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Accent. Great. Thank you very much. So, hello everyone. My name's Sean Creche. She, I'm a palliative medicine physician in Scotland here in the United Kingdom. And yeah, really pleased to be with you today. I'm going to be talking about management of emergencies in palliative care. So we're going to be going through today just a reminder of the key principles of palliative care before getting to what I actually mean when we say what is a palliative care emergency? Because I know it probably sounds a bit odd to be thinking about emergencies and palliative care. Then we're going to be looking at four clinical case studies each covering one of the big four palliative care emergencies. And I'm not telling you up front what specific emergencies we're going to be covered because when we look at the cases, I want us to be thinking um a bit about what's going on and try to see if you can come up with the diagnosis yourself before I give the game away. So um about we will, we will be defining what the emergencies are as we go along. And then finally, we'll have some resources um and some suggestions for further study following today's presentation as well. By the end of the presentation, I would like you to be aware of the major emergencies, particularly the big four major emergencies which occur in a palliative care context, including the presentation of these emergencies and the principles of their management. And I have done a previous lecture as part of this series where I coverage the principles of palliative care symptom management and there was some really good interaction from the students. So as we go along, there will be times where I'm asking questions and it would be really good if we could all contribute, even if you're not able to come on Mike. But just to type in in the chat, I'd really like to hear what you think and what you understand about the questions as we go along. So to start off with as a reminder of what we are talking about with palliative care and some of the general principles um did go over this in more detail in the previous lecture. But just as a reminder, here is one definition of palliative care, which is an approach that improved the quality of life of patient's adults and Children and their families who are facing problems associated with life threatening illness. It prevents and relieves suffering from the early identification, correct assessment and treatment of pain and other problems, whether physical psychosocial or spiritual. So quite a mouthful and quite difficult to get your head around when you're trying to really understand and get to grips of what palliative care actually is. So I offer this alternative and more simple definition, which is the idea of adding life today's not days to life. So if we think about it in this way, we can see that palliative care is an approach to care which emphasizes quality of life, not necessarily lengthening life. So when we're thinking about treating patients with life limiting or terminal illness, with palliative care, we're emphasizing the quality of their life, not the length of their life. And yes, palliative care considers these four major domains, the physical, which is yes, is very important and is often what we're very concerned with as doctors as, as the physical side of things like pain and other symptoms. But we work as a multidisciplinary team as well. And we're considering the patient as a whole and taking a holistic approach. So thinking about the physical domain, the social, the psychological and the spiritual experience of their illness. And yes, end of life care is important and end of life care is included in palliative care. But palliative care is not just care for someone who's at the very end of their life or someone who's in, you know, dying in the next few days, hours. Palliative care is important even from the point of diagnosis with a life limiting illness and helping to enhance the patient's life from the point of their diagnosis. So I have gone into more detail about palliative care. And the general approach is that we take two symptom management, not in emergencies, but a general approach is in a lecture which I've given already on the second of March. But you should be able to watch that on the medal website when it's up uploaded soon if you weren't there for the first lecture, and I will be giving a second part to that lecture next week as well in the 21st of March. Uh So now thinking about what we are going to be covering today, building on what we already understand about palliative care generally. What is a palliative care emergency then? So it seems quite strange, doesn't it? Because we've spoken about how palliative care is all about adding life. Today's, it's not about uh focusing on life extending treatment or necessarily life life saving treatment. So what do we mean when we think about palliative care emergency? So there's multiple, multiple definitions. I'm sure you could find about what a medical emergency is, but this is just one simple definition or do you think about an emergency in any medical context? Think about a situation that if left untreated will immediately or imminently threatened life. So that's what we think about when we say a general medical emergency. So what then is a palliative care emergency? What do you think I'd like to hear from you? So, t has written in the chat if patient's are in acute pain or respiratory distress, which medication can be given? Sub R I M please. Um So I, so at the moment, we're talking about power to care emergencies. Um When we think about patient's with acute pain or respiratory distress, um this was covered, was covered more in more detail in my previous lecture and will be in the second part of the lecture that I give next week about pain and breathlessness management. So the simple, the simple answer is that we would think about opioid medication in patient such as that. Um but we won't be going into detail about that today, but I would advise you to watch my other lectures about that. So, but think about the question that we're asking at the moment