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The Role of Yoga in Palliative Care: Insights From a Single Case Study
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Background
This paper aimed to explore the palliative care (PC) needs and barriers to access among cancer patients in a rural region of North India with a high cancer burden.
Methods
A Participatory action research (PAR) approach was employed. Situational assessment, community sensitization workshops (CSWs) and door-to-door surveys were planned, conducted and developed over three PAR cycles. A parallel convergent mixed-methods approach was adopted wherein the quantitative data from door-to-door surveys and qualitative data from CSWs and investigator field notes were collected and analyzed to provide a comprehensive understanding of PC needs and barriers to access. Descriptive statistics and thematic analysis were used.
Results
A total of 27 CSWs involving 526 stakeholders were conducted. A total of 256 cancer patients were assessed for PC needs and symptom burden using the Supportive and Palliative Care Indicators (SPICT-4ALL) and the Edmonton Symptom Assessment System (ESAS) tool, respectively. Based on the SPICT assessment, all patients (n = 256) satisfied general and/or cancer-specific indicators for PC. The majority (56.6%) had ≥ one moderate-severe symptom, with the most common symptoms being tiredness, pain and loss of appetite. Analysis of qualitative findings generated three themes: unmet needs, burden of caregiving, and barriers and challenges. Cancer affected all domains of patients’ and their families’ lives, contributing to biopsychosocial suffering. Social stigma, discrimination, sympathizing attitudes and lack of emotional and material support contributed to psychosocial suffering among cancer patients and their caregivers. Lack of awareness, nearby healthcare facilities, transportation, essential medicines, trained manpower and education in PC, collusion, fear of social discrimination, faulty perceptions and misconceptions about cancer made access to PC difficult.
Conclusions
The study emphasize the need for and provide a roadmap for developing context-specific and culturally appropriate CBPC services to address the identified challenges and needs. The findings point towards education of CHWs in PC; improving community awareness about cancer, PC, government support schemes; ensuring an uninterrupted supply of essential medicines; and developing active linkages within the community and with NGOs to address the financial, transportation, educational, vocational and other social needs as some of the strategies to ensure holistic CBPC services.
Trial registration
Clinical Trial Registry of India (CTRI/2023/04/051357).
The therapeutic efficacy of yoga in cancer care has increasingly attracted attention due to the imperative to address the physical and psychosocial obstacles encountered by cancer patients. Despite previous research presenting conflicting findings on the effectiveness of yoga, there is a need for a comprehensive review to consolidate existing evidence and identify commonalities across studies. An umbrella review was undertaken to aggregate and analyse findings from multiple systematic reviews and meta-analyses on the role of yoga in cancer care. Relevant literature was identified through searches on the Web of Science, Cochrane Library, PubMed, and Scopus databases, using a combination of MeSH (Medical Subject Headings) terms and free-text terms with Boolean operators. The quality of the included reviews was evaluated using the AMSTAR-2 tool to ensure the reliability and validity of the discussed findings.
The outcomes revealed a predominance of favourable results associated with yoga interventions, particularly in enhancing psychosocial well-being and the quality of life among cancer patients. Consistent reports indicated significant reductions in symptoms such as anxiety, depression, and stress, as well as enhancements in physical outcomes such as fatigue and sleep quality. However, variations in the efficacy of yoga were observed and were dependent on the type of intervention, patient adherence, and comparative analyses with other forms of exercise. While the benefits were substantial in the short term, they did not uniformly surpass those of other therapeutic exercises in the medium term.
Despite yoga demonstrating significant immediate benefits in managing both the physical and psychological symptoms associated with cancer, the variability in its long-term and comparative effectiveness suggests the necessity for personalised approaches. The findings emphasise the importance of considering individual patient needs and treatment contexts when integrating yoga into cancer care protocols. Future research should focus on identifying the optimal conditions under which yoga is most beneficial to tailor interventions for enhanced therapeutic efficacy.
This editorial explores the integration of yoga into end-of-life care, emphasizing its potential to enhance the quality of life, comfort, and dignity of patients. Rooted in over 5,000 years of history, yoga’s holistic approach, encompassing physical, mental, and spiritual practices, aligns seamlessly with the goals of end-of-life care. We discuss the benefits of incorporating yoga’s diverse practices, such as physical postures, breathing exercises, and meditation, particularly in palliative care settings. These practices offer significant improvements in physical health, psychological well-being, and spiritual fulfillment, especially pertinent for older adults and patients with serious illnesses like HIV and cancer. The philosophical underpinnings of yoga, emphasizing acceptance, harmony, and peace, provide a framework for a dignified and peaceful transition, resonating deeply with the concept of a ‘good death’.
