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CRF 21.03.23 Principles of Symptom Management in Palliative and End-of-Life Care, PART 2, Dr Shaun Peter Qureshi

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Summary

This on-demand teaching session is relevant to medical professionals and will equip them with the skills to better understand and manage the symptoms of patients with palliative and end of life care. Dr. Sean Creche will help attendees explore symptom management of pain, breathlessness, nausea and agitation while also considering the multidisciplinary aspects of providing end of life care. Dr. Creche will provide his expertise on the principles of palliative care, guiding attendees through the topics in an interactive and informative discussion.

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Learning objectives

Learning Objectives:

  1. Recognize the difference between breathlessness and tachypnea.
  2. Understand the subjectivity of breathlessness and the importance of patient’s perception of it.
  3. Grasp the fundamentals of diagnosis and management of breathlessness.
  4. Appreciate the interdisciplinary approach to palliative care and its holistic approach.
  5. Assimilate the principles of symptom management for life-limiting illnesses.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Bearing with me, just read those technical difficulties. It's great to be here. Um So you may have been at uh either one of my previous lectures in this series. Um But just in case you haven't, my name is Sean Creche. She, I'm a palliative medicine physician here in Scotland in the United Kingdom. Um This is part two of uh the lecture on principles of symptom management and palliative and end of life care. Um So I delivered part one on the second of March which you may have been at um where I started of introducing what we mean when we say palliative care and to start talking about symptom management of pain, which we went into in some detail then um however, if you weren't able to make it to that two part one and you should be able to catch up on medal. Um When that is uploaded soon, am I have also given a presentation and management of emergencies um palliative care on the 14th of March and to again um catch up on with that on Medal if you weren't there for that today though, I want to continue talking about management of symptoms in palliative end of life care. Give a very brief recap of um, what we covered last time in part one. And then we'll move on to talk about breathlessness, nausea, agitation, then just some general things to bear in mind when it comes to end of life care, care of the dying, give you some links to further study as well. Um And it's just to bear in mind when we're going through this as well that it's, it's impossible to go into a lot of detail in the time that we have. So this is very much just the principles of of symptom management, but hopefully give you some tools and some approaches that you can take away with you when, when seeing your own patient's, there has been really good interaction um in the past couple of lectures which I have really appreciated. Um And I do want to hear from you today as well. However, I am just conscious that um this is already a second lecture because there was so much material to get through. So what I'm going to try to do today, do please still continue to see your comments and your questions in the chat? But what I'm going to try to do today a bit differently is just to try and rattle through the material. Um so that there's time at the end um to go over questions um and not have quite so much interaction as we go along just so that we can get to the end and then have time for questions. Okay. So to briefly recap what we meant by palliative care. I know we discussed this last time. It's a general approach to improving the quality of life of patient's and adults and their families who are facing problems associated with life threatening or life limiting illness. Um And it considers um as well as the physical domain, the psychosocial and the spiritual domains as well. There's lots of definitions out of out there which are quite worthy. Um But what I would recommend is just maintaining this concept of adding life today's not days to life. So, palliative care is really an approach which is about quality of life rather than length of life. And it's an approach that we take to care and patient's that we already know have a diagnosis of a life limiting or life threatening condition does have physical domains, which as doctors, I think that we are, that's the area that we tend to be most, most comfortable with. But that's not all that matters with a person's experience of illness or the experience of life or dying. Also, remember that we're working as a multidisciplinary team and that we are considering the other dimensions to a person's life as well. So the psychological, the social and the spiritual domains and also remembering that although end of life care is an important aspect of palliative care, it is not the entirety of palliative care. So, yes, palliative care includes end of life care, but it is bigger than that. And palliative care is appropriate for patient's with life limiting disease. Even when they're, you know, at still a stage that's far from when they're going to die from the point of their diagnosis with a life limiting illnesses when it's appropriate to start thinking about palliative care needs for our patient's and palliative care is much needed in the world. There is a significant void of, of adequate palliative care, including adequate pain control, um and other symptomatic relief worldwide. So hopefully, um I mean, I know that we have a diverse audience with us today from, you know, various places in the world. But hopefully, what we can take away from this is the importance of, of palliative care, including pain control and symptomatic management for patient's no matter where they are in the world. And remembering that that is a priority for our patient's. Um So once again, just to recap that this is not going to be a comprehensive lecture. We don't have time to go into details about pharmacology or management. We're talking about the principles today. Also, um pediatric palliative care is very important, but I am not in a position to teach you about that. Unfortunately, in Scotland, that's separate from