about what a palliative care emergency is. So a Neela has written in the chat, a palliative care is focused on improving the overall wellness of people with serious illnesses. Yeah, very good since it's based on individual needs can be different from one person to the next alleviating symptoms improve. Yeah, these are all good definitions about palliative care. But what is the palliative care emergency? Do you think? So there's a couple of hands up, hands up and so Assad, did you want to speak? Uh just as the definition goes from the palate, a person who is are suffering from a chronic disease in which has lead to not a good lifestyle or uh hindrance of the life, day to day life. So they need the care. But if they're not getting any care or not getting any support, like in a financial sense, but sometimes palliative care is not cheap. Some sometimes it get by charity but sometimes it's not cheap. So the failure of getting a palliative care either via emotional support or family and support or medical support can lead to an emergency which can the person can the tends to suicide or some other alternatives such as the skin. So these are the questions you can support. Okay. Yeah, these are good, good ideas. And I think you certainly have a good understanding of, of palliative care. Any kind of things that patient's will be going through. Um Christie, did you have your hand up as well? Yes, I was, I was just going to say, you know, these group of patient's who was already uh got an established diagnosis where they are going through palliative care and uh they have developed symptoms which could be reversed to improve their quality of life. And that certain time period, it could be a severe acute pain, uh the background of chronic pain or it could be uh severe breathlessness, bowel, obstructions, uh ablations and that kind of symptoms. Yeah. Excellent, excellent. All good ideas. And I see Jeb is written in the chat as well, maybe reversible causes which can lead to death ultimately. So this is all very good you're definitely thinking along the right lines. And so it was a bit mean of me to ask you that question actually, because it is quite difficult to get your head around. So if you think about just, you know, generally working as a doctor across most specialties, we think about a medical emergency is when something is immediately or imminently, life threatening to a patient that in palliative care, a palliative care emergency. We think about something being um if it was left untreated, seriously threatens the quality of life of the patient and then there's the quality of the remaining life of the patient. So hopefully, when we get into the kind of Caucasians, you'll see, you'll see what we mean. Um And actually, you know, Christy has already mentioned at least one of the one of the type of diseases that we're going to be talking about today. So generally, yes, good, good politic care is planned and politic care is not an emergency service generally. Um But emergencies do occur and they require prompt assessment and treatment decisions and thinking about the fact that these can, can occur in our patient's or may occur in our patient's allows us to plan, make a plan in advance and overall provides and anticipate these emergencies coming up and provide better care. So now that now we're getting into the clinical cases and this is just a reminder that when we talk about the management here of the disease is, we're talking about the management of emergencies in the context of a patient with a life limiting disease. So this is, this is very different from what an A and E doctor which tell you to manage a patient who is young and healthy and doesn't have any comorbidities coming into the emergency department with an in an acute crisis. That's a very different thing. Today, we're talking about palliative care context where we know that these patient's have a life limiting disease and have, you know, months or weeks only left of life due to their diagnosis. Um I'm not talking about thing management at kind of an an advanced level and going into all the details of what we might do here in the UK with the, the privilege of access to lots of different types of drugs that we might have here. So focusing on much more on kind of more simple pragmatic things that you might do in these situations. Um and just to note as well that these cases aren't based on any real patient that kind of amalgamated hypothetical um cases to convey the point. So start off then with her first case today. So this is a case of a young female patient, 45 years old, she got cancer of the larynx, uh squamous cell cancer and initially treated with curative intent two years ago. Um she did have uh surgery and adjuvant radiotherapy. However, unfortunately, her disease record and she had some further um surgery and chemo radiation with palliative intent in the past year. But now her disease is continuing to progress. She unfortunately is progressing despite the previous treatment she's had and she's not now going to have any further oncological or surgical treatment. So this, she's got this, this head and neck cancer which is advancing a lot locally. She doesn't have distant metastases, but it is growing bigger um within her head and neck and is starting to um advance and invade into local structures. So, you know, thinking about palliative care for our patient such as this, remember, we talked about the principles of the physical, social, psychological and spiritual domains. I mean, there's probably a huge amount going on in this patient's life right now. If we were going to take a palliative care approach to her management and her holistic care, you think about the physical domains, like all the things that might maybe going on for her, she's got this horrible laryngeal cancer. How is that affecting her ability to swallow medication, taken nutrition and hydration? Um probably very painful and you think about the fact that it's probably invading into local nerves as well. So she probably has, you know, make sure of different types of pain. How is this affecting her breathing? Does she need a tracheostomy? Everything