Changes

==Preamble of Indriya Sthana (Section on Determinants of Remaining Lifespan of Patients)==

==Preamble of Indriya Sthana (Section on Determinants of Remaining Lifespan of Patients)==

This section of Caraka Samhita called Indriya sthana deals with signs and symptoms useful in determining the remaining lifespan of patients, these are called arishta lakshana. Contents of this treatise are several thousand years old. In the present era, because of advancements in medical sciences, many arishta lakshanas are well treatable and do not predict death but are important indicators of prognosis of disease and helpful in management of patients .  

This section of [[Caraka Samhita]] called Indriya Sthana deals with the signs and symptoms useful in determining the remaining lifespan of patients (also called ''arishta lakshana''). In the present era, because of advancements in medical sciences, many ''arishta lakshanas'' are well treatable and cannot be considered as "predictors" of death as they used to even a few centuries back. However, these signs and symptoms could serve as important indicators of prognosis of disease and therefore, would be helpful in the management of patients.  

Life begins with association of consciousness with Panch mahabhoota and ends in dissolutions of their combination. This union or life is by no means permanent, with the possibility of dissolution or death any time. The signs and symptoms pertaining to prediction of imminent death are classified in 12 chapters. Even though all of them cannot be explained by rational scientific parameters, but are experienced and documented by people worldwide.  Physicians are advised to thoroughly examine the patient for the moribund signs and investigate with biomarkers to stop the therapeutic treatment in those terminal patients and provide palliative care.

 

When a person enters the final stage of the dying process, two different dynamics are at work and are closely interrelated and interdependent. On the physical plane, the body begins the final process of shutting down, which will end when all the physical systems cease to function. Usually this is an orderly and undramatic progressive series of physical changes, which are not medical emergencies requiring invasive interventions. These physical changes are a normal and natural way in which the body prepares itself for death.  

Life begins with the association of consciousness, or the ''atma'', with the five fundamental elements (earth, air, fire, ether, and water, or the''panchamahabhuta'') and ends in the dissolution of this association. Since this union (that results in a living being) is by no means permanent and since there is always a possibility of dissolution or death anytime, Ayurvedic texts emphasized on identifying certain signs and symptoms that could forebear, with some level of certainty, imminent death. This section is dedicated to such determinants and is structured in the form of 12 chapters. Even though all of these cannot be explained by rational scientific parameters, some of these signs and symptoms have been documented and reported as having been experienced by people in various parts of the world.  Within the treatise ([[Charaka Samhita]]), physicians have been instructed to thoroughly examine the patient for certain telltale signs that indicate terminal illness and investigate using biomarkers. The treatise then advises physicians to stop any therapeutic treatment being given to such terminal patients and provide them palliative care instead.

The other dynamics of the dying process at work is, on the spiritual and psychological plane, and is a different kind of process. The spirit of the dying person begins the final process of release from the body, its immediate environment, and all attachments. This release also tends to follow its own priorities, which may include the resolution of unfinished tasks of practical nature and reception of permission to “let go” from family members. In these events the spirit prepares, to move from this existence to the next dimension of life. The most appropriate response to the spiritual and psychological changes is that, which supports and encourage this release and transition.   

 

Now-a-days importance is given for identification of signs of approaching death. Educational and training programs are organized to educate family members/relatives/attendants so that, patient care is not neglected near death and this specialized field is commonly known as ‘Palliative care’. The World Health Organization (WHO) defines palliative care as 'an approach that improves the quality of life of individuals and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual'.  

When a person enters the final stage of the dying process, two different dynamics are at work and are closely interrelated and interdependent. On the physical plane, the body begins the final process of shutting down, which will end when all the physical systems cease to function. Usually, this is an orderly and undramatic progressive series of physical changes, which are not medical emergencies requiring invasive interventions. These physical changes are a normal and natural way in which the body prepares itself for death.  

The other dynamics of the dying process, per Ayurveda, are on a spiritual and psychological plane. The spirit of the dying person begins the final process of leaving the body, its immediate environment, and all (material/worldly) attachments. This release also tends to follow its own priorities, which may include the resolution of unfinished tasks of practical nature and reception of permission to “let go” from one's kin. In these events, the spirit prepares to move from this existence to the next dimension of life. The most appropriate response to the spiritual and psychological changes is that which supports and encourages this release and transition.   

 

Palliative care to the terminally ill/dying patients is provided today in all communities across the world. It is a specialized field of healthcare that encompasses educational and training programs organized to educate family members/relatives/attendants to ensure patient care is not neglected especially in terminal cases. The World Health Organization (WHO) defines palliative care as 'an approach that improves the quality of life of individuals and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual'.  

The aging of the population, with the numerous chronic debilitating and malignant conditions associated with growing older, has focused attention on palliative care. The terminal state is an integral process and a time to reconcile differences so that patient and family may accept death with a minimum of physical, spiritual, and psychosocial anguish. Hospice care is a specialized philosophy and system of care for the terminally ill patient that accepts death in an affirmative way and provides palliative care and emotional support to dying patients and their families. Hospice and palliative care philosophy lays emphasis on relieving suffering and improving quality of life at the end of life in order to permit experiences that will have positive meaning. The role of the physician is central in providing this care. When recovery is uncertain it is better to discuss this rather than giving false hope to the patient and family. This is generally perceived as strength in the doctor-patient relationship and helps to build trust. Charaka also supports this view and states that those near death should not be treated. Thus it becomes important that physician should be well trained in identifying features of impending death.

The aging of the population, with the numerous chronic debilitating and malignant conditions associated with growing older, has focused attention on palliative care. The terminal state is an integral process and a time to reconcile differences so that patient and family may accept death with a minimum of physical, spiritual, and psychosocial anguish. Hospice care is a specialized philosophy and system of care for the terminally ill patient that accepts death in an affirmative way and provides palliative care and emotional support to dying patients and their families. Hospice and palliative care philosophy lays emphasis on relieving suffering and improving quality of life at the end of life in order to permit experiences that will have positive meaning. The role of the physician is central in providing this care. When recovery is uncertain it is better to discuss this rather than giving false hope to the patient and family. This is generally perceived as strength in the doctor-patient relationship and helps to build trust. Charaka also supports this view and states that those near death should not be treated. Thus it becomes important that physician should be well trained in identifying features of impending death.

In order to care for dying patients it is essential to “identify dying”. This aim can be attained by applying the knowledge given in these chapters. Presently to predict prognostic value, few tools have been designed. Most widely-used prognostic tool is the Palliative Performance Scale (PPS) which has been studied primarily in inpatient settings and in patients with cancer. Few researches are ongoing to develop tools for prognosis in other diseases also.  Research can be done to develop a scale based on parameters described in Ayurvedic Arishta Vigyana and these chapters can also contribute a lot in making such kind of tool.

In order to care for dying patients it is essential to “identify dying”. This aim can be attained by applying the knowledge given in these chapters. Presently to predict prognostic value, few tools have been designed. Most widely-used prognostic tool is the Palliative Performance Scale (PPS) which has been studied primarily in inpatient settings and in patients with cancer. Few researches are ongoing to develop tools for prognosis in other diseases also.  Research can be done to develop a scale based on parameters described in Ayurvedic Arishta Vigyana and these chapters can also contribute a lot in making such kind of tool.