adult palliative care and adult medicine and I am an adult physician. So we just bear that in mind that the things that I speak about, especially when it comes to drugs and drug doses and things. I'm talking about adults here. So we need to get advice and instruction from a pediatrician. Before we think about what, um, medications access to use in Children. We're not talking about people with acute illness. Um, we're talking about people with, um, life limiting illness. So the approach is that I talk about here to pain and other things are appropriate for people who we already know have a life limiting disease. They're not appropriate approaches. For example, if you're working in A and E or somewhere else where you're dealing with people with an acute illness, um that it may be that they can recover from and survive from. Okay. So just as a brief recap, now of what we spoke about last time about pain, I do advise you to go back and watch my previous lecture for much more detail about this. And it's such an important topic. But if you remember the pain is subjective and people express and experienced pain in different ways and the approach that we should take to our patient's is that pain is what the patient says. It is, is not up to us as doctors to um you know, believe or not believe. Um So some patient's and then not and then believe others because uh they're acting in different ways. Um People don't necessarily all act the way that you would expect them to in pain. Um But if the patient tells you they're in pain, then they are in pain because pain is what the patient says is. In summary, we spoke about um when we're assessing a patient, we spoke about the approach to taking a detailed history of the physical and nonphysical dimensions of the pain. Um And using the Socrates acronym as well to remind us about how to do a further assessment. We spoke about how it's important to an examination. Um and how we're aiming to establish the underlying positive pathology because if we can um have an idea about what's causing the pain, that's going to give us a clue about how we can do something about it. We spoke about management. We've got far pharmacological approach and are non pharmacological approach. And when we're thinking about the pharmacological approach to pain, we spoke about how important is to be to cheat pain when we can by mouth, talk about regular pain relief, trying to maintain a steady state concentration in the bloodstream of analgesia. So making sure we're prescribing that regular by the clock and how we are are being guided by the World Health Organization Analgesic bladder. But that we are also taking an individual approach to pain because the World Health Organization pain like there is useful. Yes. But remember that our patient's are individuals. So there will always be um slight variations or changes depending on the patient's individual condition and remembering that um where we were prescribing opioids is very important to prescribe laxatives as well. Okay. So I know sorry that that's not going to be enough information for anyone who wasn't at the previous lecture. But this was just to try to give you um the summary of the pain management section, which I didn't have time to do last time. But I do advise everyone to go back if you weren't there and re watch my first lecture where I spoke in detail about, about pain management. Okay. So I'm moving on now to just start covering the new material today. So we're going to start with symptom management of breathlessness. I'm just going to quickly check the chat just because there's a couple of messages. No, that's fine. That's just folk telling us where they're from, which is brilliant. Um But like I say, if you do you have questions as we go along or there's anything that's not clear I am trying to get through the material and then we can hopefully have a discussion at the end. Okay. So great. So let's move on to talk about breathlessness now. So, um I'm not going to ask you for answers, but I suppose it's, it's worth just reflecting for yourself what, what you think breathlessness means because like pain, it's another symptom that we speak about all the time in medicine. Um But it's not something that we necessarily define um frequently. Um It's kind of like you think, you think, you know what you mean or you think, you know what patient means when they say breathlessness. But what I suppose what one of the main things uh I'd like to think about is that breathlessness is not the same as tachypnea necessarily. So breathlessness is not necessarily the same as increased respiratory rate. So we think about, you know what, sometimes if you speak to a patient who's got chronic Obstructive Pulmonary disease, they've got a chronic lung disease. Sometimes they're resting respiratory rate. You sit and you speak to them and they have a respiratory rate. That's, you know, 28 30 32 high resting respiratory rate. And then you ask them, do you feel breathless? And they say no, I'm fine because they're so used to um having a respiratory rate at that level. Um and their body has adapted to the chronic lung disease that they have. So they don't have the subjective experience of breathlessness even though they're tackled NAIC. In contrast, um you what you can have and what we often see in palliative care is a patient with a normal respiratory rate or even a low respiratory rate, brad apnea. Um and they are, they have this sensation of breath Asus, which is an uncomfortable awareness of breathing or an increased respiratory effort that is unpleasant and regarded as the patient by the patient as inappropriate. Okay, the breathlessness again is a subjective thing and yes, off often it is accompanied by tachypnea if we think about conditions like uh pulmonary embolism, but it doesn't, it's not equivalent to tachypnea. So we think about how we assess the patient of breathlessness. Again, same kind of standard approach that we would take um to other medical problems, history taking or an information gathering and then physical examination and assessment. So when you're, when you're at the stage of your assessment, which is the information gathering, what you want to do is to seek further details about the breathlessness. Are there precipitating and or alleviating factors associated symptoms? And what effect is it having on the patient's activities of daily living? And