Mainstreaming Ayurveda for Comprehensive Palliative Care
Palliative care is an integrated approach towards specialized and customized holistic care for people suffering from life-limiting illnesses or life-threatening conditions. Governed by cultural and social norms and legislations, it poses challenges to both care givers as well as recipients, varying from society to society. Especially in developing countries like India, where there is a large gap between the needs of terminally-ill patients and sources available to them, there is a crying need for a comprehensive model for palliative care. This study aims at reviewing what Ayurveda has to offer as a complement to the present healthcare system; so it can be integrated into the mainstream healthcare system. The holistic approach towards day-to-day living that incorporates dietary and regimen related guidelines can be successfully blended with the ongoing management of the target population for better results and a farther outreach. The concept of asādhyavyādhi or incurable diseases can also be gainfully revisited in the context of palliative care for innovative insights in this endeavour.
Palliative care is an integrated approach towards a specialized and customized holistic care for people suffering from life-limiting illnesses or life-threatening conditions. The dictionary definition of palliative means “affording relief, also the drug that acts so.” It aims at improving the quality of life of the patient and also to lessen the suffering of their loved ones. Although it does not replace active treatment, it works towards alleviating the suffering incurred due to the underlying disease condition, or those due to the side effects of the ongoing treatment; or the anxiety or depression caused by the fear of the diagnosis and/or the unsure future. Often, palliative care continues even after loss (of the patient), to support the family through the process of bereavement.
The indicators of palliative care have been identified for cancer patients by the American Society of Clinical Oncology. However, these guidelines are being extended to other conditions as well. Palliative care is increasingly being offered to illnesses such as neurodegenerative conditions, chronic heart failure, chronic renal disease, HIV/AIDS. Another fast-growing field showing requirements of tailor-made palliative care is in the pediatric group for children with serious illness due to cancer, genetic or birth defects.
While palliative care has common goals towards relief from suffering, management of pain, providing physical, psychological, social and spiritual comfort; yet the approach and support that an adult requires to cope with his condition is very different from the needs and the difficulties of a child or an adolescent. Also, the rehabilitation that the individual’s family requires if the patient is a child, is both different and difficult at the empirical, spiritual, ethical and emotional level as well as the physical, financial, and social levels. Hence, palliative care for children is a special, albeit closely related field to adult palliative care. The WHO has given a distinct, criteria-based definition for palliative care for children. Some salient features in the definition being, need for comprehensive care of the body, mind and spirit of the child; care advised regardless of status of disease-directed treatment; multi-disciplinary approach of care that includes the family, and makes community resources available which may be provided at tertiary care facilities, community health centres and even in children’s homes.
A widely cited report in 2007 of a randomized controlled trial of 298 patients found that palliative care delivered to patients and their care givers at home, improved satisfaction with care, while decreasing the use of medical services and the cost of care.
Challenges to a universal model for palliative care:
Palliative care having a multipronged approach, depends much on the society where it is required. It is governed by the cultural and social norms of ethicals as well as current legislations in the place where practiced. This naturally poses varying challenges to both care givers as well as recipients, from society to society and nation to nation.
In the United States for instance, the Supreme Court has unequivocally supported the need for adequate pain relief; and palliative medicine has become a specialised field in its own right. In the Indian scenario vis-à-vis palliative care, the foremost fear in opioid drug availability is that of drug abuse. The Indian Narcotics and Psychotropic Substance Act closely regulates the use of medicinal opioids like morphine.
Further more, “a range of technologies and health care options may ensure adequate nutrition, communication, cardiac and respiratory functioning, bowel motility and skin integrity, but all require learning and adjustment by the individual and family.” It also requires specialist teams for providing the most suitable palliative care for an individual. However, in India the outpatient treatment in combination with home care teams visiting patients is found to be a better assimilated mode for availing palliative care. Although this definitely reduces autonomy of the individual in decision-making, it has certainly proven to be more cost-effective and convenient.
Thus, although there might be the desire, and in some instances (with good reason), to imitate the palliative care models with proven efficacy and utility of Western countries, the limitations and challenges of the Indian healthcare system, vis-a-vis its social milieu and legal constraints, necessitate the development of a more conducive working model adapted to the Indian patient, economy and government cohort.
