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right, So runs the thing that's up with the day guys, and I'm just going to be a week ever talk on on death and dying. I had planned for this talk to be said earlier in the day, So we were intending on such a throw Bart, Newt, but and actually hope for, um, this talk, we'll get some positivity around on a positive note, and so I think is important. And I think we've mentioned a few times about, you know, palliation the yolks down. Give us a talk on on palliation. But even during the trauma talk, we were talking about it on seasons of care, decisions on site and when enough is enough. Okay, so and I'm hoping No, you just give a quick review you off. Some of them have thought processes that go on in terms of deciding when the patients up into the life on home, you should go by to manage them in the So I'm just trying to get us for May. Once. Well, there, then I read these me glasses. Now just bear with two seconds to trying to less to work for me, right? So the stream just having troubles here. That's from these knots. Not work on the other screen. Okay, so, um, the first thing really is I'll be about about the GMC. So the DMC basically tell us that if we don't know what patient, um then our default position should be that we should start CPR if we find them and cardiac arrest. Okay, so if you don't have time to go and um uh, you speak to the ms, But for Alice's, the company's er when you find something cardiac arrest, then we should be doing CPR on the instance that should be a default position for all patients. I think that's important. Just start off. Um, but, um, nothing's changed from the GMC and however they help the document about a decision's made an immediate by the end of life care or tennis CPR decisions. And they're actually good either in module, which and the trust has access to you for us in terms of some of this stuff. And but this is pro on the key and stemmers I wanted to tease out, which is if a patient has a bit of the hospital acutely unwell or becomes chronically on stable. Um in their home or other place of care. There are foreseeable risk of cardiac or spiritually arrest judgment. Likely benefits, burdens and risks of CPR should be me. It as early as possible. That means, if we can, a patient who comes into e. D on there acutely on Well, we should Absolutely, if you thinking about making a Dennis CPR decision on them, even if you know actively dying in resource. Okay, and that's usually important. Um, patient should be having this conversation half of them when they arrive, and 80 because I want to say that I am. You know, if the patient is on label Teo, have a conversation with you, or that you think that there's considerable burden will be please placed on the patient to have that conversation with them. Then we should be speaking to the proxy for the next of kin, or they're legal Africa. And but what's really important and what the DNC guidance teases or is that you have to be really clear with the next of kin, the urinal asking them Teo sign of any CPR or to make that decision because the active this is really station in that context is a medical treatment like any other. So it's just the same Mr Side in the IV line and someone or tickets, My IV, antibiotics and the decision thio and making any CPR is for the medical team to make on what you're doing with the next of kin is your train. Teo. Find out what the pieces wishes would be or what you're trying to work out. What would be in the patient's past on trusts and for that what? That what that looks like is it's just trying to see what the BS Lane quality of life is like for the patient. So they may be tetraplegic in nursing the bad choice for all transfers. But their quality of life, the next of kin might say, is really good. And that's that's the information that we're trying to get from next to 10. We're know asking next can send in a CPR or two greeted in a CPR on What you're wanting to do as part of our conversation is explain your rationalist why you think and recess might not be in there and their best interest. I like again 100 without what we're trying to say here is This is not being a just a So I haven't mentioned aged. So you could have a 97 year old who actually could benefit from resource. And you could have, ah, 63 year old who wouldn't. That's a case by case decision about hae appropriate resuscitation and the event of cardiac arrest should or would be as part of that conversation, you're gonna talk about reasons why recess might know. Pick their interest. Uh, expose them. Most helpful way think about is what is the disease process is probably to cardiac arrest, and if they have a cardiac arrest, you minds to get return, it's pretend circulation. How long or what was the longevity of that? It's probably the circulation. So as Carl was talking about, you know, on elderly patient comes in with severe sepsis may deteriorate to the point. Without the cardiac arrest on that may not have any cardiac history and my already goods heart on, you might be able to get them by from, ah, cardiac arrest with constipation. How long lived? Well, that return it's been in circulation be because during the cardiac arrest, you haven't fixed the severe sepsis. You might every sort of the heart, but you haven't fix the problem that cause the cardiac arrest in the first place. And the idea is when I find so helpful when you're faking the family off and the next Kevin's is discussing the disease process that has led them to the point, there are just nine. So also, ghost goes to say, with, um, you know, patients with advanced and your muscle diseases, for example. And what we're going to say is that they can't stop point. They have a cardiac arrest. Even if you get return, it's been in circulation. Yeah, that return of potentially might not be long left on. The next thing on for my is that we have to ask your shells if we got our ask where that patient be going to. Really, they're probably in 10 chance of care fast majority of patients who get rust from local intensive care, And