you can, if you want, you can use um one of the predefined scales, for example, this is from the Medical Research Council dyspnea scale on 0 to 4 um about the severity of dyspnea to give you a bit of an idea. But this is really to guide you about what you're trying to get from the patient is. How much of an impact is the breathlessness having on their activities of daily living? And what does the patient need to do to have the breathlessness? Come on, for example, is it mild where there's really no, you know, it's hardly noticeable or it's maybe um there may be feeling short of breath when you're going up a hill or are the other extreme? Are they to breathlessness to leave? Are they too breathless to leave? The house. Are they too breathless to get dressed? Can they go to the bathroom by themselves? Are they too breathless to complete a sentence? Do they have to, um, are they able to lie down flat? So, really, there's quite a spectrum about the severity of dyspnea and it's important to try to establish, um, what effect it is having on the patient. Um, and you want to try to establish what is known already about the patient's preexisting medical history and the extent of their disease in palliative care as well. We think about some of the common underlying causes which could be contributing to the breathlessness. So, anemia, very common in palliative care, pulmonary embolism. We think about the pro thrombotic states of having a metastatic malignancy, pleural effusion, pulmonary edema and also the risk of superior vena cava obstruction, particularly in lung cancer. And I did um cover that in more detail in my lecture on management of emergencies and palliative care. Then we're also bearing in mind these common causes of breathlessness when we come to physical assessment of our patient's. So, yes, we, we want to examine their chest and we want to measure their respiratory rate. But we're also thinking about, do they have signs of anemia? Do they have, you know, a swollen leg that might make you think about venous thromboembolism are the signs of pleural effusion, superior vena cable obstruction. And we want to measure their oxygen saturations and we want to check their hemoglobin as well. So when we move on to what we're going to do about the breathlessness. Once we've done our assessment, we've really thinking about the non pharmacological and pharmacological domains. So we think about non pharmacological management of breathlessness. Remembering that breakfast, this is a very distressing symptom. Um If for people who feel this, that they can't catch their breath or that they have this sense of air hunger, that there's just not enough oxygen coming into their lungs. This is very anxiety provoking. So like we tend to do with our other symptoms, try to maintain as peaceful and a calm as common environment around the patient as possible. Also, we think about, you know, for those patients at the severe end of the spectrum with breath assist, do can we nurse them? Um so that they're upright in bed, they're propped up, they don't have to lie flat and also have patient's um with air blowing on their face. So fans are very useful, especially like handheld fans and if the air can blow directly onto their lips and onto their, um knows this can give the patient the sensation that they're getting more air and can help relieve their sensation of breathlessness. There's also a non pharmacological approach to breathlessness that we can take with our patient's which this is called the calming hand. I think this is something um and even as medical students, uh even something we can do as you could do as a medication or you can do this even if you don't have access to any medication. This is something that you can teach your patient's about self management. And it's called the calming hand. And it's for the patient when they have, um when they feel the sensation of anxiety rising and breathlessness rising themselves, they can look at their hands, grab the first finger, recognize that the anxiety of breathlessness is coming on and they can do something about it to control it by focusing on their hand. They moved to their second finger and they let us i out, they moved to the third finger and they inhale slowly and then move to the fourth finger and exhale slowly and then move to the fifth finger and then they can stretch and relax. But if they feel the need to go through the process again, that is um you know, they can, they can repeat and go back to step one and you know, this sounds too simple to be effective, but actually just the mindfulness and the calmness of doing this um is effective for patient's. Um And like I said, is quite simple intervention that we can all teach to our patient's. So um that is something very useful to take away and read more about um information about that online. It's called the calming hand for breathlessness. So when we come to the Pharmacological Management, so as we can break this up into if, whether or not you've identified an underlying cause for breathlessness. So, dissipation have breakfast because they're symptomatic of anemia. In which case, the answer would likely be transfusion. Do they have pulmonary edema and require look diuretic? Have they got a pleural effusion? Um In which case, you know, depending on how fit they are or the extent of the infusion or what kind of effusion is, you might consider pleural drainage. Um And then do they have a superior vena cable obstruction? Um As per my other lecture, you would look to be treating that um with high dose steroids. But beyond that, beyond, if beyond whether or not there's something um disease modifying that you can treat, we think about how we're going to manage the symptoms of breathlessness. Well, much like what we said about pain. Last time when it comes to breathlessness, the mainstay of symptomatic management is morphine. So if we think about what we did last time for our hypothetical patient who was in pain are hypothetical patient who has breath. Is this? Now, we can do the same thing. We make sure that they have a regular prescription of morphine that maintains a steady state concentration in their system throughout the 24 hour period. And we can give them additional morphine as required for pain or breathlessness. So, actually, what you'll find in patient's who have, you know, our complex patient's that we see in palliative care