Role of Ayurveda as a complementary approach:
In developing countries like India, there exists a gaping breach in the percentage of terminally-ill populace as opposed to the percentage of resources available to fight the diseases. It is, therefore, no surprise that several Indians choose to explore other lesser known forms of medicine like Ayurveda, alongside the conventional allopathic medicine; the reasons governing this choice being accessibility, affordability, social coaxing between peers, among other reasons. Vaidya et al, stated that Ayurvedic formulations have effectively controlled the side effects of chemotherapy.
However, this integration is often off-the-record and hence by not taking the consulting physician into confidence, the physician is rarely making a knowledgeable decision in either allowing or disallowing such interventions.
This study aims to review and bring forth what Ayurveda has to offer as a complement to the present healthcare system; to include its comprehensive integration into the mainstream healthcare system. Its implementation in terms of informed and trained healthcare providers and fully-equipped care centres, will help to maximize outreach and procure positive feedback especially in palliative care.
The forming of the department of AYUSH (Ayurveda, Yoga, Unani, Siddha, and Homeopathy) from under the Ministry of Health and Family Welfare to becoming the Ministry of AYUSH in 2014, may be looked upon as the initial steps into main streaming. However, such policy decisions require more ground work at the grass root level to ensure that significant strides will result.
Palliative care requires a holistic approach which caters to the physical, psychological, social and spiritual needs of the individual. For a child this is even more underscored due to their constant developing and altering physical, mental and psychological status.
Ayurveda literally means the “science of life” and it is a science that aims foremost at preserving health and if required, at treating disease.
[CharakaSamhitā, Sūtrasthāna, Chapter 30, Verse 26]
This approach highlights two aspects: first, the exclusive approach Ayurveda has towards every individual and second, its implicit emphasis on making a comprehensive assessment of his/her condition before planning treatment and/or management.
It is also pertinent to note the definition of health and disease that the science professes. Swāsthya(Health) is a state of optimal balance in the activities of the doṣa, agni, dhātu and mala and a congenial state of the soul, senses and manas.
[SuśrutaSamhitā, Sūtrasthāna, Chapter 15, Verse 45]
Furthermore, ĀchāryaCharaka opines, an imbalance of dhātu may be termed as vikāra (broadly understood as disease) and a balance of dhātu is the nature of health. Thus, ārogya or absence of disease is the state of well-being and vikāra portents grief.
[CharakaSamhitā, Sūtrasthāna, Chapter 9, Verse 4]
The state of disease has several classifications based on different criteria. But for the purpose of the present study, the following criterion is applicable: on the basis of its response to treatment/management, disease is divided into two main types namely;
i. Sādhya- that which is curable
ii. Asādhya- that which is incurable
Each of these categories are further subdivided into two types each.
i. Sādhya is further subdivided into :
(a)Sukh-sādhya – that which has conducive environment for an easy cure
(b)Kṛcchrasādhya– that which is cured with much difficulty and a strenuous investment of time and effort.
ii. Asādhya also has two sub types :
(a)Yāpya– that in which longevity is solely dependent on a strict pathya-sevanaor a custom diet-regimen.
(b)Anupakrama – that which allows no management.
The concept of asādhyavyādhi or incurable diseases can be gainfully studied in the purview of palliative care. In the context of palliative care, the mention of health may seem superfluous but when focusing on improving the quality of life by cultivating a sense of well-being in the patient, the wholesomeness of the definitions of health and disease, becomes a beacon of hope.
Two important definitions help to underscore this statement both of which are etymologies of the synonyms for the physical body namely, śareera and kāya. The etymology of the word śareera or the physical body is: that entity which is constantly undergoing destruction.
शृणातिशीर्यतेवातत्शरीरम्। (अमर. २/६/७०-७१: रामाश्रमी)
Kāya is that entity which is nourished by food.
चीयतेऽन्नादिभिरितिकायः।(आमर. २/६/७०-७१: रामाश्रमी)
Food that nourishes the body also has a nourishing effect on the manas and the senses. For instance, it is mentioned that a proper diet, which is congenial in appearance, aroma, palatability and perception of touch and is consumed with adherence to the principle of proper eating as mentioned in the 8th chapter of Charaka Samhitā is the very life of the living; for such a nutriment will fuel the digestive fire, energise the manas, improve the array of body constituents in strength and color and improve in essence the senses of the individual. Whereas food consumed by flaunting the said principles will cause an opposing effect thereby capable of causing disease or worsening the pre-existent state of illness.
