Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 4607

AbstractConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Reviews
Year : 2022 | Month : April | Volume : 16 | Issue : 4 | Page : ZE20 - ZE24 Full Version

End of Life Care in Terminal Head and Neck Cancer- An Amalgamated Approach


Published: April 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/52188.16155
Karthikeya Patil, Nagabhushana Doggalli, VG Mahima, CJ Sanjay, Romali Panda

1. Professor and Head, Department of Oral Medicine and Radiology, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India. 2. Reader, Department of Oral Medicine and Radiology, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India. 3. Professor, Department of Oral Medicine and Radiology, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India. 4. Reader, Department of Oral Medicine and Radiology, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India. 5. Postgraduate Student, Department of Oral Medicine and Radiology, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India.

Correspondence Address :
Dr. Nagabhushana Doggalli,
Reader, Department of Oral Medicine and Radiology, JSS Dental College and
Hospital, JSS Academy of Higher Education and Research, Bannimantap,
Mysuru, Karnataka, India.
E-mail: dr.nagabhushand@jssuni.edu.in

Abstract

Oral cancer is among the leading causes of cancer morbidity and mortality worldwide, and palliative care is a critical requirement for cancer patients. It is a multidisciplinary strategy that involves professionals from a variety of medical specialties. Yet, a stomatologist’s presence in the palliative care group is unavoidable. Although oral care is considered one of the most fundamental nursing practices, it might be affected in cancer patients due to the disease or various treatment regimens. The present review focuses on combined approach, starting with breaking down news to the family and progressing to palliative care measures for head and neck cancer patients. This includes pain management, aftereffects of chemoradiation therapy, outcome of cytoreduction, management of external fungating lesion, postradiotherapy dysgeusia management, postmalignancy therapy trismus management and xerostomia management. Furthermore, this also includes special interest topics like results of altered anatomy, cancer cachexia and Euthanasia legalisation in Indian scenario. Prioritising cure along with prolonging survival of the patient with minimal suffering is the basic goal of palliative care. As a result, a respectable death is one that is painless, serene, and honourable, occurring in the presence of loved ones and without the need for unnecessary brave interventions.

Keywords

Euthanasia, Head and neck neoplasms, Quality of life, Survival, Terminal care

“Life is pleasant; death is serene; it is only the transition that is difficult”.

India has the highest number of oral cancer cases, accounting for one-third of the global burden. Oral cancer is a severe health threat in countries going through economic change (1). Every year, over 77,000 new cases and 52,000 fatalities are recorded in India, accounting for almost one-fourth of global incidents (2). Oral cancer is a far bigger issue in India than it is in the west, with over 70% of cases being reported in the late stages (American Joint Committee on Cancer, Stage III-IV). Because to the late identification, the odds of cure are extremely slim or nearly non existent, with five-year survival rates hovering around 20% (3).

As per the World Health Organisation (WHO), palliative consideration is “a methodology that is planned for improving the individual Quality of Life (QoL) of patients and their families confronting the issues related with life threatening sickness, through the avoidance and alleviation of endurance by methods for early identification and faultless evaluation and treatment of agony and different issues, physically, psychosocially and spiritually” (4) Numerous cancer patients are said to die in an inhumane manner as a result of poorly treated symptoms (5). A decent death is one that is painless, serene, and dignified, occurring in a location of one’s choice, with family present, and without heroic measures that serve no purpose (6). Prior research on treatment quality has indicated that the primary concern for patients and their families is effective pain and symptom management, followed by maintaining the patient’s dignity and hygiene (7). Fried T et al., in his research, elucidates valuable information regarding a patient’s dying hours (8). Pain was a prevalent complaint (84%) that was well controlled in all of the patients, with 93 percent getting opioids. Other symptoms were well-managed, with the exception of neuropsychologic issues. Only 22% of patients had a family present when they died, while 63% of patients died in the hospital. Although none of the patients were admitted to the Intensive Care Unit (ICU) or required resuscitation, only 65% of the patients mentioned it. In the last month of life, 53% of patients were hospitalised as an emergency, and the most prevalent reason for admission was haemorrhage (8). Aird DW et al., considered one-fifty patients with head and neck cancer and pronounced eight major complaints in those patients which compromised with the QoL were pain (50%), dysphagia (38%), airway obstruction (28%), fungating wound (14%), nausea and vomiting (12%), mucosal dryness (10%), conductive deafness (<5%) and bleeding (<1%) (9). Additionally, other research indicates an excessive prevalence of pain, weight loss, feeding problems, difficulty in breathing signs and symptoms and speech problems (10),(11). Oral cancer is reported to be the most common cancer in India, accounting for 32-40% of all cancer cases. The production and consumption of tobacco on a vast scale by the Indians is the primary underlying cause (12). End of life care is a critical requirement for cancer patients all around the world. However, in underdeveloped countries like India, where patients are detected in advanced stages and have limited access to preventive measures and treatment services, it plays a significant role (13).