often have pain and breathlessness and we can really kill two birds with one stone by prescribing that with opioid medication. And you'll often see this type of prescription in palliative care, morphine for pain or breathlessness. Um for patients who have particular anxiety related to the breathlessness where you think about benzodiazepines. There's something like sub lingual LORazepam or old diazePAM. Again, remembering that this is um we're talking here about patient's, you have a life threatening illness, a terminal illness already. So, you know, a young person who didn't have a life, a life threatening illness or a terminal illness. I wouldn't be advocating that you start them off on, you know, a benzodiazepine prescription. But in our patient cohort that is, that is quite an appropriate thing to do. Um I wonder if anyone's thought about oxygen and whether or not um you would prescribe oxygen for a patient who's got breathlessness um because it seems like quite a logical thing, doesn't it? But really it's going to depend on the individual patient. Um So you might have some more information about what's causing the breathlessness if they have an infusion or a pe or any reason to have hypoxia. And you've got proven hypoxia on your um oxygen saturation probe, then we could consider giving the patient supplemental oxygen. Um And certainly here in Scotland, there is a capacity for patient's to have home oxygen as well. If they have a terminal illness, we call that palliative palliative oxygen prescription. However, for a patient who is breathless and they might be very breathless, but they still don't necessarily have hypoxia, they could be breathless and have a normal oxygen saturation. There's no indication in those patients to give them supplemental oxygen. But what we can do because if you think about the way oxygen goes in either through a mask or through a nasal cannula, the patient feels that sensation of their, the oxygen going into their face, over the nose, into their mouth. That can be um relaxing and relieving for the patient. But actually, for a patient who doesn't have hypoxia, we can kind of simulate the same thing with a handheld fan or just having plenty of airflow onto the face. Um So, you know, for like, basically, in summary, for a patient who doesn't have proven hypoxia, I would suggest a simple fan. Whereas for a patient who does have low oxygen sats um demonstrated, then we'll be thinking about supplemental oxygen. I just wanted to very briefly um say um something about secretions, I'm not going to focus on this for long, but um I don't know what experience you have had so far about being with a dying person. Um and with dying patient's um but really noisy breathing at the end of life is very, very common. Um And so there's different ways to talk about that. I mean, some people talk about a death rattle which um is obviously, it's quite negative connotations for our patients' families if we start talking about that. But basically, what we're talking about is respiratory secretions. And this is a natural part of dying, especially when someone is very close to the end of life and they lose consciousness. Think patient's are not able to cough, their muscles, relax their airways, start to relax and all the secretions that would normally be naturally cleared, stop clearing. And so that can be, you know, really very noisy to listen to. Um And what one of the things that we find is that this is very, can be very distressing for patient's relatives, you know, at the bedside to listen to this noisy breathing. However, is often coincides with times when the patient is dying and really reached the stage of unconsciousness. So it's important to differentiate whether or not the patient is actually uncomfortable, whether the secretions are not the same as being breathless. Secretions are not the same as being in distress. And actually really, yes, there are pharmacological things we can do about the secretions. But really, I'd say the most important aspect of the management is the communication with the patient's relatives in their families. If you examine the patient and you see that there really unconscious. Yes, they have this noisy breathing, but the patient themselves is not aware of it and they're not distressed by it, then you can communicate that to the relatives and make them. Um reassured. Okay. And the other thing to bear in mind that there are, um, medications that we can give to try to reduce those secretions. Um, so I've given some examples on the screen there, but remember as well that those medications are anti cholinergic. So you could, um, you know, if a patient is comfortable, you could actually make the patient, um, feel more uncomfortable if you start making them feel more thirsty. For example, with anti cholinergic drugs because you're trying to reduce the secretions. So it's important to try to get a bit balance there. Okay. Great. So, just to summarize what we said about breathlessness, it's subjective, consider what the possible underlying causes for the breathlessness and our patient's because we want to try and see if we can reverse what can be reversed. And then when it comes to managing the symptom itself, there's non pharmacological options we spoke about and there's the pharmacological symptom management and the mainstay of pharmacological management is morphine. So if you can remember, mainstay of um pain management, pharmacological is the World Health Organization Analgesic Bladder mainstay of pharmacological breathlessness management, morphine. Okay. And we also mentioned that respiratory tract secretions are mainly distressing to the patient's loved ones rather than to the patient themselves. And communication is very important. Okay. So let's move on to our next set of since is that we're going to be talking about and that's nausea and vomiting. So, again, our approach to assessment um is our medical approach of information gathering with history taking and then moving on to physical examination and assessment. So, nausea and vomiting can be quite a complex business. There's multiple causes for this and there's multiple reasons why palliative care patient may be experiencing this. So we really want to try to get a detailed history and to try to differentiate as well. When the patient says they feel sick, are they actually vomiting or is it a constant state of