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So, hi guys. Um Thanks for joining us. Um We've just gone live on Medal. Um We're just trying to sort out some technical stuff with all our presenters today and so we're just a bit behind. Um So today we've actually been very lucky to have Dan from the BM to come and talk to us as well before the palliative session. Um So Dan, can you hear us and are things working from your end? I guess that's a no. So, right. Fair enough. So, um we, we'll, we'll try this out, unfortunately, Dan can't hear us but we can hear him. So we'll just start um with this. Hi, everyone. Um Hope you can hear me. Um I've got a strange situation where I can, I can hear myself. Um but I can't hear anyone else. Um But ok, I, I'll be really quick, um just want to um just quickly talk to you before before the session begins. Um You should be able to see that. I have no idea of knowing if you can or not. Um So yeah, I'm here from the B ma. My name's Dan. Um I'm sure everybody is a member already. Um But yeah, I just wanted to make you aware that, that there's been, there's been a free offer going on which comes to an end in a few days time. What we got about a week left of this. So, genuinely, if you're not a member of the B MA now, really, really is the time to do it. You get three months free. You've used that QR code. Um And yeah, obviously there's still, there's still time to get your, your ballot as well. Um So yeah, so please join, if you haven't already there, there's no other offer like this. Once that ends, that will be it if you join you start paying. So do do take advantage of that offer if you haven't already. Um We've still got 1000 F one s um outstanding that haven't updated their place of work um and therefore haven't had their ballot yet. Um So again, we are at the final, final stages. Now, if you haven't updated your QR, if you haven't updated your um details of your place of work, if you haven't had your ballot yet, please do this um today. Scan that QR code. It will take you to your login. We need your place of work details so that we can, we can include you for the ballot. So your address obviously has to be correct. And so does your place of work details. It's imperative that that we have those details correct. So, yeah, if you haven't had your ballot yet, this will be the reason why. So please update your details. Um Yeah, just, just know that we're around, I'm not going to take up too much time, speaking about what we do sort of day to day. Um But the, the, the most, the most important thing I'm going to going to go on to is getting your contract checked if you haven't sent your contract to us yet and you remember, please do 25% of the contracts we checked last year were wrong and we check about 8000 of them. So, yeah, what we do is forward it to sport at B ma dot org dot UK. Um All the information was on our website as well, but if you haven't had your, your contract checked yet, please do so. Um big, yeah, big. The big thing, the core of them last year were wrong. So just, just for peace of mind for you that it's correct if you've signed it. Um Don't worry if it's wrong, it's wrong. We can still help and, and get it rec just because you've signed, it doesn't mean that it's stuck. Uh We also have a road checking tool as well, which, which you can, which is more straightforward. Um You just turn your ro or flag up to us. If it's wrong with that, we have less problem. Um You, you know about the resources we have again, I can't go into too much detail um today, but B MA library is fully online now. So, so every book you could possibly need everything for research is on the clinical key. You would have had access to it in med school. You've got full access to that with no pay walls or anything um through the B MA. So yeah, download that app and log in using your B MA log in. That's a really good tool. Um We run a series of webinars as well throughout the year. There's a few of them on the screen that might be of interest to you. Um You obviously get full access to BMJ learning as being a member and you should start start to get your bmjs through the post. Now, if you haven't been getting the bmjs through the post, that's a telltale sign that we, we probably don't have the correct address for you um very early to be thinking about this. But specialty exploratory is a good tool to use and roundabout. Now, um when you start to think about your specialty, so start thinking early, it's an online psychometric test takes about 20 minutes to complete, ask all sorts of work life balance questions. And at the end gives you a really detailed report breaking down. Um The specialties that would be suitable for you. We've got an amazing wellbeing service. So the so to everybody um 24 7, regardless of whether you're a member or not. Um And it's completely confidential and the unique thing is you have the choice who speak to a peer support doctor for someone who's been through similar to you or, or a counselor. So yeah, just that's, it really, really is minimal for me so you can get on with the session. Um Just please keep your B MA membership up to date your place of work details and your place of work. I know you hear this from us a lot. Sadly, the government made it so difficult to get these, these ballots done. It has to be paper. We have to have all these details correct. Um So yeah, so you haven't had your ballot yet. That'll be the reason we, we only have 10 days left until the ballot closes. So now really is the time to, to act if you haven't had your, your ballot