about the psychological side. I mean, this is such a significant illness to be affecting her, to know that it's progressing, she's probably highly anxious as anyone would be. And then if she's got these other symptoms as well, like pain and breathlessness and remembering that breathless, feeling, breathless can contribute to anxiety. Um And then just the fact she doesn't exactly know what's going to happen. There's a lot of unknowns and uncertainties and then the social size, I mean, she's only a young woman so she's, she might have a family, she might have young Children. This isn't just effect. She not just got to worry about the effects of her illness on herself. She's gonna worry about how that affects everyone else around her and everyone she cares about. And you know, does she, does she have a job? What's her financial situation? And is she worried about how her Children are going to be looked after after she dies? And then there's the spiritual side. The big existential question is like, why has this happened to me? And there's probably so much more that she wanted to do with her life at this age is feeling that she's got needs and wants her unfulfilled. And we don't know anything about her religious faith yet either. We would need to find that out, but she may have religious needs that needs to be addressed. So, in the palliative care context and um you know, forming a holistic management plan for this patient, there's so much to think about and this is the exact type of um you know, complex um palliative care patient that we want to help across all these domains to improve the quality of life that they have for the remaining um time that they have left. However, today we're not going to be focusing on all these different aspects I mentioned today, we're focusing on one aspect which is thinking about um a palliative care emergency which we should be suspicious of um in a patient such as this a palliative care emergency that we need to be prepared for in a patient like this. Um Does anyone know what uh what emergency presentation may come may come up in this patient? Um like say that imagine you're seeing this patient and you can even see just from looking at her at the end of the bed that her face in her neck are swollen because the cancer is advancing so much into the structures of her neck. Trying like uh so some of such strider I think. So that's, that's a very good idea. Yeah, Stridor is possible. It's not SVZ compression. Okay. So um this, if you imagine this cancer is not progress is not advanced um inferior early into the thorax. Um So s we see, oh um not, it's not at that stage to have advanced to impede on the superior vena cava. Um Okay. What about, but I like the fact that you're thinking about blood vessels though. Can you think about another major blood vessel which is in the neck, the corroded um compression, uh um yeah, carotid artery is right. So, so Jeff has written respiratory obstruction as well. So, yeah, these are all good ideas and you're right that strider could, could um be a problem, but that's not in this specific case. So we are thinking about the carotids and this was actually I should I show you the next clue. Uh The patient might drop the BP because if the airways occluded, it might not be having enough oxygen for the heart to work properly. So the BP might drop. Yeah. Australia therapy, karate erosion is possible if there is uh extending cancer that can erode the carotid artery. Yeah, the lottery rupture is the major emergency. Yeah, exactly. Exactly. So, um you know, all, all these um the ideas that you've all come up with, there are all things that could potentially happen, but we're thinking about, you know, the most likely emergency that's gonna arise in a patient's such as this, we are, you know, some of these things we are going to talk about later on with some of the other clinical cases. But right here we're talking about, I'm not the potential for a massive bleed and it's like a terminal bleed. So, um there is various ways of thinking about, you know, what constitutes a terminal blade. This is just one of definition in which comes from the UK Palliative Care guidelines, which we think about a, a major arterial hemorrhage from a patient in whom active treatment is not appropriate or possible in which will inevitably cause death in minutes, loss of more than 1.5 liters and 30 seconds. So, we're thinking about if you imagine if someone has a major bleed from the carotid artery, um really losing a huge amount of blood in a short period of time. So these are really patient's who quite frankly bleed to death in front of our eyes. Um And again, really emphasizing that what we're talking about here is a palliative care context. So yes, in a, in a patient who doesn't have a, doesn't have a life limiting disease. And you know, if you're calling an ambulance for and is rushed into any, you would take a different management approach. But in here, you know, we're dealing with a patient who has advancing cancer that we know we can't treat and it is only going to get worse and we know that she is going to die at some point soon. So we're preparing for the worst and thinking what if this lady has a massive hemorrhage? Um and this is something which is a very feared complication, especially with head and neck cancers. You think about the local structures in the major blood vessels and it can be very distressing for the patient to experience. And as you would might imagine for the relatives to witness as well, and this is something that we think about or have to deal with in palliative care. Um because we think about the different types of pathology and that we see in our patient's, there may be structural invasion of vasculature. So that might include like we said, head and neck cancer, the carotid artery, but also, you know, pelvic disease, which might invade into the femoral artery. We also have patient's who have clotting pathology like huma to logical militants team. And you know, we don't just treat cancer patient's, we treat patients with all types of life limiting disease. So we have end stage liver disease, patient's