nausea? And um it may not surprise you to hear that patient's often say that vomiting itself is not as bad as the sensation of nausea and that if someone feels constantly not nauseated when they, when they do vomit, they get some relief from that. And so actually, like I say, vomiting is not as bad as the the nausea itself. So what are the triggering factors is associated with a particular drug? Is the reflux are bowels opening? Our is, are we talking about intestinal obstruction here? And do they have abdominal pain which might also point towards uh intestinal obstruction? And what else is in the patient's history? And these, you know, common things that we see in patients with life threatening and terminal illness, you know, are they on chemotherapy? Is this chemotherapy induced nausea? Do they have hepatic metastases which is causing, you know, a metabolic picture from liver failure? Do they have cerebral irritation or meningeal irritation from cerebral metastases? Is this intra abdominal and pelvic metastases lots of detail um that we need and lots of potential causes for um the nausea. And when we assess our patient's physically, we want to assess, are they dehydrated? Do they have jaundice? Which would again point towards liver disease, need to examine their abdomen and say is there anything in the abdomen which would point towards um the underlying cause? Do they have a tympanic abdomen or their bowel? Sounds? Think about pr if appropriate every thinking about intestinal impaction, if we think this has a neurological cause, we need to do a neurological examination. And I would really advocate looking in the vomit bowls themselves and it's actually really insightful. Um because, you know, patient's can tell you that they've been sick all night. Um But actually sometimes you can look in in the vomit balls and there's very little actual volume of vomitous material in there where you're thinking actually, this is not high volume vomiting, this is more of a nausea picture. Um Where in, you know, another situation, you might examine the vomit balls and see that they're full to the brim of feculent um, vomitous, which again would point towards intestinal obstruction. And um I'd also advocate during a urine death is about to check whether this is a urine tract infection. So we think about non pharmacological management of, of vomiting and our patient's so there's simple things you can do like avoid triggering smells and foods um support their oral intake. Um Think about ceasing um any drugs which might be causing the symptoms or contributing to symptoms. Think about the fact that in palliative care, many of our patients are very friel. So even if they have um you know, an intestinal obstruction, they're not going to necessarily be fit to go to the operating theater um and have that managed by a general surgeon. Um or, and, or they may have, you know, complex lots of metastases in the peritoneum or the lots of pelvic disease, for example, causing intestinal obstruction that multiple levels. So, surgery is generally not an option for the type of patient that I'm talking about here. And then we're thinking about what can we do more conservatively in which case, we'll be thinking about nasal gastric drainage in terms of pharmacological management. Well, I'm afraid that there's no one single answer here. Um And more so than any of the other symptoms that we're talking about. The pharmacological management of nausea is going to um rely on what the underlying cause is. So for example, drug induced or metabolic toxicity or chemotherapy, we're thinking about an antipsychotic drug, like leave them a promazine or haloperidol for a patient who's maybe got an alias, but they don't have complete obstruction and you just want to get the bowel active in moving again. We'll be thinking about, you know, a pro kinetic agent like medical provides and obviously treating constipation as well. If you think that that is the cause that they've got has has slowed down, whereas the patient has a complete intestinal obstruction with large volume vomits. You know that patient who is not fit to go to the operating theater. In that case, you don't want to give them a pro kinetic agent because that's just going to make give them abdominal pain um and not solve the problem. So, in this case, we're trying to reduce the volume of intentional secretions, reduce the volume of the vomits and give them anti secretary drugs. Uh for those patients who have raised intracranial pressure, for example, from cerebral metastases. Uh we're looking at something like cyclizine and we think about steroids as well to reduce cerebral edema. And then, you know, just a generic approach. If you don't, if you, if you don't know that there's uh what the underlying causes or you know, it's very common for patients to just have kind of quite nonspecific nausea when they're approaching the end of life. And certainly in Scotland are generic approach would be to use the antipsychotic drugs, um leave them a promising or haloperidol. So to summarize this section about nausea, nausea is common and distressing, we want to try to establish the underlying cause. So we should always examine the patient. There are some things you can do non pharmacologically, non, non. Um quite simple things. Um Remembering the option for an N G drainage and our patient who has inoperable international obstruction. Uh but our pharmacological management is going to depend on the likely underlying cause. Um And so sorry that there's no, I can't give you a clear cut answer about that. Um You know, so if we think about how are simple, we bear in mind pain. The World Health Organization analogies, gladder, breathlessness, the mainstay of pharmacological management is morphine, bit nausea. We really need to try to identify the likely underlying cause um and treat that appropriately. So just check there is, yeah, I see the question about haliperodol. So I am going to try to get through the next section um and then come to questions, but just to get just to tell you the answer because it's quite simple. Yes, how the paradoxes contra indicated in Parkinson's disease and Parkinson's plus syndromes. Okay. So, uh so yeah, we'll move on now to the next symptom that we're going to talk about today and as agitation. So, again, a common symptom that we see as patient's are approaching the end of life, common in the