yet because every, every vote is very important. Um Get your vote contract check by us. If you, if you haven't done already, your ro is there as well vote obviously and yeah, come to come to us whenever you need. Um That's it. If you, if you're not a member sign up three months free um for the next 10 days or so. So, yeah, you, you'll still be doing the ballot if you, if you do it today. Um We should just about be able to get it out. But yeah, this, this really is the last chance to, to get three months free membership. Ok. That's it. Thank you for having me. I try to be as, as quick as, as possible. Um And I will let you crack on with the session. Thank you, Dan. Um That's, that's great. Um So now moving on to the main se session, main part of the session, I guess is the palliative team. Um So today we've got um Beth and Nuala who have kindly taken the time to present about an end of life care. They're actually um the co-lead for the palliative part of mind, the bleep or the palliative section sector of mind, the bleep. So, um I'll now hand over to them to introduce themselves further. Thank you. Thanks so much, Sh and Dan. Um My name's Beth, I'm a junior doctor working in the northeast. I've just started a job as a palliative care teaching fellow, but just a few weeks ago, I was an F two and um I'm very much still getting to grips with how we manage palliative patients as junior doctors and as part of the team. Um I'm Nuala, I'm an IMT one working in Northeast London, I think, OK, if we have the next slide. Yeah. So today we're going to talk to you about DNA R conversations and just some tips for a bit of a structure for how to have those conversations. And then in the second half, we're going to talk about end of life, their pathways kind of in broad terms, Beth's going to talk about symptom management and then I'm going to talk a bit about medication rationalization. I think there's a slide about os hydration and nutrition and then spiritual and religious care. So I'm sure you're all familiar, but just so that we kind of, we know where we are. And so DNA CPR documents um are a piece of a document that says that that patient should not be for CPR in the event of a cardiac arrest. It's not a legally binding document. Um which means it's sort of clinical, it's guidance for the clinical teams, but there are situations where a team might decide to do CPR anyway. Um and it's also a medical decision. So we'll talk about kind of how to speak to patients and their families about it, but it's not ultimately their decision, whether they're for CPR or not. That being said, if a patient has capacity and they want a DNA CPR, they can, it's kind of, it's the difference between demanding a treatment and refusing a treatment. So because patients don't have the right in the NHS to demand a treatment, they can't ask, they can't have CPR just because they want it. It's a medical decision, but they can refuse to have CPR if they don't want to have it. So even if the medical team feel that CPR might be successful, if a patient is clear that they don't want it. You can put in a DNA CPR. I hope that makes sense. So, whilst it is a medical decision, best practice is that it should be discussed with um the patient and if that's not possible, they a representative. So a next of kin, a family member or a friend and there have been some legal cases in the past where they weren't discussed. And the kind of ruling now is that unless there's a strong belief that talking about the DNA CPR will cause psychological or physical harm to the patient, it should be discussed. OK, big side. So this is I'm just going to talk to you about a sort of example, structure for how you might have a DNA R conversation. So as an F one, you're most likely to be seeing these conversations happening in an acute setting, for instance, on the medical take, they do also happen in the community, they might happen at GP care teams might have them home. Um But as an F one, you'll probably be seeing them happen in hospital and you're most likely to be watching your seniors have these conversations and documenting them rather than having them yourself. But there may be situations where you're asked to have a DNA R conversation and if you feel comfortable, you can do. So I did, I did have some DNA conversations with patients as an F one on the medical take and there's no kind of one right way to have this conversation. And one thing I think is useful is when you are observing your seniors having the conversations, you can have a think about what you think went well in the conversations and what you think didn't go well in the conversations. And from that your technique for, for um how you like to do it. This is just an example structure, this is how I tend to do it. And I think this works quite well because it, it's quite structured and, and, and aims to be quite clear. So the first thing we do is introduce the, oh, I think we've um lost Nulla. I will see if we can find her. Um I think, I think there must be some sort of internet connection issue because um towards the end when she was speaking, it was just sort of we couldn't quite hear her. It was quite robotic sound. Sorry guys. Um Apologies for the technical issues today. I think we're having just one after another which is, which isn't usually the case. Please start with this. Yeah. Sorry, everyone. I will try and get new back. If we can't get her back quickly, then I will take over. But I'll just see if we can, we can get hi. Can you hear me? Yes, sorry. That was it. I think that was an internet