END OF LIFE CARE

Conversing with the Family

When faced with cancer that may be terminal, honest, open and legitimate communication is critical. A cancer nurse, an oncologist and a general physician are required at the very least in a successful head and neck cancer approach (14). Poor performance status, age greater than 70 years (for chemotherapy), history of past treatment (prior doses of radiation and chemotherapy), extent of cancer and predicted survival are some of the considerations for refusal of treatment for advanced cancer (15). This staffing offers many degrees of social care, medical assistance, and counselling for the numerous tests and visits that a patient may face. Patient and family satisfaction with the treatment they receive is improved considerably by such a service (14). The patient’s general wellbeing status is significant.

Measures of Palliative Care

Pain management: Cancer patients may experience excruciating pain as a result of the disease or as a side-effect of therapy. The goal of palliative treatment for such individuals should be to alleviate this discomfort on both levels (15). The severity and features of the pain, the patient’s emotional response, and the impact of pain on the patient’s capacity to function should all be evaluated by the physician.

In general, pain management in palliative care consists of a basic pain-relieving strategy and the potential options for future therapy. The administration of nociceptive pain medications (anticonvulsive and antidepressants-gabapentin, carbamazepine, phenytoin, amitriptyline and Nortriptyline) and therapy with adjuvants are the most important pain-relieving measures, according to World Health Organisation (WHO) (corticosteroids, tranquilisers, antiemetic, alfa-2 agonists, local anaesthetics, N-methyl-D-Aspartate (NMDA) receptor antagonists and so on) can be used as a “step-by-step” approach (16),(17),(18).

Generally, the pain reduces on pharmacological treatment with analgesics and adjuvants taken orally. The effective use of oral opioids for moderate to severe pain is the most significant aspect of the WHO approach and the rationale for its success. Morphine is the standard ‘step 3’ opioid, and there are recommendations for its usage in cancer pain treatment since 1996. {Expert Working Group of the European Association of Palliative Care (EAPC), 1996}. Morphine appears to have no clinically significant analgesia ceiling effect: dosages of oral morphine can be varied 1000-fold or more to attain the same pain relief threshold (19).

Aftermath of Chemoradiation Therapy

The decision to pursue curative chemoradiation vs palliative treatment is frequently challenging, and it necessitates honest dialogue with the patient and family. When palliative care is chosen, the objective must be to give maximal alleviation while minimising treatment adverse effects and recognising that cure is not the goal (14). When induction treatment was utilised before combination chemoradiotherapy rather than induction chemotherapy and radiation, Yogi V and Singh OP found that patients had better survival and symptom alleviation (20). Graf R et al., wanted to see if treating inoperable head and neck tumours with concurrent radiation and chemotherapy would be better than the standard way of sequential treatment with induction chemotherapy followed by radiation (21). Two sessions of neoadjuvant chemotherapy, cisplatin and 5-fluorouracil, were followed by a course of radiation utilising standard fractionation up to 70 Gy in a sequential procedure. The concurrent treatment included two sessions of 5-fluorouracil with mitomycin, as well as a normal fractionated Radiotherapy (RT)course of up to 30 Gy, followed by a hyper fractionated course of up to 72 Gy. After five years, the group that had concurrent radiation and chemotherapy followed by radiation had significantly greater response rates and local control, as well as a tendency toward higher disease-specific and overall survival rates. In both groups, late toxicity of RT was found to be close such as dysgeusia, postradiotherapy trismus, Osteoradionecrosis (ORN)and xerostomia (21).

Outcome of cytoreduction: Cytoreduction or tumour debulking is a cancer treatment approach that aims to reduce the number of cancer cells by removing the primary tumour or metastatic deposits to minimise the potential immunosuppressive tumour burden, relieve symptoms, and prevent complications (22). Airway obstruction, dysphagia, discomfort, and death are among serious consequences of terminal head and neck malignancy. The purpose of palliative surgery, according to Forbes (23), is to improve a patient’s QoL by lowering symptoms while avoiding surgical consequences. He emphasised various points on the importance of surgery in palliation, as well as the principles of preoperative care, advanced cancer surgery, and postoperative care (Table/Fig 1) (23).