as well who have portal hypertension and may have esophageal varices and upper gi bleeds and think about the the types of drugs that are patient's are on as well. So that may be iatrogenic causes as well for blades such as anti coagulation and steroids. So he's staying again again. This is a young lady, 45 years old. She's got a life limiting diagnosis of this advanced head and neck cancer is getting bigger and it's invading into local structures in the neck. And let's just, there are some patient's in whom you have um a warning bleed. So they may have uh you know, a relatively small bleed that proceeds a much larger terminal bleed. But let's just imagine that this is a patient who she hasn't bled yet. And as far as you know, it hasn't occurred to her that she might have a terminal bleed. Um, what would you do? Do you think you would tell the patient, do you think you would tell her relatives that this might happen? What would you do? Um, I think you need to be, um, open with the relatives and have, uh, pragmatic expectations and, um, make them able to deal with this when the moment comes that you have to make these announcements, you need to make them aware of the situation. Um Yeah, that's a good, yeah, that's good. I mean, again, this is uh this is a difficult question. I'm not expecting you to. Um no one answered. It's 100% right or 100% wrong, but it's, it's a joy ing uh it's a dilemmas that you will come up against in clinical practice um and impacted care. So maybe you'll have a better we talked about about the management and you'll have a bit of a clearer idea about what you would do in this situation. So, um we think about the pharmacological management of a patient. So let's say, I think about a patient is absolutely gushing blood in front of you. Um And they're losing so much blood that they are going to die in the next few minutes. Um So pharmacologically what we could do for a patient like this, um because this is going to be very, very distressing thing for the patient to experience at the end of their life is that we could give them a high dose sedative agent. So for example, we might, if we have access to benzodiazepines, we might give them an injection of midazolam 10 mg. Um Can anyone think about what route we should? You know, I've already said injection. So, you know, it's an injection, but you can you think about what route exactly we should use for if we were going to give a midazolam to a patient like this baby. Uh So that's a good idea, some good other ways. Yeah. So in this context, I would advocate to give the patient um this injection through the intra muscular writ rather than intravenous or sub cart. Um So a couple of it, I mean, intramuscular is pretty remembering that you're probably going to be pretty worked up as well if you're seeing a patient who's experiencing this because it's, it's a pretty horrible thing to see. Um So intramascular is quite easy to do in a hurry. Um But more importantly from the patient's point of view, remember that if someone is losing that much blood, suddenly the whole vascular system is gonna vasoconstrictor and they're gonna go into shock. So the the vascular access is not going to be good, the their blood flow is not going to be good. So the the intravenous route is not going to be as effective as the intramuscular route in this uh context. However, I actually I have put pharmacological management lower down because I don't think that's going to be, I don't think that should be our primary um thought process when we're managing a patient like this. And if you just imagine that if uh you're with the patient on the ward and then this was to happen, um I don't, you know, and you to imagine you to run off, try and find some Midazolam draw, you know, you're probably a bit worked up so you might drop it. You, you, you'd have to do it again. You come back in the room all this time, you left the patient on their own. Um, um, and by the time you've got, you've got them a dad'll, I'm ready to give the patient's either unconscious or they've died already. Um, and they've been left on their own through this horrifying experience. So, actually, yes, pharmacological management is appropriate, but I think the most important thing is to think about the non pharmacological things that we could do. So we shouldn't leave the patient on their own. Um The good thing about being prepared to think about what this, this might, the fact that this might happen is that we can, you know, have something set out in advance, we can have what we use this dark towels and so you can even have red towels. But some people use um, green or blue towels, but basically is the patient lying there and they're bleeding and they see their blood that can be very distressing for them. But if you lay the towels on top of them to absorb the blood, it doesn't, um the idea is that it doesn't uh look like there's as much blood as the rest. Um Really, uh this is obviously going to be very difficult given the circumstances, but really trying to reassure the patient maintain uh and environment as possible. Um And you know, it may not be appropriate, get depending on the patient and the exact circumstances, but thinking about the recovery position and applying pressure to where they're bleeding from as well. Um So the priority is different if there's, there's someone else you can stay with the patient, but the priority um should be with trying to maintain as let less distressing an environment for the patient as they can have and not leaving them on their own rather than running off and getting the Midazolam and bringing it back. If there's someone else who can stay with the patient, then yes, go and get the med as lamb and but prioritize the non pharmacological management of this emergency rather than the pharmacological. Uh Did you put your hand up? Uh what if the patient, let me tell them everything, the situation and what just uh so sorry. I I couldn't quite hear what if the patient after explaining the patient everything like it's the diagnosis, what uh complications they had treatable or untreatable. They give them the explain the possibilities