failure on my part. Um Yeah. Yes. Sorry you. Thank you. Um So yeah, I think I was just at the beginning basically. So you're just going to introduce the conversation and check that the patient's happy to have that conversation with you. And you can ask if there's anybody that they'd like to have with them for the conversation. So the next thing I would do is I would explain what we mean by resuscitation and CPR. So it's easy to assume that patients will understand what these terms mean, but they actually may not at all. And I think it's in order for them to kind of know what the discussion is about, they need to understand. So I would, I think it can feel like you don't want to be really explicit because it can feel scary. But I think it's best to be really clear. So I would say we're talking about the situation in which a patient's heart has stopped beating. And I say that in that situation, we have two main options. So one is to do nothing and allow that person to die. And the other option is to attempt to resuscitate them. And that involves a combination of compressions on the chest, using electric shocks to try to restart the heart and normally doing things to help the patient's breathing, including putting a tube into their lungs to breathe for them. And most people, when you say that they, you know, they've seen enough on TV to know when, when you talk about the compressions on the chest they know what that means. Then I would explain a bit about the risks and the benefits. And I think this is really important because what a lot of nonmedical people don't understand is how, how, how rare it is that CPR is actually successful. And a lot of patients will think that it's successful most of the time. So the common risks we could say are that it's not successful, that it causes physical damage to the body such as breaking ribs. And also that it, that whilst we're able to restart the heart, there has been a sufficient period where the brain hasn't been getting oxygen, that the brain that there's damage to the brain. So the patient, it we're able to kind of keep them alive, but there's damage to the brain and that that can be as significant as the not being able to talk and not really being able to have any independence. The benefit is that we keep the patient alive and we can then carry on treating whatever medical condition it it is that has brought them into hospital. I think it's also important to explain that they will not, it will not solve their other medical problems and it will not if they. So let's say they, they're being treated for a pneumonia and their heart stops and we do CPR and we are able to restart the heart. We're still going to deal with the pneumonia. It won't solve any, it won't solve those issues. At that point, I would check that all of that's made sense. I would ask them if they've got any questions that they want to ask and I would ask them if they have any thoughts or feelings about what I've said so far. At this point, I would then say that I would explain the medical position and you can say that it's the team that's come to this decision. as an F one, you won't be deciding for yourself that the patient needs a DNA R. It's much more likely that a consultant will have told you that that's what needs to be done and you'll be having the conversation sort of on the behalf of the consultant. So you can say that your consultant doesn't feel for whatever reasons that are going to be specific to that patient, that CPR would be in their best interest. And I think it's important to make it specific to the patient based on their preexisting medical conditions or whatever acute situation is going on for them. But ultimately, you're saying the medical team don't feel that it would be in their best interest because they don't feel that CPR would be successful. Yeah, at that point, if the patient is in agreement, then you can complete your DNR paperwork if they're not in agreement. So you've explained that the medical team don't think that it's in their best interest if they're saying no, I really want to be for CPR, I really want you to do everything. At that point. I would ask your seniors to come and help you because that, that complicates the decision making. And I think that's kind of above your level. I hope that all makes sense. We'll have the opportunity for some questions at the end. So if you have any questions about anything I've sent there, please let me know. Great. So now we're going to talk a bit about end of life care pathways. So what we mean by this is this is a kind of a kind of set of different things that are done for patients when they're recognized to be at the end of life. And we're thinking really in a hospital setting here, although all of this could apply in the community or in a hospice, um everywhere that you work is likely to have a different name for this. And there's often a sort of proform that you'll use that kind of triggers you to go through and think about all these different settings. So when you work, when you start working somewhere new or you all will be new in whatever hospitals you've started working in, it's worth asking around finding out what do we call it in this trust? And is there a document? But wherever you work, it's going to contain largely the same things. A lot of this will be being led by your seniors and you won't be making these decisions yourself. But it's really helpful to understand what the different components of it are. And also sometimes you'll find, I have found in my experience, the consultant will have quite a quick