However, challenges exist in integrating yoga into end-of-life care, including limited research, cultural and religious considerations, physical and emotional limitations of patients, and logistical constraints within healthcare settings. Ethical considerations are also paramount, focusing on patient-centered approaches, respect for individual beliefs, informed consent, and patient autonomy.
The editorial concludes by underscoring the need for further research to evaluate the long-term effects of yoga in end-of-life care and to establish comprehensive ethical guidelines. The integration of yoga offers a multifaceted approach to address not only physical discomfort but also provide emotional and spiritual solace for terminally ill patients, thereby enhancing the overall quality of end-of-life care.
Background
To achieve sustainable development goal 3.8, countries must prioritise the provision of palliative care. We aimed to estimate the prevalence of palliative care needs in India.
Methods
A systematic literature search was conducted in databases of PubMed, Cochrane, Embase, Web of Science, and EBSCO Host. We included community-based studies published in English between inception and April 30, 2023. We excluded hospital-based studies that were conducted solely including diseased patients. Data were extracted independently, and a quality assessment was performed. To estimate the pooled prevalence and 95% confidence intervals (CI), we used the random-effects model. Heterogeneity was assessed using the Q statistic and I ² test. Subgroup analyses were conducted based on the study site, urban–rural distribution, gender, and age groups. Publication bias was evaluated using a funnel plot and Egger test. STATA software was used for data analysis.
Results
Out of the 2632 articles identified, 8 cross-sectional studies were included. Using the random-effects model, the pooled estimate of palliative care needs was found to be 6.21/1000 population (95% CI: 2.42–11.64). The southern region showed a prevalence of 10.83/1000 compared to 2.24/1000 in the northern region. Urban areas had a prevalence of 3.34/1000, while rural areas had a prevalence of 7.69/1000. Among females, the prevalence was 9.64/1000, compared to 6.77/1000 among males. Notably, individuals aged over 60 years had a higher prevalence of palliative care needs, with a rate of 37.86/1000 population.
Conclusion
This systematic review and meta-analysis highlight a substantial need for palliative care in India, with a prevalence of 6.21 individuals/1000 population.
Background:
Palliative care is comprehensive care that provides symptomatic relief and enhances the quality of life for people experiencing serious health-related suffering. There is an increasing need for palliative care services in India. Estimates for population requiring these services are essential in order to meet the increasing need for palliative care services.
Objectives:
The objective was to assess the proportion of population requiring and receiving palliative care services.
Materials and methods:
A descriptive cross-sectional research design was adopted for the study. The study was carried out in the village, Dhanas, Chandigarh. All the residents residing in the selected rural area were included in the study. Tools used for data collection were a screening questionnaire consisting of three questions, a sociodemographic sheet, a clinical profile, the Barthel Index of activities of daily living (ADL), and a pain rating scale. Analysis of the data was done using SPSS version 19 (IBM SPSS Statistics for Windows, Version 19.0.: IBM Corp).
Results:
A total of 10,021 people from 884 households were screened in the study. The results revealed that the prevalence of need for palliative care services was 2/1000 population. None of the 19 participants with unmet palliative care needs were receiving any home- or institutional-based palliative care services at the time of assessment. Nearly, one-fourth of the participants had total dependency on caregivers for ADL.
Conclusion:
The study concluded that there is a need of palliative care services in the studied rural community of Chandigarh. These data can be used for planning and implementing community-based palliative care services in the studied area.
Background
Terminal illness not only causes physical suffering but also spiritual distress. Spiritual care has been widely implemented by healthcare professionals to assist patients coping with spiritual distress. However, the effects of spiritual care need to be clear.
Aim
To evaluate the effects of spiritual care on quality of life and spiritual well-being among patients with terminal illness.
Design
Systematic review according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance.
Data sources
A comprehensive search was conducted in nine electronic databases from date of inception to May 2017. Hand searches of the bibliographies of relevant articles were also performed. The studies were independently reviewed by two investigators who scored them for methodological quality using the Cochrane Risk of Bias Tool.
Results
No statistical pooling of outcomes was performed and a narrative summary was chosen to describe the included studies. A total of 19 studies with 1548 participants were identified in the systematic review, corresponding to seven kinds of interventions. The risk of bias for these studies were all rated as moderate. A majority of studies indicated that spiritual care had a potential beneficial effect on quality of life and spiritual well-being among patients with terminal illness.
Conclusion
It is suggested that healthcare professionals integrate spiritual care with usual care in palliative care. When providing spiritual care, healthcare professionals should take into consideration patients’ spiritual needs, preference, and cultural background. More multicenter and disciplinary studies with rigorous designs are needed in the future.