that you think of them? What if, after, even after buying a good parent, if the patient starts asking for an act of urination, how should we, should we talk it, talk the patient out of it or should we get the coat? Get the one with the case as a high goats to get involved in this? Should we wait or, uh, depending or we should tell them, I think a few days and then I think again, we should just follow through with it. So, um I can't, I couldn't um catch everything you said. But what I think you said was that what if you to explain the patient the situation? And they ask, let me ask, let me say, let me say it again. If you can tell after telling everything like every prognosis, you know what is going to happen, what is their condition right now? The definition is like uh uh we tell every possibility treatable or untreatable, we tell them everything. And after knowing all this, what if the patient starts demanding for you? The nation? Yeah. So what should we do? We should show to wait or we should tell them to think again. We should. So what your question is? What should you do if the patient asked for euthanasia? Yes. Okay. So, I mean, I, I think it's important to understand that, you know, palliative care is completely separate from euthanasia. And so, you know, what we do is try to enhance people's quality of life, what we do, we don't end people's life, which is what euthanasia is. Um, so the issue of euthanasia is such a huge topic. Um, and it's not the topic that we're discussing in this lecture today. So it's not, it's too big a topic to try to cover quickly. Um, and it's also going to depend, um, a bit on what both were the attitudes and what's legal in the country in which you're practicing. Um So, for example, in Candida, in the Netherlands, in um some places in the United States, there are um they do have legal processes towards euthanasia in the United Kingdom where I live and where I work that we do not have euthanasia here, it's not legal. Um And it's not something that I'm involved with in practice. However, I think, you know, regardless of that, you're right, that patient's can, patients can feel suicidal, patient's can want um euthanasia. Um And it is a very difficult thing to deal with. Um So I think it's not, there's no simple answer to that. Um And we're really thinking about remembering the physical, psychological, social and spiritual domains of someone's care. We're trying to think about what we can do for this individual patient to make them as comfortable as possible as under stressed as possible and have as good a quality of life as possible. And so that might involve, you know, counseling and other things to try to um improve the quality of life. Um, but um, euthanasia is not something that I um involved in and would always try to encourage um, a patient to live and to have as good a quality of life as possible. So that was so we've spoken about management of terminal blades. And so hopefully, that's given you a bit more perspective on what you would think about if you were to tell a patient. I mean, in this case, I would advocate that we should be telling patient's in the relatives that this could happen if you think about this young woman and that allows you to put things in place like having those dark towels there, um having the medication ready, making sure that someone stays with a patient if this was. Uh so we're going to move into our next emergency now. So we think about a six year old patient has got metastatic renal cell cancer. They previously had anticancer therapy, but they're now not for any further oncological treatment. So we know that they have a life limiting diagnosis. They are going to die from the renal cell cancer overall. They have a pretty good performance status. Um So they, you know, they're not um at the quality of life that they were when they were before the diagnosis of candidate, but they have a pretty good quality of life posturing around at home, living with their wife. Um and pretty normally pretty uncomplaining. But today you've been contacted by the patient's wife. She's concerned that her husband is confused and she also mentions that he's been more unwell the past couple of days and mentioned constipation. So at this stage, there is so many things that could possibly be on your mind is a differential diagnosis causes of confusion in this patient is a bit like how long is a piece of strength? So you really need more information, you need to assess the patient. So you go to, you go to see them and you find that they're dry, dry mucous membranes, sunken appearance. So they're, they're dehydrated but they're apyrexia. Well, so maybe infection is less, is lower down on your list of differentials. Um They're quite slow to celebrate, they're hypoactive, they're generally uncomfortable. Um You examine their, their abdomen and it's a bit full like they're constipated, but there's no guarding and they're just generally tender and not right? And they're going to the toilet frequently, but they're not opening their bowels. They are constipated, but what they're, they're doing is they, they're peeing a lot when they go to the toilet. So they have polyuria. Um So that might really think, oh, is this patient hyperglycemic? But then you check their blood glucose and their blood glucose is normal. It's fine. Um So you do some blood results, you do some blood tests on, you get the results. Uh So you might be thinking, have they got an acute organ dysfunction and you see that the urea and creatinine are mildly elevated. So, but um not elevated enough to think this is an acute kidney injury which is causing uh their presentation. But then you find that they have a corrected calcium which is very elevated. So, this patient has hypercalcemia. So, hypercalcemia is very common in cancer. Um it's most common breast lung prostate myeloma and renal cancers, but can, can present in other cancers. Um We often think about the impatient with bone Mets, but that's not always present. And we remember that the majority of um malignancy associated hypercalcemia cases are caused by parathyroid hormone related protein, but rather