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Palliative care, nonprofit healthcare, patient autonomy, holistic approach, eligibility criteria, suffering, Indian healthcare system.

Introduction

The introduction of palliative care into the Indian medical landscape from the Western world has presented unique challenges and opportunities. While the concept originated in Western cultures and is often driven by insurance protocols, its implementation in India requires a subtle approach that considers cultural, economic, and healthcare system differences. In this paper, the advantages of providing palliative care outside healthcare financing schemes, particularly in nonprofit healthcare settings, are discussed. The significance of addressing suffering beyond the conventional six-month prognosis period and advocating for patient autonomy in healthcare decisionmaking is also discussed.

Cultural and Economic Context

The introduction of palliative care in India has been influenced by Western philosophies and practices, which may not always align with the cultural and economic realities of the country. Unlike Western societies where insurance-driven models dominate, the majority of the Indian population relies on government-sponsored healthcare services. Government offers free healthcare through government-run general hospitals or healthcare centers and specialized government hospitals. The services offered in general hospitals are free and can be availed by any citizen but are mostly utilized by the population living below the poverty line or in rural areas. However, these hospitals may have limitations in terms of resources and capacity. The government specialty hospitals, which specifically deal with life-limiting illnesses such as cancer, are accessible only through government-sponsored health insurance. People with these insurances approach these specialty hospitals for treatments, but these insurance schemes have a cap on the amount of money that can be availed.In India, there is a greater dependency on the free healthcare offered by the government, as many individuals feel entitled to it, and the government encourages this dependency for various reasons. This creates a barrier in terms of people not preparing for healthcare emergencies when a serious health issue arises. In many instances, people only register for these government-sponsored health insurance schemes after being struck by a life-limiting disease. Culturally, many people do not practice preparedness for healthcare emergencies, not only in rural areas but also in urban settings [1].

Challenges in Implementation

One of the key challenges in implementing palliative care in India is the mismatch between Western protocols and Indian healthcare realities when Western protocols are taken as guidelines. The conventional model of palliative care, which focuses primarily on medical eligibility and prognosis, may not fully address the psychosocial and spiritual needs of patients and their families. Moreover, the emphasis on insurance-driven models may exclude individuals who do not meet strict eligibility criteria, leading to gaps in care for those who need it most.As previously mentioned, numerous individuals find themselves classified as terminal not only due to delayed diagnosis but also because they lack insurance coverage, either through government programs or privately. There is also a lack of financial preparedness, with government scheme caps often being reached before treatment completion. Some individuals opt not to pursue active treatments by choice, particularly when facing prolonged periods of illness without showing improvement, such as in cases of paralysis or comatose states. Additionally, healthcare costs continue to rise, contributing to the challenges faced in accessing necessary medical care [2].

Advantages of Nonprofit Healthcare Settings

Nonprofit healthcare settings offer a more patient centric approach to palliative care, prioritising holistic care and patient autonomy. Unlike insurance-driven models, nonprofit healthcare settings do not restrict access to care based on rigid eligibility criteria. Instead, they focus on meeting the individual needs and preferences of patients, regardless of their economic status or insurance coverage. This ensures that no individual falls through the gaps in care and that everyone receives the support and dignity they deserve. A major advantage is that both the patient and their family can choose the timing of their palliative care. This empowers families to seek support from these nonprofit organizations at their preferred time without financial implications. This represents a strength in the sense that true autonomy for patients and families is practiced without being bound by the notion that support is only available if the prognosis is six months or less.

Patient Autonomy

In nonprofit healthcare settings, patient autonomy is paramount. Individuals have the freedom to make informed decisions about their treatment options, without being constrained by insurance norms or prognosis criteria. This gives patients the power to pick the care that matches what they want and believe in, making them feel respected and in charge of their healthcare choices. True patient autonomy can mean having no restrictions on decisions, except those imposed by law. When battling a terminal illness, insurance limitations can strip away their true autonomy. In some cases, what seems like guided autonomy can actually mean having no autonomy at all.

Holistic Approach

Nonprofit healthcare settings emphasise a holistic approach to palliative care, addressing not only the medical needs of patients but also their psychosocial, emotional, and spiritual well-being. While these concepts are not new, achieving the true holistic nature of palliative care in the Indian context requires understanding the points discussed above, which explain the time gap between treatments and typical palliative care. This comprehensive approach recognises that a person can be eligible for palliative care not only due to a poor medical prognosis but also by choice. It truly acknowledges suffering beyond the physical symptoms of illness and extends support to patients and their families throughout their journey, even prior to the six-month bracket for palliative care. By considering the whole person, nonprofit healthcare settings provide meaningful support that enhances quality of life and promotes well-being from the time of the choice of the patient or family.

Flexible Eligibility Criteria

Unlike insurance-driven models that prioritise medical eligibility, nonprofit healthcare settings offer flexible eligibility criteria for palliative care. Patients have access to care based on their individual needs and preferences, rather than strict medical prognosis. This ensures that no individual is denied care due to economic status or insurance coverage, promoting inclusivity and accessibility in healthcare delivery.

Extended Support

Nonprofit healthcare settings provide extended support to patients and families facing prolonged suffering, whether due to terminal illness, suspended treatments, or personal choices to forego curative options. This support goes beyond the conventional six-month timeframe, acknowledging the varied experiences of patients and their families and providing comfort and care throughout their journey. By offering continuity of care and emotional support, nonprofit healthcare settings alleviate the burden of suffering and enhance quality of life for patients and their loved ones.

Conclusion

In conclusion, providing palliative care outside healthcare financing schemes, particularly in nonprofit healthcare settings, offers numerous advantages that cater to the diverse needs of patients in India. By prioritising patient autonomy, adopting a holistic approach to care, and offering flexible eligibility criteria, nonprofit healthcare settings ensure that individuals facing terminal illnesses or prolonged suffering receive the support and dignity they deserve. This model of palliative care transcends the limitations of conventional insurancedriven approaches and embraces a compassionate and patient centric approach to healthcare in the complete sense.

1. Ms Padma Sesha Sarada, personal experience as reference (counseling in charge and psychologist, Sparsh Hospice, Hyderabad, India)
2. Ministry of Health and Family Welfare (2024). Health and Family Welfare Statistics in India report.