In near future, the elderly population will increase to a high proportion. This will increase the burden of Age-Related Diseases (ARDs) to a significant level. Most of the ARDs need palliative care (PC) for a fairly long duration. Some statistical extrapolations are discussed to help in identifying this future burden. The existing PC centers are limited in numbers, situated mainly in urban areas, and mostly attached to cancer hospitals. Socioeconomic vulnerabilities of the elderly, especially in rural areas, are high, and access to health is also not optimal. In the coming decades, the number of needy people, as well as the demand for PC, will increase. Existing numbers indicate that exponential increment in quantum and quality of PC services is required to deal with the imminent burden. Specific suggestions are made to use existing public health programs to cater to the rural elderly.
The Open Society Foundation's International Palliative Care Initiative (IPCI) began to support palliative care development in Central and Eastern Europe and the Former Soviet Union in 1999. Twenty-five country representatives were invited to discuss the need for palliative care in their countries and to identify key areas that should be addressed to improve the care of adults and children with life-limiting illnesses. As a public health concern, progress in palliative care requires integration into health policy, education and training of health care professionals, availability of essential pain relieving medications, and health care services. IPCI created the Palliative Care Roadmap to serve as a model for government and/or nongovernment organizations to use to frame the necessary elements and steps for palliative care integration. The roadmap includes the creation of multiple Ministry of Health-approved working groups to address: palliative care inclusion in national health policy, legislation, and finance; availability of essential palliative care medications, especially oral opioids; education and training of health care professionals; and the implementation of palliative care services at home or in inpatient settings for adults and children. Each working group is tasked with developing a pathway with multiple signposts as indicators of progress made. The roadmap may be entered at different signposts depending upon the state of palliative care development in the country. The progress of the working groups often takes place simultaneously but at variable rates. Based on our experience, the IPCI Roadmap is one possible framework for palliative care development in resource constrained countries but requires both health care professional engagement and political will for progress to be made.
Background
The diagnosis and treatment of cancer poses severe psychologic distress that impacts functional quality of life. While cancer directed treatments are directed purely against tumor killing, interventions that reduce treatment related distress and improve quality of life are the need of the hour. Yoga is one such mind body intervention that is gaining popularity among cancer patients.
Method
Several research studies in the last two decades unravel the benefits of yoga in terms of improved mood states, symptom reduction, stress reduction and improved quality of life apart from improving host factors that are known to affect survival in cancer patients. However, several metaanalysis and reviews show equivocal benefits for yoga. In this review, we will study the Yoga interventions in cancer patients with respect to expectations, benefits and risks and analyse the principles behind tailoring yoga interventions in cancer patients.
Results
The studies on Yoga show heterogeneity with varied types of Yoga Interventions, duration, exposure, practices and indications. It also elucidates the situational context for reaping benefits and cautions against its use in several others. However, there are several reviews and bibliometric analysis of effects of yoga; most of them have not enlarged the scope of their review to cover the basic principles behind use of these practices in cancer patients.
Conclusion
This review offers insight into the principles and practice of yoga in cancer patients.
Up to 90% of cancer patients report symptoms of insomnia during and after treatment. Symptoms of insomnia include excessive daytime sleepiness, difficulty falling asleep, difficulty staying asleep, and waking up too early. Insomnia symptoms are among the most prevalent, distressing and persistent cancer- and cancer treatment-related toxicities reported by patients, and can be severe enough to increase cancer morbidity and mortality. Despite the ubiquity of insomnia symptoms, they are under-screened, under-diagnosed, and under-treated in cancer patients. When insomnia symptoms are identified, providers are hesitant to prescribe, and patients are hesitant to take pharmaceuticals due to polypharmacy concerns. In addition, sleep medications do not cure insomnia. Yoga is a well-tolerated mode of exercise with promising evidence for its efficacy in improving insomnia symptoms among cancer patients. This article reviews existing clinical research on the effectiveness of yoga for treating insomnia among cancer patients. The article also provides clinical recommendations for prescribing yoga for the treatment of insomnia in this population.
There are many and varied types of trauma. The extent to which trauma influences the mental health of an individual depends on the nature of trauma, as well as on the individual's coping capabilities. Often trauma is followed by depression, anxiety, and PTSD. As the pharmacological remedies for these conditions often have undesirable side-effects, nonpharmacological remedies are thought of as a possible add-on treatment. Yoga is one such mind-body intervention. This paper covers eleven studies indexed in PubMed, in which mental health disorders resulting from trauma were managed through yoga including meditation. The aim was to evaluate the use of yoga in managing trauma-related depression, anxiety, PTSD and physiological stress following exposure to natural calamities, war, interpersonal violence, and incarceration in a correctional facility. An attempt has also been made to explore possible mechanisms underlying benefits seen. As most of these studies were not done on persons exposed to trauma that had practiced yoga, this is a definite area for further research.
