over the last few years use of short message services ( sms ) and smartphone - based communication applications in health care has shown its wide application and potential to improve access to health care ; enhance efficiency of service delivery ; improve diagnosis , facilitate timely treatment and support public health programmes .
this effective means of communication is providing timely and accurate results to the correct recipient , safeguarding their privacy and confidentiality and avoids misunderstanding and misinterpretation of the results .
there are various uses of mobile phone message services and smartphone - based communication applications such as : appointment remainders ; to monitor chronic medical conditions ; to improve treatment compliance ; to provide psychological support ; managing communicable diseases via contact tracing and partner notification for sexually transmitted illnesses and to promote health promotion programs like smoking cessation .
tata memorial hospital uses many modes of health related e - communications such as web based electronic medical records ( emr ) where patients and families can access their medical records , blood investigations , scans and all patient - related information using an individual patient login key and password .
this information can be accessed at home or any other remote setting using a computer or smartphone .
the other modes of e - communications used are e - mail , short message service ( sms ) , multimedia messaging service ( mms ) and whatsapp ( text , pictures , and video ) .
although these applications are not substitute for face - to - face interview and clinical examination , in most of the situations especially in palliative care setting it minimizes needless transport of the patient , cost and logistics involved .
it also provides a means for quick information sharing , cuts the waiting time and facilitates initiation of the treatment at the earliest .
it also forms a means of communication with local general practitioner and local health care provider such that continuity of the care is maintained .
a 60-year - old pleasant lady , widow , high school educated , who is known to have type 2 diabetes mellitus , ischemic heart disease , and metastatic carcinoma breast with nodal and skeletal metastasis was referred to palliative medicine for symptom control and supportive care . during her initial outpatient visit to palliative medicine department she had 8/10 somatic nociceptive pain over spine and ribs , extreme fatigue , anorexia and had an eastern cooperative oncology group ( ecog ) of 4 .
her mobility was impaired due to severe pain and spine metastasis , which had a great impact on her activity of daily living .
initial symptom control and supportive care measures were instituted and she was referred to palliative home care services where she was triaged as priority 1 ( scheduled home visit within 3 days ) .
the homecare services are coded as high ( 01 ) , medium ( 02 ) and low ( 03 ) priority . in high priority
, patients received home visit in 0 - 3 working days , medium priority , in 0 - 10 working days and low priority , in 0 - 15 working days .
she was on step 1 non - steroidal anti - inflammatory drugs ( nsaids ) + step 3 ( transdermal fentanyl ) + adjuvant ( pregabalin ) analgesics for pain .
the immediate caregivers were distant relatives staying close to her house and visiting her daily .
her niece , who is a practicing dermatologist , was facilitating her ongoing medical care .
patient was fully aware of the diagnosis and prognosis , and maintained a positive outlook toward illness and life .
she was on a regular follow - up with palliative home care and over next few weeks on a weekend she developed diplopia and painful weakness of the right upper limb .
information of her illness was shared with the palliative home care doctors by her niece via text messages , patient pictures and a video through whatsapp .
the doctor reviewing these e - communications requested for an urgent mr brain and plain x - ray of right shoulder .
mr brain was suggestive of base of brain disease with leptomeningeal and skull base involvement .
plain x - ray of right shoulder was suggestive of pathological fracture . scanned copy of the mr and x - ray reports were sent to the local general practitioner and management plan for raised intracranial tension and pathological fracture was communicated .
patient 's daughters who returned to see her mother was in constant touch with the palliative home care doctors through call and text .
they frequently use to send patient 's pictures and reports and occasionally patient videos via whatsapp and on call palliative homecare doctor was able to provide after - hours consultation .
the timely symptom management improved the quality of life of the patient and caregivers were very satisfied by the support they received .
her analgesic doses and complications ( seizures , aspiration pneumonitis ) were managed at home with the help of local general practitioner support with continued input from palliative home care . with this process needless hospitalization
we felt smartphone applications played a crucial role in providing timely and continued palliative care input .
a 64-year - old gentleman , known hypertensive , having advanced stage of adenocarcinoma of stomach with peritoneal metastasis , bilateral pleural effusion , and ascites was referred to department of palliative medicine for symptom control and ongoing supportive care .
ascites needed paracentesis to relieve dyspnea and patient was maintained on oral frusemide / spironolactone combination for both ascites and edema .