Laccourreye O et al., employed the CO2 laser to debulk endolaryngeal tumours in a 10-year study of 42 patients (24). They had a 95 percent success rate in patients who were awaiting final therapy for their condition and an 87.5 percent success rate in patients who were receiving palliative care. Recently, Phelan E et al., reported effective debulking and reestablishment of airways in patients with obstructive laryngeal malignancies using microdebriders (25).

Management of External Fungating Lesion

There is an increased risk of clinically significant oral fungal infection during cancer therapy. Because of the persistent and debilitating nature of a fungating sore, patients usually suffer excruciating emotional and physical agony. Patients may see morphological changes in their bodies, which might affect their confidence and willingness to collaborate in social situations. They also have a foul odour that interferes with their communication. Foundational anti-toxins, topical metronidazole, and charcoal dressings are three tools suggested by Grocott P to aid with fetid odour (26). Wound management is frequently a perplexing process. Cleaning and dressing with antiseptics are only required for injuries that produce excessive exudates, purulence, or serous liquids (27).

Postradiotherapy Dysgeusia Management

For individuals with malignant development of the head and neck, RT is an important therapeutic option. It is usually presented as a last therapy or as an adjuvant treatment following a medical procedure (28). Many patients are treated with significant doses of RT applied to large areas of the body, including the dentition, oral mucosa, salivary organs, maxilla, and mandible. Oral manifestations, such as dental caries, xerostomia, oral mucositis, taste adjustment, and candidiasis, are common during and after treatment due to the immediate or atypical effects of ionising radiation.

Despite the fact that critical tumours in the head and neck region do not often affect taste directly, the majority of Head and Neck Cancer (HNC) patients report changes in their sense of taste (29),(30). Dysgeusia treatment focuses on basic dental hygiene, dietary changes, and counselling (31).

Postmalignancy Therapy Trismus Management

Trismus, or a limited mouth opening, is common in individuals with head and neck malignant development and interferes with basic functions such as eating, swallowing, and conversing (32),(33). It also interferes with dental hygiene, which can be very bothersome to sufferers (34). Trismus can be caused by tumour penetration into the masticatory muscles, namely the pterygoids, or the Temporomandibular Joint (TMJ), or it can be triggered by cancer treatment, such as surgery or RT (34),(35). Post-treatment trismus is unpredictable in terms of frequency and severity, and often manifests three months after radiation (34). It commonly develops into a long-term problem (35).

Osteoradionecrosis (ORN) Management

Based on clinical presentation and observation, the most often accepted definition of ORN affecting the jaws is: Irradiated bone becomes non vital and gets exposed through the overlaying skin or mucosa for about three months, without healing and repairing, with no recurrence of the tumour (36),(37),(38).

Conservative Management of Osteoradionecrosis (ORN)

Local irrigation (saline solution, NaHCO3, or chlorhexidine 0.2 percent), systemic antibiotics in acute infection episodes, avoidance of irritants (tobacco, alcohol, denture usage), and dental hygiene instruction are all part of “conservative therapy.” In addition to these conservative treatments, “simple management” refers to the careful removal of sequestrum in sequestrating lesions (without local anaesthesia). In situations with persistent pain, inability to respond to conventional therapies, and progressive worsening, resection, Hyperbaric Oxygen (HBO) therapy, or both were used. The treatment ended on the date of resection or the first HBO dive (39).

Hyperbarric oxygen therapy in the treatment of Late Radiation Tissue Injury (LTRI ): Bennett MH et al., conducted a systematic review by assessing the quality of eleven relevant randomised control trials and extracting data from the trials using the Cochrane Handbook for Systematic Reviews of Interventions criteria (40). Based on its capacity to enhance the blood flow to these tissues, Hyperbaric Oxygen Therapy (HBOT) has been recommended as a treatment for LRTI, according to the review. The HBOT is thought to aid tissue repair as well as the avoidance of complications following surgery. There was no indication of a benefit in clinical outcomes when there was known radiation harm to brain tissue, and there was no data on the use of HBOT to treat other LRTI presentations. In an irradiated area, HBOT also appears to minimise the risk of ORN after tooth extraction. The HBOT treatment of specific individuals and tissues may be warranted (40).