than osteolytic metastases. So we should think about it as a differential in all cancers, not just those with bone Mets. And it may, it's very important to think that this may present like advancing disease. So it can, it's, it's not uncommon to have a patient that, you know, is dying. You know, they have a life limiting diagnosis and then they present as if they are um now deteriorating and they can actually look like they're, you know, this is the very end of their life and you might think, oh, this is all just down to the cancer until you check the calcium. And there's very few things in medicine where you, someone looks like they're about to die and then you can relatively simply correct a problem and then they can have a new, almost a new lease of life. But hypercalcemia is one of these things. So it's very important to check for in a patient with advanced cancer who is deteriorating. So in terms of how we would manage these patient's, um first of all, our main state is rehydration with crystalloid to replete the volume that they've lost your dehydration, but also to increase reno calcium clearance. So, I mean, because of, you know, if you check some of the guidelines, they say really quite high levels of um fluid to be given within 24 hours, but reduce in comorbidities, you know, the patient's that I treat almost all our frail with comorbidities. So we're really looking at something like 2 to 4 liters, normal sailing within 24 hours. Um you know, in mild cases of hypercalcemia, the fluids treatment may be enough, but really with advanced cancer, we would be expecting that we need to give something else. So we're starting up with the re hydration and then we want to reduce the bone release of calcium by using bisphosphonates and they're poorly absorbed by the oral route. So we are giving intravenous bisphosphonate. So, um here in Scotland, what we would normally give with the zoledronic acid 4 mg. Um And we'd expect that to start to take effect within four days and then we'd last about four weeks and that would normally reduce hypercalcemia in um about 90% of cases. So then if we think about our elderly or are older patient who had advanced cancer looked like they were dying from the cancer. But actually when we checked the bloods, um, they had a high calcium and now that we've reversed the high calcium, yes, they still have a life limiting diagnosis. Yes, they're still may die from their cancer in the next, you know, few months to a few weeks. But actually you've managed to revive them to such an extent that the confusion is gone. And for the time that they have left, they can still have a relatively good quality of life. So I would like to drill home with you all that. You always remember to check calcium and your patient's and reverse what is reversible. Okay. So now moving on, just going a little bit swifter now, just because with awareness of the time we have left, but now moving on to K three. So given some of the answers that you've already provided uh with, with case one, I'm expecting you to get this case. No problem. So we think about a 65 year old man with lung cancer, pulmonary and plural Metastases and now he's increasingly short of breath in the last week. His family is that they think he's looking more puffy. So is there something I wonder if there's already something on your mind about what you might think about with a patient with lung cancer who has become more short breath and is now appearing more edematous. So maybe there's something already on your mind. But let's, let's see what you find an assessment. So, assessment, you find upper limb edema, distention of the neck veins, dilated collateral veins, facial swelling, he's breathing faster. I is a bit blue. So what, what do you think the diagnosis is here? Yes, we ceo heart failure. Okay. So yeah, SPC oh is the answer someone else had heart failure? Um So that is a good thought. So I think that would definitely be in your differential. But imagine you go to see a patient um with we're talking about patient who's upper body offer thorax, arms, face neck is edematous, but out of proportion to the way that their legs are a dermatitis. So that was that would be unusual for heart failure, heart failure. We're thinking more about dependent edema. So um lower limb adama more so than upper limb. So in this case, upper limit edema, we're thinking SPC oh especially in the context of lung cancer. So yeah, you see in this image, we can see the distended um thoracic uh SPC. Oh Was that? Yeah. So I'll show you superior vena cava obstruction. So it's obstruction of the superior vena cava blood flow, which can be caused by external compression or direct invasion by a tumor or it could be caused by a thrombus directly in the superior vena cava. Um It may present acutely or it may be more subtle insidious presentation and the most common causes lung cancer. It's very rare to have this condition um for a non malignant reason, but it may be the first presentation of cancer. So this may be a patient may present like this and it may be the first time you or they have known that they have cancer, right? So, in terms of what you're going to do about a patient with superior vena cable obstruction. Well, you need to do something. Um So this patient has one of the great vessels compressed. Um They are, you know, if they don't have sufficient venous, return, sufficient um cardiac output and this can, you know, progress to coma and increasing confusion and death. Um However, we're thinking about our patient group who have advanced cancer, life limiting disease. So, the extent of what you can do is going to depend a bit on what their overall condition is. How close to the end of life you think they are and the severity of the disease. So kind of more invasive or intensive things would be to discuss with our oncological colleagues about radiotherapy. Um in some cases, they may give chemotherapy as well like a small cell lung cancer, which is very responsive to chemotherapy. Or we might speak to our colleagues and interventional radiology about putting in a stent as well um to widen the superior vena cava from the