so for older, free or patients they have much lowers or physiological reserve on D. It could be really challenge to get a ventilator. Um, as you get older, your risk of having a slowing from a car from a from a Bentley ER is much higher. And what that means is that people potentially you're talking about months on eventually or whether Dracula's to me, um, months to recovery. And as we get older and frailer, our ability to to cope with that kind of invasive treatment gets lower and lower. So for our small number of these patients were old, um, Friel, committing them to that kind of IUs of treatment intensive treatment for a number of months. There's no in their interest because you will not get them back. Teo. Call of life, which they're used to, I think having those kind of kind of conversations with families. And if you if you practiced having a conversation of practice using those kind of words on that language and having some of those ideas t bring into the conversation, you very rarely needs some meet somebody. She disagrees with what you're saying. Thought the GNC does say that if the Mexican doesn't agree with what you're recommending, then we should be offering them, um, a second opinion so and you're gonna go and get a coli, probably from a different specialty to come on, but revealing Attribute the patient on have a conversation of the next can. Also uh huh to see if they also are in agreement. Ultimately, would you get some of these cases of actually called us far as legal? Do you need it again here of patients in variation, It's ending up and go through a legal challenge for the courts because the doctor told me after the patient feel of patients who have a DNA CPR but the family don't that's actually quite sorry, because what we can do, instead is we can prioritize, are positive care palliation of the patient, which and when you end up in a court battle, gets kind of lost a little. Okay, so and this is about to say this isn't making and but it's also about communicate on. I think so much of what we do is about communication and again bring him back. And what we said a couple times today is we want to be communicating our decisions with family on next of Kevin in particular and even more sure with covert and no, I haven't seen a number of family and department these conversations happening for the full, so it's really key that we probably recommend occasion schools practice having these conversations with the reasons current. So am I should just document, which is essentially leading to CPR in conjunction with the BMA and the RCN. And that's really helpful document and just to give us about a framework in terms of how we approach these conversations on the key element can revise one called the respect with the recommended some replying for emergency Karen treatment. I'm really, well, the respect his bike is making decisions in advance when the patient is fairly well about what they would want to happen or what should happen to them when on the athletic A born well, when that kind of sets having hard with the trust Some tests. Very careful going and what well, which again that spearheaded by Emily My Control Sugar from this morning and where that team are going actively into nursing homes and with GPS looking at patients on generate and test pretty character on and which makes some of these decisions and that funds okay on again. Hopefully you've all seen news comes from department Patients will come with a plan and police about whether they should have IV antibiotics or fluids or being on it. Or, you know, some of them, you can say, should not be taking the hospital in a circumstance. And, um, that's really helpful and process, you know, seeing our DNA, CPR forms. These are a regional on documents. They all look the same. Um, it's important. That's all. Feldene correctly. So occasionally I will come across form in the department. It's not really properly filled in. So before this to be a legal document, it must have all the base of demographics. Colon, you must have a d it art on now. Many towns for those three textbooks questions. Okay, Um uh, which is well, really it into is that the aspiration got capacity, and if not, have the kind of bounced a system of our CPR? Yes. And if not, have the got a well for attorney or ah, part of attorney, like on their behalf. Then we summarized on the kind of problems on reasons why CPR will be an appropriate on successful or not patients. Best interests. These, that's for must have each box. Feldon on number three down is communication with the patient. Or the next day was right on the patient or the welfare eternally on the number four is the communication with patients. Trial doesn't friends. Five is from members and et contributing to the decision again. That should really have, you know there's a senior nurse calls, and the decision that standard was named should go on there to you on the health care professional, completing a form, 1000 a box sex on. That's anyone of other half. I would, uh, of that. Number seven is for the most senior health professional. He really is your consultant. And so, in terms of 80 not numbers have a boat should be completed either by the CD consultants on the floor or by the physician or this consultant surgeon who doesn't prostate wardrobing. And then the D so can frequently come across patients. I've been in the for three days, and they never had their red form creditor signed again. This guy didn't say that I should be done within 12 hours before being completed, and it was just bright red, so we should be using for copies on this, read the well visible that's just stay in the front of the notes so that everyone's aware of what's happening Community air forms. Generally, we get a full copy and the full coffee is not valid piece documentation in the hospital. So if you have met Sorry S E and someone who's come in with a community form on it's a full copy black and white copy. Then they must have one of these ran original forms fallen and in the department. You wouldn't necessarily. And go and speak the