Ultrasound in the Management of Osteoradionecrosis (ORN)

The physical effects of therapeutic US on cells and tissues can be achieved through both thermal and non thermal processes. In physiotherapy, thermal effects are utilised to treat acute injuries, strains, and pain alleviation (41). Tissue regeneration, venous ulcer healing, pressure sore healing, blood flow in chronically ischemic muscles, protein synthesis in fibroblasts, and tendon repair are all aided by nonthermal effects. Ultrasound impacts bone through accelerating bone healing in animals and humans and inducing bone growth in vitro. Non thermal influences have been proven to aid in the healing of mandibular ORN. According to Young and Dyson, the main benefit is the activation of angiogenesis. Activation, basement membrane disintegration, migration and proliferation of endothelial cells from pre-existing venules, capillary tube creation, and maturation of new capillaries are all involved in the generation of new capillaries (42). Therapeutic angiogenesis is utilised to improve tissue healing and lessen negative tissue consequences produced by local hypoxia, such as ORN. The use of ultrasonography for revascularisation of mandibular ORN has been suggested by Harris M. Ultrasound (3 MHz, pulsed 1:4, 1 W/cm) was used to treat the patients for 40 sessions 15-minute each day (38). Only one case required mandibular resection and reconstruction, and ten of the twenty-one cases (48 percent) healed with debridement and ultrasound alone. Eleven cases remained unhealed after ultrasound therapy and debridement were covered with a local flap, and only one case required mandibular resection and reconstruction (38).

Pentoxifylline and tocopherol in the management of osteoradionecrosis: New therapy regimens have been established to counteract alterations in reactive oxygen species that cause radiation-induced fibrosis and, eventually, ORN. Pentoxifylline is a methylxanthine derivative that reduces inflammatory responses in vivo, enhances erythrocyte flexibility, dilates blood vessels, inhibits proliferation of human dermal fibroblasts and extracellular matrix synthesis, and increases collagenase activity in vitro. It is combined with tocopherol (vitamin E), which protects cell membranes against peroxidation of lipids, partial suppression of Transforming Growth Factor-1 (TGF-1), and production of procollagen genes, hence decreasing fibrosis. These two medications work together as a powerful antifibrotic agent. The treatment comprises of 400 mg of pentoxifylline twice a day and 1000 IU of tocopherol once a day (31).

Surgical management of ORN: Reconstruction surgery has made significant breakthroughs in the surgical management of ORN. The invention of myocutaneous flaps and the utilisation of microvascular free bone flaps allowed for significant changes in the surgical ablation of vast ORN. The replacement of the dead bone with a vascularised bone-containing flap will restore mandibular continuity while also providing non irradiated soft-tissue covering with an intact blood supply. Fibular flaps, ileac crest flaps, and scapular-parascapular flaps are all often utilised flaps (43).

Xerostomia management: Xerostomia can be caused by a multitude of factors, including radiation and chemotherapy. One of the most common radiation-induced toxicities in postradiotherapy head and neck patients is xerostomia, which is caused by damage to the salivary glands (44),(45). The four goals of xerostomia therapy are to increase existing saliva flow or replace lost secretions, to maintain oral health, to prevent dental caries, and to treat potential infections (46). The use ofcholinergic pharmacological preparations like pilocarpine or cevimeline can help increase salivary flow. The Food and Drug Administration (FDA) has licenced both of these parasympathomimetic medications for the treatment of xerostomia: pilocarpine for Sjögren’s syndrome and RT-induced xerostomia, while cevimeline appears to be more specific for Sjögren’s syndrome. Pilocarpine, a natural alkaloid, is a parasympathomimetic drug with adrenergic effects that stimulates the salivary glands residual activity by activating cholinergic receptors and 5 mg orally three times a day is the recommended dosage (47),(48),(49),(50). Cevimeline is similar to acetylcholine in that it binds to muscarinic acetylcholine receptors in exocrine glands, especially the M1 and M3 subtypes found, for example, in the salivary and lachrymal gland epithelium, causing an increase in exocrine gland production, such as saliva and perspiration. In heart and respiratory organs, M2 and M4 receptor sites predominate. The systemic side-effects of muscarinic–cholinergic stimulation is believed to be mitigated by this receptor subtype specificity (50).

SPECIAL INTEREST TOPICS

Results of altered anatomy: “A scar just indicates that you are tougher than whatever attempted to harm you...”

Our physical appearance plays a significant role in our everyday lives and is usually overlooked. Patients go through a lot when their physical appearance changes as a result of diligent therapy. No two patients have the same scars, heal the same way, or have the same perceptions about their appearance and in such scenario psychological counselling is of utmost significance (14).