the daughter was counseled and poor prognosis of the patient was discussed . as per patient 's wishes , patient was cared at home .
the wife was elderly , not literate and had poor perspective of illness or care process .
the son was a young adult who studied and worked simultaneously and had little involvement in the care process .
the daughter was married and has an 18-month - old child and resided in a different place .
she was the major support and was main portal for communication between palliative home care team and family .
she used whatsapp to send text messages , patient images and patient videos to the team .
the team worked in close liaison with the family physician , which helped in maintaining the continuity of care .
patient had a sudden worsening of clinical condition due to malignant bowel obstruction and also developed acute renal failure secondary to obstructive uropathy . in accordance
to patient 's wishes and preferences , patient was managed at home with iv hydration , nasogastric tube , anti - secretory drugs , transdermal fentanyl and iv steroids .
progress of management was monitored through continuous exchange of images and videos through whatsapp and symptom control was assessed through direct patient interview via video chat .
this process complemented the homecare provided and enabled the daughter to balance her time both at work and home .
patient died peacefully at home and the total duration of home - based palliative care contact was 39 days .
bereavement follow - up showed patient 's family was coping well and were pleased with the care provided .
a 60-year - old pleasant lady , widow , high school educated , who is known to have type 2 diabetes mellitus , ischemic heart disease , and metastatic carcinoma breast with nodal and skeletal metastasis was referred to palliative medicine for symptom control and supportive care . during her initial outpatient visit to palliative medicine department she had 8/10 somatic nociceptive pain over spine and ribs , extreme fatigue , anorexia and had an eastern cooperative oncology group ( ecog ) of 4 .
her mobility was impaired due to severe pain and spine metastasis , which had a great impact on her activity of daily living .
initial symptom control and supportive care measures were instituted and she was referred to palliative home care services where she was triaged as priority 1 ( scheduled home visit within 3 days ) .
the homecare services are coded as high ( 01 ) , medium ( 02 ) and low ( 03 ) priority . in high priority
, patients received home visit in 0 - 3 working days , medium priority , in 0 - 10 working days and low priority , in 0 - 15 working days .
she was on step 1 non - steroidal anti - inflammatory drugs ( nsaids ) + step 3 ( transdermal fentanyl ) + adjuvant ( pregabalin ) analgesics for pain .
the immediate caregivers were distant relatives staying close to her house and visiting her daily .
her niece , who is a practicing dermatologist , was facilitating her ongoing medical care .
patient was fully aware of the diagnosis and prognosis , and maintained a positive outlook toward illness and life .
she was on a regular follow - up with palliative home care and over next few weeks on a weekend she developed diplopia and painful weakness of the right upper limb .
information of her illness was shared with the palliative home care doctors by her niece via text messages , patient pictures and a video through whatsapp .
the doctor reviewing these e - communications requested for an urgent mr brain and plain x - ray of right shoulder .
mr brain was suggestive of base of brain disease with leptomeningeal and skull base involvement .
plain x - ray of right shoulder was suggestive of pathological fracture . scanned copy of the mr and x - ray reports were sent to the local general practitioner and management plan for raised intracranial tension and pathological fracture was communicated .
patient 's daughters who returned to see her mother was in constant touch with the palliative home care doctors through call and text .
they frequently use to send patient 's pictures and reports and occasionally patient videos via whatsapp and on call palliative homecare doctor was able to provide after - hours consultation .
the timely symptom management improved the quality of life of the patient and caregivers were very satisfied by the support they received .
her analgesic doses and complications ( seizures , aspiration pneumonitis ) were managed at home with the help of local general practitioner support with continued input from palliative home care . with this process needless hospitalization
we felt smartphone applications played a crucial role in providing timely and continued palliative care input .
a 64-year - old gentleman , known hypertensive , having advanced stage of adenocarcinoma of stomach with peritoneal metastasis , bilateral pleural effusion , and ascites was referred to department of palliative medicine for symptom control and ongoing supportive care .
ascites needed paracentesis to relieve dyspnea and patient was maintained on oral frusemide / spironolactone combination for both ascites and edema .
the daughter was counseled and poor prognosis of the patient was discussed . as per patient 's wishes , patient was cared at home .
the wife was elderly , not literate and had poor perspective of illness or care process .
the son was a young adult who studied and worked simultaneously and had little involvement in the care process .
