Retired British physician Robert Twycross’s contribution to palliative care and its recognition as an accepted field of modern medicine have been tremendous. As head of the World Health Organisation Collaborating Centre for Palliative Care and Clinical Reader in Palliative Medicine at Oxford University, he has envisioned palliative care as a solace that extends beyond end-stage cancer patients to those with other serious ailments.
He first began visiting Kerala nearly 25 years ago, and in the mid to late 90s, would even come twice a year to help with courses in palliative care. R.K. Roshni caught up with him post a meeting to felicitate him. Edited excerpts from an interview:
On palliative care in the State
Palliative care reached Kerala by the early to mid 90s, and has spread dramatically since then. The State has led the way in palliative care not only because of those who learn about it and work in it but also because they are powerful advocates of the system.
What are the challenges for palliative care in India where even access to basic health care is limited?
Palliative care poses an enormous challenge in India. It came here as care of people with advanced incurable cancer.
In terms of number of people with advanced incurable cancer, there are probably 10 lakh to 15 lakh patients who die each year and who need access to palliative care, but maybe only 2 or 3 per cent of them get it. If palliative care is expanded beyond end-stage cancer to those with advanced incurable heart or kidney disease or neurological conditions, the potential number of patients who benefit doubles. In Kerala, because of the visionary approach of advocates of palliative care, it is being extended to groups such as paraplegics who after discharge would normally go home and languish there with bed sores and infections and ultimately die. Paraplegics, from what I have heard, are prominent among the non-cancer group being looked after by palliative care services.
Do you see any role for hospices in India?
Many palliative care services find they need inpatient beds to back up their outpatient departments and home care.
Expensive palatial hospices are not needed, but some inpatient beds are necessary to manage those with difficult conditions. With dedicated, enthusiastic and talented volunteers that such services attract, home care could go on for much longer for most patients.
What is the future of palliative care?
Palliative care is a form of intensive care without machinery — high-touch, low-tech. One has to get in and turn the situation around in a short time.
It is part of the vision of the Central government here, but the actual implementation depends on States. So far, only three States have published a policy on palliative care — Kerala, Maharashtra, and now Karnataka.
Each State should form a task force, and prepare its palliative care policy, and roll out programmes for the policy to become a reality. But a lot has happened that gives encouragement.
Your thoughts on the euthanasia debate in the country
The term passive euthanasia that is being tossed around is confusing and should be abandoned.
We should avoid using euthanasia in relation to withholding or withdrawing treatment in situations where it no longer makes biological sense to intervene in a resuscitative way.
One is allowing someone to die when continued medical intervention is essentially futile, that is allowing natural death.
Euthanasia is when a doctor deliberately injects a lethal dose of poisonous drugs to end life.
In relation to withdrawing life support measures such as ventilation, decision should be made on a cases-to-cases basis and by doctors in a particular institution, and seeking advice from a court should be a rare necessity.