There is some evidence to suggest that nutrition is still undervalued in the European health care system, often due to lack of awareness and education.[13,14] As a natural fallout of this, “the role of dietitians in specialist palliative care teams has received scant attention in the literature.” On the other hand, it is poignant to note that the trinity of Ayurvedic texts, namely Charaka Samhitā, Sushruta Samhitā and Astānga Sangraha begin with much emphasis and detailed guidelines of āhārā, vihāra , āchārai.e.food, regimen, moral behaviour and a code of conduct respectively to ensure that health be maintained; it is then followed byaushadha, chikitsā karmaor medicine and medical procedures respectively to treat diseases.
This is achieved with a certain significance given to day-to-day activity of an individual, that respects the diurnal changes in dinacharyā,[16,17] and seasonal alterations in ṛitucharyā.[18,19] Similarly, there is no generalisation of a particular medicine or a diet with respect to the disease or a specific condition alone; the individual is screened for age, gender, personal and other history, occupation, general constitution, the place of birth, present place of residence, time in terms of seasonal advent, and the stage and chronicity of disease. This is followed by advice regarding food with specifications such as:
(I) what to eat,
(ii) how to eat,
(iii) when to eat,
(iv) how much to eat,
(v) how to cook,
(vi) what are conducive combinations
(vii) what combinations are to be avoided,
(viii) which vehicle or adjuvant are to be eaten with,
(ix) which rasa (taste) is best avoided
(x) which rasa(sweet, sour, salty, bitter, pungent, astringent) to predominantly consume
Considering that palliative care is turned to when the nature of the ailment ceases to respond to expectations of health restoration, the considerations turn to relief in symptoms, reduction in pain and discomfort for instance due to constipation, acidity, anorexia, indigestion, sleeplessness, pacifying emotional disturbances like anxiety, depression, lethargy and managing vide counsel and medication the psychological issues in the attempt to improve the quality of life. This very individualistic approach expected in palliative care is ingrained in Ayurveda and its perspective of approaching with assessment followed by advice can be beneficial.
It is relevant to mention here that when Ayurveda uses the term Chikitsā, it has a very broad scope and does not limit itself merely to a simplistic translational equivalent like “treatment”. The practice by way of which the śareeradhātu or body constituents are returned to their state of harmony and balance is termed as chikitsā, and accomplishing this is the duty of the bhiṣak or the treating physician.
याभिःक़ियाभिर्जायन्तेशरीरेधातवःसमाः।साचिकित्साविकाराणांकर्मतद्भिषजांस्मृतम्॥ (च.सू.१६/३४ )
[CharakaSamhitā, Sūtrasthāna, Chapter 16, Verse 34]
[Bhāvaprakāśa, Pūrvakhaṇḍa, Miśrādhyāya, Verse11]
However, from the point of view of providing palliative care, a definition that stands out that is very concise and limits itself to nidānaparivarjana, i.e., the removal or disconnect from the exposure to the causative factor(s).
[SuśrutaSamhitā, Uttaratantra, Chapter 1, Verse 25]
Although this may not apply to the actual underlying disease it is very true for symptoms like constipation, acidity, flatulence, heartburn, sleeplessness, pain etc. which require attention. Further more, as it assists in better nourishment thereby improving one’s sense of well-being. After all, body constituents and diseases both stem out of the food one eats.
[CharakaSamhitā, Sūtrasthāna, Chapter 28, Verse 44]
Food nourishes and develops the body, and adds to the ojas (vitality), bala (strength), varna (lustre) only when it is digested by the most optimal agni or digestive fire; for a below par agni, results in undigested food which is unable to produce a potent and healthy body structure. When optimal, the agni leads to proper digestion for healthier appearing colour and radiance of the skin, optimal anabolism, zestfulness of the spirit, vigour and so forth. Thus a diet which assesses and improves the digestive capacity, will also improve the vitality of an individual in palliative care.