inside. And then what could we do uh which is more conservative and less invasive, which are things that we can do for all patient's not only those who are, who are well enough to um go to the Oncology Hospital and go to the radiology suite. So we give high dose steroids to reduce swelling. Um So we'd give start off with dexamethasone, 16 mg in 24 hours and remembering to give gastro protection with a PPI as well and not forgetting. Very importantly, symptomatic treatments. So, morphine for breathlessness or benzodiazepines for breathlessness and anxiety and all those other things that we think about, which are very important um in palliative care, holistic care, encompassing the physical, psychological, social and spiritual domains, so forth case, we're now into the fourth of a big fourth of the big four major emergencies and palliative care. Um So, I don't think this is one that's come up in conversation so far. Um But um yeah, hopefully you'll be able to uh it's one that you recognize quite easily. So you think about a 62 year old man with metastatic prostate cancer, we know that he has multiple skeletal metastases, including vertebra metastases and but overall his disease is stable. Yes, he does have a life limiting diagnosis. Um But as far as you know, it's not advancing particularly quickly and he's, he's relatively stable on hormonal treatment for the prostate cancer. He has chronic back pain. Um but he manages all right at home. He described himself as having aches and pains as he goes along. Um and he's already on an established morphine regime. So he does remember if you were at the last presentation when we spoke about managing pain, we spoke about patient's on regular morphine and the prn add required morphine. So he's on an established regime like that. And he has, he's managed all right, for the last few weeks to months, has not particularly needed any um increases to the morphine regime in that time. However, now he contacts you and he says the morphine just isn't working anymore past past day or so, the morphine stopped working. And when you ask him specifically what he means, he's saying his back pain is really um radically increased. So, so we got a couple of comments. No, sorry, I think they're just from Hannah. That's fine. So, so this gentleman metastatic prostate cancer, we know he's got vertebral metastases and his back pain has now drastically increased. So once you think the emergency is here that we need to think about, I see do all of the technological fracture. You can do it to metal stresses. So you said pathological fracture and you have trouble. Sorry, what was the last thing? Uh maybe cleave off already published. My thing is not working that it's the morphine is not smoking too and I just hope you're double. Okay. So um right, so this is a bit um round about because we have to what we have to remember is that patient's are going to tell us their symptoms, but they're not going to tell us them, they're not going to come to us with the diagnosis. So we have to be like Sherlock Holmes and um, actually try to get to the bottom of what's going on. So it would be the reason why. So if someone says they're, they're morphine was working fine. Uh, but now it's not working anymore. So, yeah, maybe something weird has happened like no inflammation, you know, might be emailed from the back, might be compressed, orals. Okay. So you definitely along the right lines. So the reason the patient, the patient might say my morphine is not working anymore. But what they're what they're actually really saying when you get department but is that the pain has escalated and so the it's not necessarily the morphine isn't working, it's the morphine now isn't sufficient because the pain has increased so much. So, yeah, so someone else said pathological fracture. So what specifically would a pathological fracture in the spine possibly cause? Which is an emergency? Is it metastatic spinal cord compression? Yes. Excellent. Yes. So that's what I'm getting at here. So in this patient, we need to be highly suspicious of metastatic spinal cord compression. Um So something that I would really like you to take away from today is to have a very high index of suspicion of this emergency in any patient with cancer. Okay. So I get just a diagram to show you uh metastatic spinal cord compression. So you need more information. So you go to assess this patient and you see that they're in pain. Um So, and then they're complaining they've got a tight band now sensation around their waist, which is worse on coughing and they do, when you ask them, they say they've got a bit of tingling in their legs. Okay. Um I'm not going to ask you these questions just because we're running out of time, but I'll tell you the answer. Is that what you really need to ask this patient? Um Remembering that patient's don't always volunteer all this significant information you to ask these patient's about the toilet ng particularly, have they gone into urinary retention or, you know, it might be a partial urinary retention. So when you ask the patient that they might say, oh, actually I am passing urine, but every time I go, it's like, you know, it's a hard, it's hard to get going and then I stopped part of the way through. And I, you know, I've not completely avoided my bladder. Have they, have they developed fecal incontinence? Have they noticed any saddle anesthesia? So the way you would ask a patient that is to ask them when they wiped their backside, can they still feel themselves wiping, wiping there and also asking about any weakness in the legs and what you want to examine specifically. Obviously, you want to examine the patient generally, but you particularly want to do a neurological examination. So, um looking for say upper motor neuron signs or weakness in the legs. So let's just imagine then that you go to see this patient with this history, skeletal metastasis, worsening back pain, a little bit of tingling in the legs, but no other major neurological symptoms. And you don't particularly find anything on neurological examination. Um Their, their legs aren't week. So, what do you