last, um you know, a few days, two hours of life, uh sometimes described terminal terminal restlessness. And this is, I mean, really quite um really quite an unpleasant symptom and really quite difficult for um the loved ones of the patient's to have to see. And also for, you know, any healthcare staff who are involved to try to manage the patient because Um And again, I'm not sure yet what experience you've had of being around dying people. But it is uh is common, especially with younger people to have this um for them to, to experience this sense, absolute sense of, of restlessness, what while they're approaching the end of life. Um And sometimes it can be, it can happen around the times that the patient is confused and can happen when the pieces gone past the stage where they're really able to articulate themselves, where they're really able to explain what's wrong. So it's very difficult for, it can be very difficult for everyone. Um There are some, some general approaches that we can, we can take. Um so we want to try to gather information about the patient history from the patient as much as able, but probably trying to get collateral history as well from others who are involved with caring for the patient. Um Are there any specific triggers or causes for the agitation that have been identified? Is it linked to any particular symptoms? Like is the patient in pain? And that's what's causing them to appear agitated? Are their bowels opened? Is this constipation that's manifesting as agitation? Are they passing urine or are they in urinary retention? Um Any drugs which can cause agitation, for example, steroids or salbutamol. Um You know how much, you know, this might be the first time that you're fined, you're discovering that the patient actually was dependent on alcohol or another drug. Um Actually no one's mentioned it so far, but actually, now that the patient's dying and they can't take that drug themselves, um, it's manifesting as withdrawal and agitation. So we do our best to try to see if there are any specific triggers or any underlying causes. Although, you know, often times there isn't anything specific and it actually is just, just part of what this person is experiencing as they die. We try best to do a physical assessment on the dying patient as well thinking, you know, are they, are they dehydrated with their agitation, be relieved by maybe getting some parental fluids? Do they look like they're in pain or is there other some other physical symptom that's causing them to feel agitated? Do they have a palpable bladder? Um If you, you know, if appropriate, we would do a pr to check that. Um I mean, obviously if you know what patients' bowels are opening, you don't need to do this. But you know, if you, if you're not sure or it's been some time since the bowels have opened, we would do a pr to check for rectal impaction and we can give a rectal intervention at the same time. And if you remember if you were present for my other lecture on management of emergencies in clouds of care, um We think about hypercalcemia as a potential cause as well. Very common in our patient population. Very common in cancer. Um and patient with hypercalcemia can present as if they're dying with terminal agitation. And it's a simple blood test that we can take. Well, you know, relative in the grand scheme of things, relatively simple to treat if appropriate. And it can cause a patient to, you know, bounce back with some vigor for some time. But, but at the very least can treating the hypercalcemia can help them to feel less agitated as well. So again, we're looking for any underlying cause. There may not be any underlying cause you can pinpoint, but it's important to check to see if there is. And again, we're thinking about our management or non pharmacological approaches as well as our pharmacological approach. So again, are nice plumbing um under stressing environment that we're trying to maintain to um address the kind of a psychosocial and spiritual aspects of this patient's experience of their, their illness and the dying process. Communication with the family. Very important to address their concerns. Thinking about urinary catheterization, facing any unnecessary treatments or any contributing treatments to their agitation and input from other members of the multidisciplinary team as well like Chaplin seen. Anyway, think about what we can do pharmacologically to help manage a patient with agitation. So we want to have established if they have withdrawal from alcohol or some other um any other drugs like nicotine. So we might think about nicotine patch for a patient who's withdrawing from nicotine or management benzodiazepines for patient's withdrawing from alcohol. Um want to think about treatment of any exacerbating physical symptoms. So, actually, is this a manifestation that the patient isn't getting enough analgesia? And really our management for this patient's agitation has to be better pain management. Um But then we can look at what drugs we would give for a patient who is restless and agitated the at the end of life. So that would be the options of uh subcutaneous benzodiazepine, for example, subcutaneous midazolam, 2 mg or uh leave them a promazine uh starting dose of 2.5 mg to 5 mg. Um And if it's, but you know, for these patient's who are at home, very agitated and very um stressful for the family looking after them and to see um to see their loved ones in this condition. Um the patient may require admission to hospital or a specialist palliative care unit if that is available where you're practicing just gonna take a quick look at the time. So we've got about 15 minutes left. So in summary, um management of agitation, um agitation is distressing for the patient and a loved one, there may be uh positive uh factor that we can identify. So we're thinking about is there an inter current illness? Um hypercalcemia, bladder or bowel dysfunction, dehydration. Um but they're often is not. So we're thinking about what non pharmacological management we can institute to try to make things more manageable and then we're thinking about our pharmacological management with Midazolam or an antipsychotic medication. I'll just check the chat quickly. Yeah, that's why I think that's a message from Hannah. Right. So I'm just, we've spoken um, about this specific symptoms we were going to discuss today. I'm just gonna go