next to come before we do that because it got community for me. Please. But when you're having the conversation with the family member for your Clarinex story and what what, you will and discuss that and mention that you've had a rough I that form in the Navy. Okay, so it's part of these talks. We often will get. Family, he will say, will be okay after, um, you know what's going on and produce kind of difficult. So I think Don mentioned earlier about your patient, he's actively dying in front of you on D, and you look at them on your your gut just tells you that they are dying. They're in the final stages of life under dying and lots of variables, just like to see, and but the ones are kind of in between here, just really set. And they probably got a news of tan, but you're not really sure that might serve. I even it might not. It can be really difficult to tell. So I came across and the study, which was from 2015. It was basically twenties. Course your spells continued. Researchers looked at it over 10 just on a 10.5 frozen and patients here a minute into an emergency medical take so on. Take your medicine as an emergency. Um, over the course of 13 days, Onda the basically looked at them. The a looked all of their risk factors, whether it on be used and governance census data until the cart mortality at one year. Okay, that's really interesting. So I think I think this could be you would translate that into our populations, a similar kind of population and across those different demographics. Is that What if I was? And if I could just write? You said that the if I cross is the top line of with graphs You got female left me on the right. So of all the females that we're a minute and 36% of them were dance or than a year. And the ovary, if I see for the meals 52% of the more damage than a year for them on the Radio five group. So really, that's quite something is not so. That's just all medical admissions that covers full social missions. Noon is, and I and any range of reason to be, um, uh, the towel on acute, well spelled and on medicine and but really quite a high mortality rate in the groups. And if we go down to the 65 the other one with we say, don't triangles the white one. So it's 22% of those and women with dad within a year, um, on around 3% of the man with that. Okay, So even for the protective 5657 degree, they still have a higher mortality for having one a mission and Teo medical bad. I guess what I'm trying to get with a slight is that your patient, whose 90 and how to fall under coming with pneumonia, may not be at every day. No, but if it's a man, they've probably for 2% chance. It'll be better than a year. Um, and you We need to be thinking about that. So it might not be other one a day in this admission, But if they've never had a conversation about resource than C's opportunity and have that conversation with them while they're here and then well enough to have a conversation with you, these researchers, then that, uh, coke progression looked at independent with factors for mortality on me and fighters where, firstly, increasing age, which we could expect and gender of This is a clear deficit genders in terms of their mortality, risk and diagnosis of concert. So again, conservations in this court on previous was probably pretty single Professor. Previous hospital mission kinds is an individual risk factor for and on your mortality. And that was all kind of a compared against their own demographic. So if you came from a really per amore really Offenbach friend, you are compared against the general population of four at that Seem so. See, we don't like bomb that you came from. So you say what next? So what? Um, what about, um Well, basically, we want to have these conversations. We want to be talking to people about their wishes towards the end of life. And this is ah, consult never even called them. The dykes He does this Campion, which is talking about that death of dying that actually looks really want to die campeon. You tickle dying matters and they have, ah, yearly dying Matters week, where the tramp promotes and feels talk about death of dying. Um honestly, is that they did and has shown more than 45 people would prefer to diet. Wonder asked. So if you ask the combination, any percent will say I want it I have my own bed Time comes but nearly a quarter off The general population of the UK don't want to over death or dying. You don't want to talk about the rheumatology and on the official figures a rush are suggesting that 24 day will have an increase of and by 90% the number of whom deaths. So, um, and we're expecting people to begin to start to choose diet more on this Crestor scary figure they came up with, which is at 74% off the April adult population haven't ran during or it'll people what they would prefer at the end of the life. That's maybe something that you've done yourself, you know, be so avoid what you prefer to happen end of your life. But you haven't told anyone. Yeah. So what's gonna happen without phone rings about either you or your left one? And are they going to know what your wishes are? Do you know what your wishes are? And I'm really I could come out. That's what we're trying to challenge you. Teo. Fix up a fix that today, if you can. But we're only one that we that But it's just thinking about how we as needed team approach these conversations and these difficult conversations about someone dying or someone being coming towards the end of their life. And what one of the states, right? Bring it. Waas the weed. Prepare ourselves too. Do you know when these conversations by just walk into rallies room and sat down and and I actually take a moment just to think about what you want to go? You have the meeting or that conversation and you want to stop you think about what what you think is an appropriate saving the treatment for the patient where you think that comes should be, and I'm compose himself before you go and have a think about it. Don't quit on your own so and we should always be going in with another idea with the nurse about ground nurse. These