Care of the patient who is terminally ill and has no hope for recovery is the saddest and most difficult chapter in Medical Management. These patients are mostly suffering from advanced cancer, paralytic ailments, senile dementia or multiple diseases. The common factor is that they have come to the end of the treatment rope, and there is no hope for survival. The question is what we can do for them to make them pain free, odour free, mobile (if possible) and keep up their sagging morale. Hospitals don’t admit them and there are insufficient Hospice beds to accommodate them. Besides most patients in India would like to be amongst their dear and near ones. Most Indian homes are small, families have become nuclear, space is a problem and transportation is difficult. Man power may be sufficient but when it comes to fixing responsibilities, family members shun and tend to pass the buck to others. We have to develop domiciliary hospice care (DHC), which seems to be the answer at present. DHC needs a task force of doctors, nurses, social workers, counsellors, and religious people — All socially committed and strong willed. This can form a nucleus around which patient care can be given. For the patient requirements would be :

1. *Fowlers Bed.
2. *An air mattress.
3. *A foldable wheel chair.
4. Material for dressing bed sores.
5. Linements, ointments etc.
6. *Suction machine.
7. *Oxygen cylinder with attachments.
8. Call bell.

The patient will need a good supply of pain killing medicines, diapers, bed pans, urine pot etc. One or two of the family members can be trained in basic nursing techniques and a nurse and social worker can visit the patient regularly. Doctors should be available but need to visit only once a week; and on call.

The protocol of the patient can be laid down, in collaboration with family members.

1. Nutritional requirements to be given orally by or through the Ryles tube. This should keep in mind the family food habits and the patient taste. Drips to be avoided as far as possible.
2. Medicines to be given as per schedule. Responsibility to be fixed. Oral, nasal or rectal route to be preferred. Avoid injection.
3. Sponging or bath to be given by family members or nurse. A weekly visit by physiotherapist and social worker is desirable. Ambulatory patients can be taken out once a day. Investigations like blood test and X-rays must be avoided. Indwelling tubes (endotracheal; Ryles; gastrostomy; urinary catheter) may pose problems. For this specially trained Nurse or Ayah will be required.

Pain relief takes top priority. If routine anodynes don’t work help may be taken from pain specialists/pain clinic and epidural route may be tried.

Feeding them is an arduous task. They have anorexia plus anxiety. Top nursing care (and mothering) is required to get round them.

Most patients are unprepared to meet their end. Spiritual and religious support is required along with counselling. Request for alternative medical care or even visits by saints and seers must not be sneered at. Visits by friends and relatives must be encouraged if the patient likes it.

Legal aspects of death must be discussed with relatives and writing a will must be encouraged.

In the final analysis, looking after a dying patient is a stressful and thankless job. Caretakers must expect no bouquets. Only execrations and criticism. They must take this into their stride - because deep down they know they have helped a helpless fellow being.