Background
Yoga can be considered supportive therapy for patients with cancer to alleviate cancer-related symptoms. However, there has been no meta-analysis examining yoga’s effects among patients with cancer undergoing chemotherapy and/or radiotherapy.
Objective
To synthesize the evidence regarding the effects of yoga on improving cancer-related fatigue, psychological distress, and quality of life among patients with cancer undergoing chemotherapy and/or radiotherapy.
Methods
Ten English databases and 2 Chinese databases were searched from inception to December 2022. Two independent reviewers screened studies and extracted the data. Randomized controlled trials examining the effects of yoga on cancer-related fatigue, psychological distress, and quality of life were included. Meta-analysis was conducted, and narrative synthesis was performed when meta-analysis was not applicable.
Results
Fourteen studies from 16 articles were included. The results showed that yoga reduced cancer-related fatigue (standardized mean difference [SMD], −0.75; 95% confidence interval [CI], −1.12 to −0.38; P < .001), anxiety (SMD, −0.91; 95% CI, −1.68 to −0.14; P = .02), but not depression (SMD, −0.82; 95% CI, −1.67 to 0.04; P = .06). The effects of yoga on distress and quality of life were inconclusive.
Conclusions
Yoga significantly helped reduce cancer-related fatigue and anxiety but did not reduce depression among patients with cancer undergoing chemotherapy and/or radiotherapy. Further rigorous studies are needed to identify the optimal characteristics of yoga for these patients.
Implications for Practice
It is possible to recommend yoga to patients with cancer undergoing chemotherapy and/or radiotherapy for managing cancer-related fatigue and anxiety after duly considering patients’ physical conditions and ensuring appropriate instructions are given.
Background
Complications of breast cancer treatment can cause physical and psychosocial distress in patients. Yoga demonstrates substantial potential as a supportive therapy for patients with breast cancer. Our aim is to conduct a meta-analysis of randomized controlled trials to evaluate the effectiveness of yoga in enhancing the quality of life (QoL) of patients with breast cancer.Methods
We searched for studies published before March 2020 in the PubMed, Embase, and Cochrane Library databases. Individual effect sizes were standardized, and the pooled effect size was calculated using a random effect model. Measured outcomes included QoL, anxiety and depression, stress, fatigue, pain severity, and sleep quality.ResultsIn total, 26 trials involving 2069 patients were reviewed. Significant enhancement in QoL was observed immediately after the yoga intervention. The pooled mean differences in social (weighted mean difference [WMD]: 1.36, 95% confidence interval [CI] 0.12–2.61), emotional (WMD: 1.46, 95% CI 0.26–2.66), and functional well-being (WMD: 2.04, 95% CI 0.21–3.87) were significantly higher in the yoga group than in the control group. Patients practicing yoga exhibited significant improvements in physical well-being, mental well-being, and sleep quality as well as reductions in anxiety, depression, stress, fatigue, and pain severity after the intervention.Conclusions
Yoga may enhance QoL in patients with breast cancer experiencing post-treatment complications. Therefore, we recommend yoga as a supportive therapy for patients with breast cancer to relieve post-treatment distress.
The FACT-L (version 3) is a 44-item self-report instrument which measures multidimensional quality of life. Available in eight languages, it is currently being used in several Phase II and III lung cancer clinical trials. Reliability and validity of the 33-item version 2 of the FACT-General (FACT-G) have previously been published. This paper reports further validation data on the FACT-G with a subsample of lung cancer patients from the original publication and, more importantly, presents data on the Lung Cancer Subscale (LCS). The nine LCS questions were administered along with the FACT-G to 116 patients with lung cancer. Internal consistency (coefficient alpha) was improved from 0.53 to 0.68 by dropping two questions which were uncorrelated with the others. A subset of 41 patients was tested again at 2 months to evaluate sensitivity to change in performance status rating (PSR) and to obtain estimates of a clinically meaningful change score for the FACT-G and the 7-item LCS. Using a linear test for trend, sensitivity to change in performance status rating (PSR) was obtained with the Total score (P = 0.03), the Physical Well Being (PWB) subscale (P = 0.02), the Functional Well Being (FWB) subscale (P = 0.05), and the LCS (P = 0.03). A 21-item Trial Outcome Index (TOI), combining scores on PWB, FWB and LCS, was highly reliable (coefficient a = 0.89) and sensitive to change in PSR F(1,38) = 4.84 (P = 0.01). This TOI is probably the most relevant and precise indicator of patient-reported quality of life available for lung cancer patients who complete the FACT-L while participating in an oncology clinical trial. The FACT-L may also be of benefit in evaluating quality of life in patients with lung diseases other than cancer.
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