Dealing with cancer cachexia: Systemic inflammation, a negative protein and energy balance, and an involuntary loss of lean body mass, are all symptoms of cancer cachexia (51). It is a deceptive condition that not only has a big influence on patients’ QoL, but it is also linked to poor treatment responses and shorter survival spans (52),(53). Despite the fact that several pathways are documented to be involved in its genesis, with a variety of cytokines suggested to have a role in the aetiology of the chronic catabolic state, cachexia remains mostly undiagnosed and untreated (53). Existing cachexia treatments, such as orexigenic appetite stimulants, are aimed at alleviating symptoms and reducing patient and family discomfort rather than extending life. A multidisciplinary strategy has been used in recent cachectic syndrome treatments. Novel pharmacological drugs such as megestrol acetate, medroxyprogesterone, ghrelin, and omega-3 fatty acid have been introduced to combination treatment with diet modification and/or exercise. These drugs have been shown to increase survival rates and QoL (51),(53).

Supreme Court Verdict on Euthanasia Legalisation in India

While dismissing Pinki Virani’s supplication for Aruna Shanbaug’s killing, the court spread out rules for latent euthanasia (54). According to these rules, detached wilful extermination includes the pulling back of treatment or food that would permit the patient to live (54). Forms of dynamic killing, including the organisation of deadly mixes, legitimate in various countries and locales including Luxemburg, Belgium and the Netherlands, just as the US conditions of Washington and Oregon, are as yet illicit in India (54),(55).

Wilful extermination/Euthanasia in India and elsewhere in the world: Active euthanasia is almost always prohibited in other parts of the world (56). The legal position of passive euthanasia, which includes the deprivation of nutrition or water, differs from country to country (57). Because there was no euthanasia statute in India, the Supreme Court’s directions became law until Parliament passed legislation. Veerappa Moily, India’s Minister of Law and Justice, in the year 2011, called for a meaningful political debate on the matter (57). The following rules were established:

1. A decision to stop life support must be made by the parents, spouse, or other close relatives, or in the absence of any of them, by a person or group of people acting as a next friend. It can also be administered by the doctors who are caring for the patient. The choice must, however, be made in the best interests of the patient.

2. Even if a decision to remove life support is made by close relatives, physicians, or a close friend, it must be witnessed by two people and countersigned by a first-class court magistrate, as well as authorised by a hospital medical board.

Hospice Care

Hospice care is a multidisciplinary programme that aims to improve a person’s QoL as they approach death, although it is not necessary that the patient has to be in a terminal condition. This programme can be administered at the patient’s preferred location, such as a nursing home, a family member’s house, or the patient’s own home. Clinical, passionate, deep, and therapeutic support may be provided. Frequently, a portion is provided for the patient’s group, which might include counselling, grief assistance, support groups, and training in how to think about their loved one. India has numerous hospice care associations and about 146 institutions nationwide which provide hospice care to the maximum involving cross department consultations and ensuring empathetic care to the patient (58).

Conclusion

Palliative care for patients with head and neck cancer is a complex issue that requires a collaborative approach. It is critical for the oral physician to communicate with the patient and family openly and honestly about incurable cancer. Open and legitimate communication is critical to palliative care success. Maintaining a high standard of living should be a priority, and patients’ treatment options should include both nonsurgical and surgical procedures. A specialist in oral medicine is a critical member of the palliative care team. Stomatologists are better able to connect with patients who have incurable head and neck cancer and are nearing the end of their lives, providing the highest level of care and empathy. Increased awareness of palliative oral care among all health care professionals will assist terminally ill patients and their families in their search for solace and comfort. While there is undeniable sadness, there is also a great deal of hope for healing and happiness. That is the objective of palliative care.