over some principles, um, to the dying patient and end of life care. Remembering that we said that end of life care is part, is a very important part of palliative care. Um It's not the entirety of, of palliative care, but this here we would discuss some more detail about care of the dying person. So, you know, in your practice as a doctor, um you are going to be in a situation many times in your career where you are going to have to be the one who um really makes the diagnosis of dying or recognizes that a patient is dying. Um And that's a very important thing for you to do for the patient, for the patient's relatives and for the whole team as well. So some, some things you might want to think about when you see a patient whose um deteriorating and you think about is the patient dying you might consider actually, is there something reversible here? So actually, is the patient dehydrated or is there an inter current infection? Are the opioid toxic? Are they withdrawing from steroids or do they have acute organ dysfunction like um acute kidney injury, delirium hypercalcemia or like we've spoken about or is there sugar deranged and then you're taking, if you can identify a reversible cause, um you think about treating that as appropriate to individual patient. And what I mean by about, well, most of, you know, many times or most of the time, if you can identify a reversible cause for a patient's deterioration that it's going to be the appropriate thing to do to give them the treatment They need to reverse that. But if you think about another, you know, some hypothetical situations, say a very elderly patient, an old woman, she's a grandmother, she's frail, she's lived all her life, um, lived a happy life, multiple grandchildren. She doesn't, she, she has a terminal illness. Um, she's at home and she wants to die at home in her own bed, surrounded by her family and then you're called up your called to see her. You're called to visit her at home because she's so sleepy and she's not eating and drinking and the pain the family thinks she's dying now. Well, you could thing actually, this patient might have hypercalcemia or this patient might have infection or this patient might have acute kidney injury. And, you know, if we reverse these things, they might have, you know, some more days of life, they might have some more weeks of life that actually speaking to the patient is speaking to their relatives. They might say we don't want you to do any of those things. Um Because yes, that's something that you would do in another patient, in another situation. But for our grandmother, um we, we know that there's more tests that could be done and we know that there's more interventions that could be done. But actually, that's not what we want right here. And right now, um so we're thinking about what is appropriate to the individual patient's situation and communication is vital at all times. Um So when you've got to the stage where you, yes, you believe this person is dying. Um So we need to communicate that to the patient if they're able to communicate with you, but if not with the loved ones, with the rest of the multidisciplinary team who are looking after the patient. So we think about medication rationalization. So stopping any unnecessary medication, we were thinking about the fact that cardiopulmonary resuscitation is not appropriate for a patient who's dying. Think about where the patient wants to be at the very end of their life. You know, for some patient's that might be hospital, for other patient's that might be their own home. And then we're thinking about the value of all medical and nursing interventions. So if a patient's passing urine and they're comfortable with that, using pads, you don't need to put a catheter in. But another patient might be in urinary retention and not passing urine and pads. And so they need a catheter, for example. So there's no, there's no one size fits all approach. However, I will say when it comes to something one size fits all. Remember the importance of mouthcare. When patient's are dying, they do naturally stop eating and they do naturally stop drinking. Um And even if the uh we have to remember that it's not that we're stopping the patient from eating and drinking. We must always continue to offer the patient food and drink and we must always continue to give the patient hydration if they want it okay. But it will get to a stage where the patient starts saying no or they're too sleepy there to unconscious to take the hydration themselves. And that is a natural part of the dying process. However, even if the patient is sleepy, even if the pieces unconscious, we have to remember the importance of regular mouthcare. So moistening the mucous membranes of the mouth and that will help reduce any discomfort um and help um any them to reduce any subjective sensation of being dehydrated. We have to be aware of the importance of whatever cultural and religious customs need to be fulfilled before the person dies. And we're thinking about what prescriptions we need to put in place and in, in anticipation of the likely symptoms or possible symptoms that, that commonly come up for a dying person. So the patient might already be on an established regime, for example, for pain or for breathlessness or for nausea, okay. But even for patients who are not on anything so far because they haven't had any very problematic symptoms when a person is dying. It's good practice to try to anticipate what are the common symptoms and what would we prescribe? So these are examples of starting prescriptions that we would give in these anticipatory prescriptions. So for pain and breathlessness, together, we would think about morphine, 2 mg sub sub cutaneously for agitation. We're thinking about midazolam 2 mg subcutaneously for nausea, something like leaving my promazine 2.5 mg subcutaneously, remembering the subcutaneous route being important at this stage. When it gets the stage where patient is dying, they're going to lose the oral route. And so prescribing oral medication is not going to be reliable for them. Okay. So we have briefly covered and really scratched the surface of the principles of symptom management of pain, breathless, nausea, anxiety, and we've gone over some general principles of end of life care. There are lots and lots of other symptoms which are common in palliative and end of life