लोकोऽयंपुरुषसम्मितम्…।यावन्तोहिलोके… तावन्तःपुरुषे, …॥(च.शा.५/३)
[CharakaSamhitā, Śārīrasthāna, Chapter 5, Verse3]
After all, the human being is the epitome of the universe. Thus, what exists in nature also exists in the human body and hence all the principles that apply to the physical universe, also apply to the human body. Hence, a proper planned diet, following the diktats of the dietary principles act as the fuel to keep the fire potent thereby ensuring the maintenance of vigour and vitality.
[CharakaSamhitā, Cikitsāsthāna, Chapter 15, Verse 40]
Man has always been on the lookout to understand the cause and the process of disease so as to be able to successfully prevent and/or arrest it in the most judicious way possible. Since the Vedic times, several different medical precepts are found to have been active with this singular aim. The three most important forms that have been stated in the CharakaSamhitā are Daivavyapāshraya, Yuktivyapāshraya and Satvāvajaya.
Forces of nature have always been studied and feared to be the cause for disease. Hence daivavyapāshraya or praying has been the first form of treatment. But with better knowledge of medicinal plants, the focus steadily moved to use of natural substances to prevent or cure diseases in yuktivyapāshraya. The third form Satvāvajaya, is a form of non-pharmacological psychotherapy which is based on the withdrawal from unwholesome stimuli (artha) which trigger the mind. These depend on the use of manonigrha (will power), astanga yoga, meditation and chanting. All three of them underscore a single principle, depending on nature to preclude or to remedy disease.
Some of the salient features of the principles of Ayurveda Chikitsāthat thus developed through the times are:
- Dependence on nature for healing – for which the swabhava-uparamavada was stated in CharakaSamhitā, Chapter 16. It states that all that exists has a natural tendency towards destruction, and there is a constant exposure to newer causes that lead to the formation of new body constituent. A healthy cause will form a healthy body structure and a vitiated cause will cause a vitiated body structure. Thus, the withdrawal from unhealthy causes or nidānaparivarjana often begins the process of restoration of health or relief (in palliative care).
- Nidānaparivarjana depends heavily on one: the diet and regimen cohort, as they are the gross causes of disease and two: the agni which digests and transforms them in the body. Hence, Ayurveda texts deal with these two aspects in much details by setting clear guidelines and simplify the subject with clear criteria. For example, all the edible food material is classified in groups; their qualities, indications and contraindications of consumption are described in detail. The details of a daily regimen are also described and are inclusive of personal hygiene, code of conduct, healthy personal habits, social norms and spiritual requisites.
- Ayurveda perceives the physical body and the mind as one unit – the principle of daiha-mānas. Every physical debility has some psychological symptom and vice-versa. Hence no plan of treatment is chalked in isolation and both these entities are always assessed in tandem.
- Every individual is made of a unique combination of the tridoṣa which are further affected by surrounding factors of parental history, period of gestation, birth and growth, social and cultural contexts which influence to create a prakṛti of that individual. This prakṛti varies from person to person and therefore assessment of the disease in the context of the prakṛti is necessary for optimal results.
- There is much stress laid on the process of cleansing and the expulsion of waste. Whether the actual physical body waste like urine, faeces, flatulence, menstrual blood or the doṣapurged out through the process of Pancakarmā. Since delayed or improper expulsion of waste cause its accumulation leading to disease when exposed to a favourable trigger.
- The most important feature of Ayurveda Chikitsais undoubtedly the stress it lays on śuddhachikitsa or an unblemished treatment plan wherein the management of one symptom/disease does not aggravate a new disease as a side effect. This is the most historically significant perspective that Ayurveda offers to the field of medicine.
The detractors might point out that there exists a deterrent saying;
[CharakaSamhitā, Sūtrasthāna, Chapter 10, Verse 8]
Which literally translates as “a physician who takes upon himself to treat an incurable condition will invariably suffer from the loss of money, knowledge, and success; he will be criticized publicly and will lose credibility as a physician.” It is hardly believable that strictures like these might be overlooked by a physician who abides by his texts and science with faith.
Yet while making an argument for mainstreaming Ayurveda in palliative care, it may seem that one is professing exactly so. However, the cautionary note here is in the interpretation of “treating the incurable.” It talks of a physician who lacks in judgement and wrongly diagnoses an incurable condition as a treatable one. This approach then subjects the physician to the above-mentioned perils.