References

1.
Gupta B, Bray F, Kumar N, Johnson NW. Associations between oral hygiene habits, diet, tobacco and alcohol and risk of oral cancer: A case–control study from India, Cancer Epidemiol.2017;51:07-14, https://doi.org/10.1016/ j.canep.2017.09.003. [crossref] [PubMed]
2.
Laprise C, Shahul HP, Madathil SA, Thekkepurakkal AS, Castonguay G, VargheseI, et al., Periodontal diseases and risk of oral cancer in Southern India: Results from the HeNCe Life study. Int J Canc. 2016;139:1512-19. https://doi.org/10.1002/ijc.30201. [crossref] [PubMed]
3.
Veluthattil A, Sudha S, Kandasamy S, Chakkalakkoombil S. Effect of hypofractionated, palliative radiotherapy on quality of life in late-stage oral cavity cancer: A prospective clinical trial. Indian J Palliat Care. 2019;25:383. https://doi.org/10.4103/IJPC.IJPC_115_18. [crossref] [PubMed]
4.
Definition of palliative care. Available from: http://www.who.int/cancer/palliative/definition/en/. [accessed on 2020 Aug 10].
5.
Ellershaw J, Ward C. Care of the dying patient: The last hours or days of life. BMJ. 2003;326:30-34. [crossref] [PubMed]
6.
Cohen LM, Poppel DM, Cohn GM, Reiter GS. A very good death: Measuring quality of dying in end stage renal disease. J Palliat Med. 2001;4:167-72. [crossref] [PubMed]
7.
Steinhauser KE, Clipp EC, McNeilly CM, Christakis NA, McIntyre LM, Tulsky JA. In search of a good death: Observations of patients, families and providers. Ann Intern Med. 2000;132:825-32. [crossref] [PubMed]
8.
Fried T, van Droom C, O’Leary J, Tinetti ME, Drickamer MA. Older persons’ preference for site of terminal care. Ann Intern Med. 1999;131:109-12. [crossref] [PubMed]
9.
Aird DW, Bihari J, Smith C. Clinical problems in the continuing care of head and neck cancer patients. Ear Nose Throat J. 1983;62:10-30.
10.
Shedd DP, Carl A, Shedd C. Problems of terminal head and neck cancer patients. Head Neck Surgery. 1980;2:476-82. [crossref] [PubMed]
11.
Forbes K. Palliative care in patients with cancer of the head and neck. Clin Otolaryngol. 1997;22:117-22. [crossref] [PubMed]
12.
Kumar S, Debnath N, Ismail MB, Kumar A, Kumar A, Badiyani BK, et al. Prevalence and risk factors for oral potentially malignant disorders in Indian population. Advances in Preventive Medicine. 2015;2015:208519. [crossref] [PubMed]
13.
Saini R, Saini S, Sugantha. Palliative care, its need and role in cancer patients, in the Indian scenario. Indian J Med Paediatr Oncol. 2009;30(3):119-20. [crossref] [PubMed]
14.
Elackattu A1, Jalisi S. Living with head and neck cancer and coping with dying when treatments fail. Otolaryngol Clin North Am. 2009;42(1):171-84. xi. Doi: 10.1016/j.otc.2008.09.004. [crossref] [PubMed]
15.
Kowalski LP, Carvalho AL. Natural history of untreated head and neck cancer. Eur J Cancer. 2000;36:1032-37. [crossref]
16.
Wiffen PJ, Derry S, Moore RA. Impact of morphine, fentanyl, oxycodone or codeine on patient consciousness, appetite and thirst when used to treat cancer pain. Cochrane Database of Systematic Reviews. 2014;5:CD011056. https://doi.org/10.1002/14651858.CD011056. [PMC free article] [PubMed] [Google Scholar]. [crossref]
17.
Salins NS, Crawford GB. Intrathecal analgesia and palliative care: A case study. Indian J Paliat Care. 2010;16(1):44-47. https://doi.org/10.4103/0973-1075. [crossref] [PubMed] 63134. PMID: 20859471. PMCid: PMC2936082. [PMC free article] [PubMed] [Google Scholar].
18.
Joseph M. The challenge of cancer induced neuropathic pain. J Palliat Care Pediatr. 2016;1(1):05-08. [Google Scholar].
19.
Hanks GW, Conno F, Cherny N, Hanna M, Kalso E, McQuay HJ, et al. Morphine and alternative opioids in cancer pain: The EAPC recommendations. Br J Cancer. 2001;84(5):587-93. Doi: 10.1054/bjoc.2001.1680. [crossref] [PubMed]
20.
Yogi V, Singh OP. Induction followed with concurrent chemoradiotherapy in advanced head and neck cancer. J Cancer Res Ther. 2005;1(4):198-203. [crossref] [PubMed]
21.