the daughter was married and has an 18-month - old child and resided in a different place .
she was the major support and was main portal for communication between palliative home care team and family .
she used whatsapp to send text messages , patient images and patient videos to the team .
the team worked in close liaison with the family physician , which helped in maintaining the continuity of care .
patient had a sudden worsening of clinical condition due to malignant bowel obstruction and also developed acute renal failure secondary to obstructive uropathy .
in accordance to patient 's wishes and preferences , patient was managed at home with iv hydration , nasogastric tube , anti - secretory drugs , transdermal fentanyl and iv steroids .
progress of management was monitored through continuous exchange of images and videos through whatsapp and symptom control was assessed through direct patient interview via video chat .
this process complemented the homecare provided and enabled the daughter to balance her time both at work and home .
patient died peacefully at home and the total duration of home - based palliative care contact was 39 days .
bereavement follow - up showed patient 's family was coping well and were pleased with the care provided .
moribund patients with advanced life - limiting illness can receive continued care at home with the help of collaborative and ongoing support from the palliative home care team and local family physician .
audio - visual communications aided through smart phone applications can improve this facilitation . using applications like whatsapp messenger , which allows the user to share clinical images , clinical video , photograph of reports
, photograph of medications and text messages can bring palliative home care management to a new level by enhancing the channels of communication between patient , palliative care doctor , caregiver and local family physician .
this technology is useful in palliative care for the patients lacking access to medical services due to both debilitating medical condition and geographic isolation . a study done by coyle et al
. demonstrated certain benefits such as limited need for daily physical examination and assessment , screening for a need for a clinical visit or admission , communication assistance to patients who can not speak or hear and increased satisfaction by the patient and the caregivers . in a palliative care
setting it also decreases monetary burden on caregiver as it saves the cost of travel and consultations and prevents unnecessary hospital admission and investigations .
the current smartphone applications like whatsapp messenger is much cheaper and easily available when compared to the teleconferencing systems .
the most teleconferencing solutions pertain to the transfer of electronic medical data from one institution to another , only a small percentage of such programs can be applied to home health care .
it is a worldwide phenomenon to incorporate the newer technologies into the field of health and social care , even though there is lack of evidence to support this .
the rapid development , adoption and use of various smartphone applications also present with crucial challenges for clinicians and users .
the important challenges are to ensure patient confidentiality , safety , establish cost - effectiveness and engage patients and clinicians to optimize their use in health decision - making .
although healthcare and academic institutions should support the improvements offered by technological advances , they must do it within a supervised framework , after thoroughly evaluating clinical outcomes and unintended consequences .
challenges in using mobile phone applications in health care also include incomplete coverage of mobile networks across regions , lack of standards , and possible information overload . at present
we have a mobile user society and the worldwide deployment of mobile and wireless networks and the wireless infrastructure in health care is able to provide healthcare to anyone , anytime , and anywhere without constraints of location or time .
it 's application in palliative home care has demonstrated significant improvement in control of physical symptoms , address non - physical issues and improves patient satisfaction .
special attention needs to be given to its potential benefits and challenges in palliative care and certainly its open a new area of research in palliative care .

 smartphone applications in palliative homecare are a novel cost - effective approach in providing timely and effective careimproves symptom control , helps in continued care at home and prevents unnecessary hospitalizationimproves patient and caregiver satisfaction .
smartphone applications in palliative homecare are a novel cost - effective approach in providing timely and effective care improves symptom control , helps in continued care at home and prevents unnecessary hospitalization improves patient and caregiver satisfaction .
 smartphone applications in healthcare delivery are a novel concept and is rapidly gaining ground in all fields of medicine . 
 the modes of e - communications such as e - mail , short message service ( sms ) , multimedia messaging service ( mms ) and whatsapp in palliative care provides a means for quick tele - consultation , information sharing , cuts the waiting time and facilitates initiation of the treatment at the earliest . 
 it also forms a means of communication with local general practitioner and local health care provider such that continuity of the care is maintained . 
 it also minimizes needless transport of the patient to hospital , prevents needless hospitalization and investigations and minimizes cost and logistics involved in the care process . 
 the two case studies provided highlights the use of smartphone application like whatsapp in palliative care practice and demonstrates its utility . 
INTRODUCTION
CASE REPORT
Case 1
Case 2
DISCUSSION
CONCLUSIONS