We strive to make the patient with the doctor an effective work team. And we see that this approach gives good results.
Therefore, we in “Medicine 24/7” want as many people as possible to know: even in the most severe cases, doctors are able to help and facilitate a person’s life, and possibly prolong it.
For example, a patient recently agreed to do molecular genetic testing. This helped to select a drug that is not related to its type of tumor in standard therapy protocols - but in this case it worked. Without such an appointment he would have remained 2 weeks, and he lived 4 months. Do not think that this is “not enough” - believe me, for a terminally ill person every day has tremendous significance and meaning.
It happens that people with cancer of stage IV get to us - they were given a conclusion in another medical institution and sent home to die. And we conduct a thorough examination and find out that the diagnosis was made incorrectly, in fact, the stage is only II, and there is a good treatment potential. Such cases are not uncommon.
It is important not to succumb to despair and fight to the last.