care like constipation, cough hiccups, etcetera that we haven't spoken about. Um But that's really out with the scope of this kind of these kind of introductory lectures. Um It is important though for you to also be aware of the major emergencies that are common in our palliative care population. Um including hypercalcemia, superior vena cava obstruction, spinal cord compression, and catastrophic catastrophic hemorrhage. And I did cover these in my lecture on the 14th of March, which you should be able to catch up on medal with. I'd like to draw attention to these free resources. Um So the websites um so these are all based out of the UK. Uh They should, yeah, they're all based out the UK. You may need to sign up for an account for these to access these, but they should, that should be free to do so, especially if you explain that you're a medical student, health professional. Um And so they will provide more detail for your um private study if you want to read about any symptom management in more detail, also like to draw attention to these apps, I Power Global and palate care because these are apps which were made um in other countries and with um provisions for low and middle income countries in mind as well. So these apps should provide um advice on management of symptoms and palliative care patient's with relatively low resource settings as well. So they're useful to look at. So our conclusions, then we've spoken about how palliative and end of life care are vitally important across the world. Um We need to consider the physical, psychological, social and spiritual domains of our symptoms. Um In our patient's, we need to consider the underlying positive pathology which is causing the symptoms. And if it's appropriate for that patient, we would look at treating the underlying cause for the symptoms in terms of symptom management, we take a holistic approach and remembering non pharmacological and pharmacological approaches. We spoke about how important pain relief is. Pain relief is a human, right? And we're going to manage our patient's with the pain relief by the mouth when we can by the clock, regular pain relief by the W H O N O G gladder and also tailored to the individual communication is essential at all points. Generally speaking, when it comes to our pharmacological approaches to all, since, since we start low and we up titrate, I will need to keep our patient's under regular review and assess effects as well. So, um I actually looks like have nearly run out of time. And so I think we've got four minutes ago. I'm just going to have a quick look at the chat um and answer any questions that I can do before um times up, but I've put my email address there as well if anyone wants to, if anyone wants to follow up with me one on one and I'll try to answer your questions. So, um just looking a question. So Dr Addy has said what calculating formula is used when switching opioids from oral MST to syringe driver doses plus breakthrough. Um So I, I mean, what I would advise you due for is to have a look at, I'll put it back on the screen, have a look at the Scottish Palliative Care guidelines, which is what I use. Um But what we have to bear in mind, generally speaking is that when we give opioids by the parenteral routes, for the vast majority of opioids including morphine, they are more potent by the parental writ. So the subcutaneous route than they are by the oral route. So a simple rule of thumb would be that oral morphine is twice as potent as subcutaneous morphine. So if we were giving a dose subcutaneously, we would, we don't want to change the dose, we want to keep it as an equivalent dose, we would divide the oral dose by two. Does that answer your question? Yeah. Okay. So yeah. And just to come back to the question about how a parad all um contact yet contraindicated in partners disease and Parkinson's plus syndromes and um also leave them. A promazine is also contra indicated. Um So again, this is part of the reason why it's so important to consider our patient's as individuals because you can't just say one size fits all. So if we know what's in our patient's past medical history, we can tailor the management plan appropriately. Um So yes, although I said that that's a generic approach, something like Lima promazine or haloperidol, that's inappropriate for a patient who has Parkinson's or Parkinson's plus. So then we will be thinking about something else which is safe for um such a patient. Um like cyclizine, for example, uh some other questions, what should you tell a patient who has a C R T D or I C D in situ and does not want it deactivated under any circumstances or asks you about lifesaving potential about externally. Where about cardio defibrillated life? This, I mean, this is very difficult and I think, um you know, that kind of ethical dilemma is really um you know, I take it there's all single right answer. But the, the question about what you should say to a patient, I think that's going to be, you know, too complicated to cover in the time that we have left. Um I mean, in general, for, I mean, because we do obviously impacted care, often have patient's, you have implantable cardiac devices, including defibrillators. So are what we aim to do is to um arrange for the device to be deactivated in anticipation of the patient's end of life because, you know, we're trying to maintain comfort for our patient's and if a patient is dying, um who knows what's going to happen to their heart rhythm and you know, it's gonna be very uncomfortable for them to experience the device um going off and trying to defibrillate them. So, um it uh most of the time patient's are in agreement but it can be, it can be very difficult um when patient's are are not in agreement. Um So okay. Um I think that's just three o'clock now. Um Hannah, do you think we should tie things up there? Yes, if no one has any more questions, we can end it here. Yeah, I'll just put my email address again in the chart. Um, um, no, that's all right, Dr addy. Um, you don't need to apologize, but it's just, um, it's just quite a, quite a conundrum to deal with in clinical practice and it's um, there's no simple answer for it. So anyway, I thank, thank you very much. Everyone hope that was useful and um feel free to follow up on email if you have any further questions. Thank you very much. All right. Okay. I'll say goodbye for now then.