think? Now, do you think we can rule out spinal cord compression? Does anyone think spinal cord compression it can be ruled out? Now? Not yet. Can, can we see an image? Yeah, exactly. So I'm really glad that you said that. So, um like I said, I really want you to remember to have a high index of suspicion in these patient's. And what we need to remember is that in the early stages of spinal cord compression, we're, what we're actually trying to do is catch the disease before there has been neurological damage. If we wait until there is neurological damage and then the patient's having neurological symptoms, the patient's got weakness in their legs, the patient's in urinary retention, etcetera, etcetera. If we wait that long, we probably waited too long. So we need to try to catch the disease and treat the disease before that damage, which could be permanent damage before that damage happened. So, um just to review spinal cord compression, it's common communist in myeloma, lung, breast and prostate cancers but can occur in any malignancy, especially those with skeletal involvement. It again, it can be the first presentation that up patient has of cancer and one in five cases of metastatic spinal cord compression actually are the first time of patient's ever diagnosed with the cancer. Late diagnosis is unfortunately common, causing permanent loss of function and significant morbidity. So, what we need to do is rapid assessment, investigation and treatment. Um So yeah, if, if we, if depending on the circumstances, if you've got an index of suspicion that the patient has an unstable spine, we need to manage them as a spinal injury really and not risk any further damage to the spinal cord. We want to arrange um urgent imaging and the gold standard would be an MRI of the spine. Um Treatment is going to involve trying to restore function or prevent any dap further damage. So, pharmacological, what we can do straight away is again, go in with our high dose steroids, dexamethasone, 16 mg per 24 hours with our gastro protection. And uh we're again, we're trying to uh be phoning the radiologists trying to arrange this urgent MRI but do not wait for the MRI to be done before giving the dexamethasone. That's something that can be done straight away. If you have um the suspicion, you can always stop it later on if the the MRI scan is clear, but do not delay starting the dexamethasone. Um in some cases, um the spinal surgeons may be able to operate, but certainly more often in my patient group, it would be the our oncology, colleagues who would be going in with radiotherapy and to try to restore function um and prevent any progressive damage to the spine and not forgetting as well. All the other things that we already know about important and symptom management and pain control um and holistic here and thinking as well. If a patient does have um you know, neurological damage, which is left them paralysed or with bowel and bladder dysfunction, we need to manage that as well with catheterization and bowel regime. So I would like to just quickly point you towards these resources which can be used for further study. Um So these websites are excellent. Uh they should be free for you to access. You may need to register uh for two of them that should be free to register if you just give your email address and explain um your medical student or a healthcare professional. There's also these smartphone apps that can be used. I fall I have global and pal care. Um and these are particularly useful for kind of a global setting because they are um designed from healthcare settings which are relatively low resourced. Um So quite should be quite pragmatic and um advise on use of management, which is hopefully quite achievable and regardless of where you are in the world. So just to summarize um what we've spoken about today, we spoke about what we mean when we say a palliative care emergency and remembering that it's something that needs treated urgently to prevent um uh deterioration, the patient's quality of life. We spoke about the big four palliative care emergencies and use clinical cases to illustrate these. Uh we spoke about a major terminal hemorrhage and main takeaway being uh they, he need to, we need to help patients' loved ones to be prepared and we should stay with the patient and make sure they're not alone if they were to have a terminal bleed. We spoke about hypercalcemia and how we should have a high index of suspicion of this and it may look like the patient's at the very end of life from there as a result of their cancer, but it can be reversed and give them another period of relative really good health. So we should always check the patient's calcium. We spoke about superior vena cava obstruction for which again, we should have a high index of suspicion, especially suspecting in patients with worsening breathlessness in lung cancer and there's different ways to treat it. But the invasiveness will depend on the individual patient and they're prognosis. I spoke about metastatic spinal cord compression, which again, we should have a high index of suspicion for especially in any new or worsening back pain and patience with cancer. And we need to investigate and treat that quickly to maintain um to prevent neurological deterioration. And before neurological signs develop ideally. So the aim of the game with spinal cord compression is to get, catch the disease and treat it before the neuro neurological damage occurs. I've given you some suggestions for further um study to uh read and use as a resource. Um And just as a reminder, my first presentation on the principles of palliative care and symptom management was on the second of March, but should soon be up on medal um which can be uh and I will be given a second part, the second part of that presentation um a week today at 2 p.m. U K time. So that was great. Thank you very much for listening. I hope that you find that helpful. I'd run exactly 23 o'clock my time. So there may not be time for questions. But if anyone does have any further questions before they head off to the next presentation, I would be happy to try and answer them.