conversation. Then you're trying to fill in the paperwork and you'll realize that there are parts of it that haven't been addressed and you might need to go back and talk to the patients or their relatives at that point. So I'll hand over to Beth, who's gonna talk about the anticipatory medication. Thanks very much Lee. So um we'll go through symptom management in kind of end of life care and palliative settings, thinking about our main symptoms that occur in palliative care. So these five are the five that you will generally be treating in hospital or community settings. A lot of them are very multifactorial influence each other. So for example, agitation can often be influenced by pain and nausea as well as fear and other emotional experiences. So it's really valuable to take the time to understand which symptoms our patients are experiencing so that we can then treat them because they often kind of feed off of each other starting with pain. This is just a reminder of the fact that in palliative care, in particular, we have this concept of total pain where a person's physiological experience is influenced by many other factors. That's the case in all of our patients. But in palliative care, in particular, it can be really worthwhile thinking about the kind of social, emotional and spiritual factors that could be at play when I'm approaching a palliative patient and thinking about how I might manage their pain. These are the main things I think about. So I think it's quite easy in palliative care to just think about treating and just jump in with pain management. But I think it's really worthwhile considering why they're in pain in the first place. For example, if a patient is in urinary retention, we can give them morphine, but actually a catheter might be more appropriate. So it is good to make sure that you do quite a thorough pain history. Um Knowing what they're taking for the pain already is also really useful, partly because it can help guide us in knowing what has or hasn't been helpful so far. And also because lots of patients will be on opioids and we want to avoid making the opiate toxics. So knowing what they've already had is important that also brings me to what is their fr if you have a palliative patient, it is really useful to consider their renal function before you prescribe and we'll talk about that a little bit later. And then also considering can this patient take oral release? So lots of palliative patients may not have a safe swallow or may no longer be conscious enough to take or leave. But it's useful to, to consider it before you begin your prescribing. So these are just the kind of main take, take homes to think about when we're prescribing for pain. Generally in palliative care, we skip straight to the top of the who pain ladder. It can still be useful to give paracetamol and adjuvants. But we'll often be giving morphine as our first line. Um Quite a lot of guidance is kind of recommend using oral where possible. So if a patient can swallow, using oral morph, can be a useful first line, we should generally think about prescribing regular or background medicines along with our PRN. So hoping to provide a kind of background of pain medication that keeps the pain at bay so that the PRN are just used. Absolutely as and when needed when we have palliative patients, we generally review their pain medicines every 24 hours if not more often. And as an F one, it might be part of your job to be reviewing these pain medications at 24 hours. And thinking about whether the dosage needs to change in a patient who has been using lots of PRN S, you would normally think about increasing your background dose. So to create that kind of greater level of threshold before they need the PRN to do that, you add up your total daily dose. So taking all of the background and all of the PRN and that gives you your new 24 hour total daily dose, that being said, because we're often working with quite strong medicines, we wouldn't increase by more than 50% a day. So if a patient is using way over 50% way over double what, what they were using, we need to think about carefully building up that increased background, then we might need to recalculate the pr dose or calculate it in the first place. And we generally look for 1/6 to 1/10 of that total daily dose in order to, to give an appropriate PRN if you have any doubts, you will have a fantastic pharmacist on all of your wards and they'll be an out of hours pharmacist and I have definitely called people in the past making sure that my maths is right. It can also be really helpful just to get a colleague to check your maths. Now, the areas that we have to think about caution with would be elderly or frail patients and those with renal impairment in terms of elderly frail patients, generally, I try to go for a smaller dose as my starting dose both for the regular and pr and you can also try and have larger number of hours between the dosing so that you don't knock them off too much or cause them to fall in renal impairment. The rough guidance is that in moderate renal impairment, use oxyCODONE instead of morphine and use Alfentanil when you have an ETF R under 30. Alfentanil is a very short acting medication. So we couldn't really use that as our kind of twice daily background. Normally, you'd need to start a syringe driver so that you're getting a gradual 24 hour dosing throughout the day. Again, if you do have doubts in patients with fr of 11 or something like that, asking for some help, either from a pharmacist or your palliative care team can