In palliative care, the scope and limitations are clearly defined. As Yogaratnakar has aptly described, that a Vaidya or a physician proceeds by proper assessment of a disease to relieve his patient of suffering. That alone is the duty of the Vaidya for he is a physician and not the Lord to bestow life.
व्याधेस्तत्वपरिज्ञानंवेदनायाश्चनिग्रहः।एतद्वैद्यस्यवैद्यत्वंनवैद्यःप्रभुरायुषः॥(यो. र. पूर्वार्ध. १/९)
[Yogaratnākar, Pūrvārdha, Chapter 1, Verse 9]
This can be the guiding light for the path ahead in palliative care with active integration of Ayurveda for a holistic approach.
- Dorland N. Dorland’s pocket medical dictionary. 29th Edition. Elsevier: 2013
- Five Things physicians and patients should question. Choosing Wisely: An initiative of the ABIM Foundation. American Society of Clinical Oncology (ASCO). Journal of Clinical Oncology.2012. www.asco.org
- Word Health Organization (WHO) World Health (WHO). https://www.who.int/cancer/palliative/definition/en
- Brumley R,Enguidanos S, Jamison P,Seitz R, Morgenstern N, Saito S, et al. Increased satisfaction with care and lower costs: results of a randomized trial of in-home palliative care. J Am Geriatr Soc. 2007; 55(7):993-1000.
- Woodruff R. Palliative medicine: Symptomatic and supportive care for patients with advanced cancer and AIDS. 3rd Edition. Oxford, New York: Oxford University Press; 1999.6.
- Mudigonda T, Mudigonda P. Palliative cancer care ethics: principles and challenges in the Indian setting; Indian J Palliat Care. 2010 Sep-Dec; 16(3):107-110.
- Kristjanson LJ, Toye C, Dawson S. New dimensions in palliative care: a palliative approach to neurodegenerative diseases and final illness in older people. Med J Aust 2003; 179 (6 Suppl): S41.
- Bollini P, Venkateswaran C, Sureshkumar K. Palliative care in Kerala, India: A model for resource-poor settings. Onkologie. 2004;27:138-42.
- Vaidya PB, Vaidya BS, Vaidya SK. Response to ayurvedic therapy in the treatment of migraine without aura. Int J Ayurveda Res. 2010;1:30-6.
- CharakaSamhitā, Sūtrasthāna, Chapter 10, Verses 7-22.
- CharakaSamhitā, Sūtrasthāna, Chapter 8, Verse 19-29.
- CharakaSamhitā,Sūtrasthāna,Chapter 27,Verse 3.
- Beck AM, Balknas UN, Fürst P, Hasunen K, Jones L, et al. Food and nutritional care in hospitals: how to prevent undernutrition – report and guidelines from the Council of Europe.ClinNutr. 2001;20:455-460.
- Beck AM, Balknas UN, Camilo ME, Fürst P, Gentile MG, et al. Practices in relation to nutritional care and support-report from the Council of Europe. ClinNutr. 2002; 21:351-354.
- Kaasa S, Torvik K, Cherny N, Hanks G, de Conno F.Patient demographics and centre description in European palliative care units. Palliat Med.2007, 21:15-22.
- Vāgbhata, Astāngahridayam, Sūtrasthāna, Chapter 2.
- CharakaSamhitā, Sūtrasthāna, Chapter 5.
- Vāgbhata, Astāngahridayam, Sūtrasthāna, Chapter 3.
- CharakaSamhitā, Sūtrasthāna, Chapter 6.
- CharakaSamhitā, Chikitsāsthāna, Chapter 15,Verse 3-4.
- CharakaSamhitā, Sūtrasthāna, Chapter 28
- Sharma PV, Ayurveda kāVaigyānikaItihās. Chaukhambha Orientalia. Reprint ed. 2016; Chapter 4, 245.
- Amin H, Sharma R. Nootropic efficacy of SatvāvajayaChikitsā and Ayurvedic drug therapy: A comparative clinical exposition. Int J Yoga [serial online]. 2015;8:109-16. Available from http://www.ijoy.org.in/text. asp?2015/8/2/109/158473
- CharakaSamhitā,Sūtrasthāna, Chapter 16, Verse20.