Graf R, Hildebrandt B, Tilly W, Riess H, Felix R, Budach V, et al. A non randomised, single-centre comparison of induction chemotherapy followed by radiochemotherapy versus concomitant chemotherapy with hyperfractionated radiotherapy in inoperable head and neck carcinomas. BMC Cancer. 2006;6:30. Published 2006 Feb 1. Doi: 10.1186/1471-2407-6-30. [crossref] [PubMed]
22.
Bryan RB, Gough MJ, Seung SK, Jutric Z, Weinberg AD, Fox BA, et al. Cytoreductive surgery for head and neck squamous cell carcinoma in the new age of immunotherapy. Oral Oncol. 2016;61:166-76. Doi: 10.1016/j.oraloncology.2016.08.020. Epub 2016 Sep 7. Erratum in: Oral Oncol. 2017;66:e3. PMID: 27614589. [crossref] [PubMed]
23.
Forbes JF. Palliative surgery in cancer patients: Principles and potential of palliative surgery in patients with advanced cancer. Recent Results Cancer Res. 1988;108:134-42. [crossref] [PubMed]
24.
Laccourreye O, Lawson G, Muscatello L, Biacabe B, Laccourreye L, Brasnu D. Carbon dioxide laser debulking for obstructing endolaryngeal carcinoma: A 10-year experience. Ann Otol Rhinol Laryngol. 1999;108(5):490-94. Doi: 10.1177/ 000348949910800513.
25.
Phelan E, Lang E, Mahesh BN, Lang J. Powered instrumentation in obstructing laryngeal tumours. The Journal of Laryngology and Otology. 2007;121:293-95. 10.1017/S0022215106003112. [crossref] [PubMed]
26.
Grocott P. The palliative management of fungating malignant wounds. J Wound Care. 2000;9(1):04-09. [crossref] [PubMed]
27.
Morrison M. A colour guide to the nursing management of wounds. London:Wolfe; 1992.
28.
Wierzbicka M, Napierata J. Updated National Comprehensive Cancer Network guidelines for treatment of head and neck cancers 2010-2017. Otolaryngol Pol. 2017;71(6):01-06. [crossref] [PubMed]
29.
Baharvand M, ShoalehSaadi N, Barakian R, Moghaddam EJ. Taste alteration and impact on quality of life after head and neck radiotherapy. J Oral Pathol Med. 2013;42:106-12. [crossref] [PubMed]
30.
Mossman K, Shattzman A, Chencharick J. Longterm effects of radiotherapy on taste and salivary function in man. Int J Radiat Oncol Biol Phys. 1982;8(6):991-97. [crossref]
31.
Michael Glick Burket’s Oral Medicine 12th edition Shelton, Connecticut, USA 2015.
32.
Jager-Wittenaar H, Dijkstra PU, Vissink A, van Oort RP, Roodenburg JLN. Variation in repeated mouth-opening measurements in head and neck cancer patients with and without trismus. Int J Oral Maxillofac Surg. 2009;38:26-30. [crossref] [PubMed]
33.
Lee LY, Chen SC, Chen WC, Huang BS, Lin CY. Postradiation trismus and its impact on quality of life in patients with head and neck cancer. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015;119:18-95. [crossref] [PubMed]
34.
Vissink A, Jansma J, Spijkervet FKL, Burlage FR, Coppes RP. Oral sequelae of head and neck radiotherapy. Crit Rev Oral Biol Med. 2003;14:199-212. [crossref] [PubMed]
35.
Ichimura K, Tanaka T. Trismus in patients with malignant tumours in the head and neck. J Laryngol Otol.1993;107:1017-20. [crossref] [PubMed]
36.
Lyons A, Ghazali N. Osteoradionecrosis of the jaws: Current understanding of its pathophysiology and treatment. Br J Oral Maxillofac Surg. 2008;46:653-60. [crossref] [PubMed]
37.
McLeod NM, Pratt CA, Mellor TK, Brennan PA. Pentoxifylline and tocopherol in the management of patients with osteoradionecrosis, the Portsmouth experience. Br J Oral Maxillofac Surg. 2012;50(1):41-44. [crossref] [PubMed]
38.
Harris M. The conservative management of osteoradionecrosis of the mandible with ultrasound therapy. Br J Oral Maxillofac Surg. 1992;30:313-18. [crossref]
39.
Wong JK, Wood RE, McLean M. Conservative management of osteoradionecrosis. Oral Surg Oral Med Oral Pathol Oral RadiolEndod. 1997;84(1):16-21. [crossref]
40.
Bennett MH, Feldmeier J, Hampson N, Smee R, Milross C. Hyperbaric oxygen therapy for late radiation tissue injury. Cochrane Database Syst Rev. 2012;5(CD005005):8. [crossref]
41.
Doan N, Reher P, Meghji S, Harris M. In vitro effects of therapeutic ultrasound on cell proliferation, protein synthesis, and cytokine production by human fibroblasts, osteoblasts, and monocytes. J Oral Maxillofac Surg. 1999;57(4):409-20. [crossref]