conversations is really what we should be doing and really important that we use the scale. Attacks from both professions were having these conversations because not supposed to ask for patients. We won't have an appropriate environment, so Rozerem is no really moved to prepare that I've ever seen. But it's at least got to wear that we can clues and new was one of our gyn you. Hopefully and it's quiet on gives you a private speech is to How about conversation? And But again, I think about that before you break bad news or how conversations? No, you with masks. Eyes are really all you see, and I want that to have this, like, just remain people. A contact, I think, is one that was powerful things and they have these conversations. It's so easy. When you got asked that difficult question or he are breaking terrible. Often you use that you look away or you look at before. Um, we really need to be looking people And the I slept, um, see the weight's of our eyes. And because that in itself is really powerful Rales really appreciate that when they knew that you're just with the rash is difficult, but you're meeting them via swell, Martha on by looking in the eye Next the line which you need to think about it. Okay, so the phrase is on the right and the pink. Or probably, if you read them, you probably think, well, that's gentler and about softer, and that's a nicer way to put it on the ones in the last in the belly Seems quite harsh. Bluhm don't lay. So you're saying she's dead where he's going to die, what time and again What we're told, it's like I will just talk tell us is that we must use the words death die. They have dying, and you have to leave our relative and absolutely new dose to what you're saying. One that wanted me to do that is to be really clear with communication, and I'm sure that I'm the nurse sleeping pill. Have told me before by, you know, a conversation happening and coming out and saying What does that mean? Like he said that she's slipping away. What was that? Actually name. Okay. And rallies want to new. What was for is you need to tell them and where they're stopping. Um, the only way to do that to be very really, really actually you're in the communication. I'm going home. 100 thighs. Silence. So you make the statement off. She is going to die tonight, all right? Or she is dying on. Then you leave the silence or not silence again is really important. You're maintaining your eye contact during that silence on your given the the rail to the next contained for that that information teasing, brilliant. And so we will help the asked me feet and really important again and trust have chaplains and get something from any of the few groups. And that's also something I think, especially with the organs that you ask a family member if you want to get if you want to get the priest of the minister or something from the group, it's something that really drives whom that the patients really sick on, but I can just reinforces that we are concerned based on a day and so again really important that that's why I asked about the same time on that. We get that organized while a patient alive Afrikaans and the next thing you realize, but origination just want to tease Oh, on again and the something about when you're preparing and you take enough, you think about where you got what you're gonna get you of the discussion is getting that again that conversation of information and they, um, organization and the UK So this a 96% of people believed in the in organisms the right thing to do. Literally 30% of people in the register You might have seen the news that you have recently changed their legislation, that it's no you knocked out and scheme so and if you know on the register, they can still take your organs on. There's legislation going through storming or proposed to put three storm one in the near future to try and change the systems that seem here would be off, but the current system, in the end of it and learned, is open. So if you know on the organization list, then you because there for a donation and but really from our perspective and we first need to have the thought about is organ donation an option here and then second, beautiful in the snow. Hard. So that's not as the specialist nurse nor definition on. That's not brief. Get three switch anyway. Um, Andi, they're pretty. It will get back to, you know, tell you well, you're spacing the soup lentils. But there's very few patients that come take and CDT. HIV active cancer are the main things that preclude you from. And there's very few things that haven't aged woman older. And so it's worth at the patient. If it's something with patient, um, to you that's worth and investigate for them. Okay, so that's just a kind of at the end. I just got some take home message from this we talked, which is first of all, think about your sense of care, really think it was appropriate and and what's and you where the patients had it con the discussion. Gonna help with family use clear language. A new silence when you're talking to them. Thank you for your, um, nation unless we just reiterate that point of have a conversation with your own family. Think about yourself on then speak to your family about it and put it in right if you need to. Okay, So, um, any questions Come right from there. I will touch on in other ways that we can wrap up no questions for nice. Waldo's just MPs than the fate back link again. So if you click on the I'm hoping attacks UTI the metal website where you can answer the feedback form, please put on a constructive feet by early con and complete it and then that will also generate year certificate for calling them on there. And that's instead of we'll try and sort less so that I can put the total along to the middle website so that if they have and Provigil nights or wherever, and they're still wanted to catch up from the talks, every to tell them and, um, they get catch up. So lastly, just thanks very much for coming on. Hopefully you find out they on a few things, if not one thing. Um, hopefully it actually thanks very much