42.
Nadella KR, Kodali RM, Guttikonda LK, Jonnalagadda A. Osteoradionecrosis of the jaws: Clinico-therapeutic management: A literature review and update. J Maxillofac Oral Surg. 2015;14(4):891-901. Doi: 10.1007/s12663-015-0762-9. [crossref] [PubMed]
43.
Ang E, Black C. Reconstructive options in the treatment of osteoradionecrosis of the craniomaxillofacial skeleton. Br J Plast Surg. 2003;56:92-99. Doi: 10.1016/S0007-1226(03)00085-7. [crossref]
44.
Wu VWC, Leung KY. A review on the assessment of radiation induced salivary gland damage after radiotherapy. Front. Oncol. 2019;9:1090. Doi: 10.3389/fonc.2019.01090. [crossref] [PubMed]
45.
Garcia MK, Meng Z, Rosenthal DI, Shen Y, Chambers M, Yang P, et al. Effect of true and sham acupuncture on radiation-induced xerostomia among patients with head and neck cancer: A randomized clinical trial. JAMA Netw Open. 2019;2(12):e1916910. Doi: 10.1001/jamanetworkopen.2019.16910. [crossref] [PubMed]
46.
Almeida JP, Kowalski LP. Pilocarpine used to treat xerostomia in patients submitted to radioactive iodine therapy: A pilot study. Braz J Otorhinolaryngol. 2010;76(5):659-62. [crossref] [PubMed]
47.
Radvansky LJ, Pace MB, Siddiqui A. Prevention and management of radiationinduced dermatitis, mucositis, and xerostomia. Am J Health Syst Pharm. 2013;70(12):1025-32. Doi: 10.2146/ajhp120467. [crossref] [PubMed]
48.
Tomiita M, Takei S, Kuwada N, Nonaka Y, Saito K, Shimojo N, et al. Efficacy and safety of orally administered pilocarpine hydrochloride for patients with juvenileonset Sjögren’s syndrome. Mod Rheumatol. 2010;20(5):486-90. [crossref] [PubMed]
49.
Ramos-Casals M, Tzioufas AG, Stone JH, Sisó A, Bosch X. Treatment of primary Sjögren syndrome: A systematic review. JAMA. 2010;304(4):452-60. [crossref] [PubMed]
50.
Hendrickson RG, Morocco AP, Greenberg MI. Pilocarpine toxicity and the treatment of xerostomia. J Emerg Med. 2004;26(4):429-32. [crossref] [PubMed]
52.
Aoyagi T, Terracina KP, Raza A, Matsubara H, Takabe K. Cancer cachexia, mechanism and treatment. World J Gastrointest Oncol. 2015;7(4):17-29. Doi: 10.4251/wjgo.v7.i4.17. [crossref] [PubMed]
52.
Fearon K, Arends J, Baracos V. Review understanding the mechanisms and treatment options in cancer cachexia. Nat Rev Clin Oncol. 2013;10(2):90-99. [crossref] [PubMed]
53.
Wijaya YT, Setiawan T, Sari IN, Nah SY, Kwon HY. Amelioration of muscle wasting by gintonin in cancer cachexia. Neoplasia. 2021;23(12):1307-17. Doi: 10.1016/j.neo.2021.11.008. [crossref] [PubMed]
54.
“Supreme Court disallows friend’s plea for mercy killing of vegetative Aruna”. The Hindu. 7 March 2011. [https://www.thehindu.com/news/national/Supreme-Courtdisallows-friends-plea-for-mercy-killing-of-vegetative-Aruna/article14939164.ece] Retrieved 7 March 2011.
55.
“India’s Supreme Court lays out euthanasia guidelines”. LA Times. 8 March 2011. [https://www.latimes.com/world/la-xpm-2011-mar-08-la-fg-india-euthanasia-20110308-story.html]Retrieved 8 March 2011.
56.
”Euthanasia: Widely debated, rarely approved”. Times of India. 8 March 2011. Retrieved 8 March 2011. [https://web.archive.org/web/20121105005023/http://articles.timesofindia.indiatimes.com/2011-03-08/india/28667689_1_euthanasiafatal-injection-terminally-ill-patients] Accessed on 20 AUG 2020].
57.
FAM 200 Appendix E: Death with Dignity. US Department of State Foreign Affairs Manual, Volume 7. [https://fam.state.gov/FAM/07FAM/07FAM0200apE.html] Accessed on 20 AUG 2020].
58.
Global directory of palliative care institutions and organisationsIAHPC [https://hospicecare.com/global-directory-of-providers-organisations/search/?idcountry=39] [accessed on 21 sept 2021].

DOI and Others

DOI: 10.7860/JCDR/2022/52188.16155

Date of Submission: Aug 31, 2021
Date of Peer Review: Oct 07, 2021
Date of Acceptance: Dec 28, 2021
Date of Publishing: Apr 01, 2022

AUTHOR DECLARATATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Sep 01, 2021
• Manual Googling: Dec 27, 2021
• iThenticate Software: Jan 04, 2022 (19%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com