be really helpful and they really don't mind you asking, moving on to nausea and vomiting. Such a horrible symptom in any situation, but can be really awful in palliative care in terms of general principles. Similarly to pain, I would always suggest thinking about why this patient is nauseous and vomiting in the first place and whether there's a reversible cause that we might be able to treat because again, just antiemetics won't cure hypercalcemia. But if you give some fluid as well, that could make the patient feel much better. Thinking about environmental factors is important and taking a thorough history from a patient can help you help make sure that they have less triggers to make them feel sick. So for example, if they are feeling sick, largely when the smell of food is in the room, you might be able to chat to the H CS and the domestics and see if we can get as little food smells as possible. In terms of the route that you'll go by. Often people who are nauseous or vomiting are absorbing quite poorly. So, subcut is generally where we'll start. I'm sure you have all gone through the horror of medicines for nausea and vomiting in med school where you learn about all of the different receptors and the places that they work that doesn't generally come up as a foundation doctor at all. Um, but I suppose if you want to look into it more that can help you think about why we use them for certain things. These I'd say they are the top medications that we use for nausea and vomiting in palliative care. Some of them have quite important contraindications. So, Parkinson's disease in metoclopramide and haloperidol really worth thinking about Levo Meprozine is one that you may or may not use in your foundation years. It's very broadly acting. So it causes a lot of sedating effects. So generally, I've only seen that prescribed by kind of the specialist palliative care team, but they might ask you to prescribe it in a patient who um hasn't been responding to other, other methods. When we choose antiemetics, we've got to keep comorbidities in mind and also previous medicines that have or haven't been helpful. Generally, if you have a patient who's approaching end of life, you'll have trust guidelines which you can follow. Often anticipatory come in a, in a set, a structured set where you just take electronically, the medicines you want. So you often don't need to choose that being said each antiemetic does have some kind of special features or aspects that make them quite useful. So, halo pill is found to be quite useful in chemical causes of nausea. So your hypercalcemia um Ondansetron is often used from chemo or radiotherapy patients. Cyclizine is a bit of a jack of all trades and often will be your first line in end of life. Um because it's useful for cause unknown as well as organ damage caused by um cancers and then the Levo Meprozine is often the last in the line. Um but can be really key in these nausea and vomiting that isn't responding to the other treatments, moving on to respiratory secretions. So often kind of referred to as the death rattle. These secretions are the noise of your breath moving through your saliva. If you aren't clearing your throat, it can make quite a kind of gurgly noise that some families find really disturbing and worrying and it can make them worry that their relative is drowning or really uncomfortable. So communication is absolutely vital in management of secretions more so than any of the other things that you can do. If I have patients who do have secretions or even just patients approaching the end of life, I'll generally explain to relatives that as they approach end of life, as they get weaker and they're awake less and sleep more, they might become so relaxed that they don't notice the tickle in their throat that we do that normally makes us clear. Our throat and they become so relaxed that that leads to this noise that sounds rattly and uncomfortable to us. But to them is just a sign of how deeply asleep they are. It can be quite helpful to, to just let relatives know that. So that instead of thinking of the agitation, their relative might be feeling, they know it's a sign of relaxation and and not being aware of that. Um alongside that we can think about positional changes. So sometimes just moving the patient in the bed can be good. Suction can be considered if secretions are causing a lot of distress in the patient, but suctioning itself can also cause a lot of distress. So in most cases, I wouldn't, I wouldn't say that's helpful. Then in terms of our medicines, Hyos Butyl bromide is often the medicine that will be in your prescribing, set for anticipatory. Um The glycopyrrolate is also sometimes used agitation similarly to everything else, considering reversible causes and trying to understand where the agitation might be coming from is really useful, then ensuring as calm an environment as possible. So hopefully, if your patient is approaching end of life, they might have a side room already. Um but if they're very agitated and they don't, you might be able to speak to one of the sisters on the ward and see if that's possible. Um ensuring familiar faces and familiar voices as much as possible. And then considering those kind of spiritual and emotional needs. Um So potentially involving the chaplain or having a conversation that the patient about what it is that the patient is worried about can be really useful. And it's really worth taking that time. Then in terms of pharmacological midazolam is generally what we use. But I would definitely suggest thinking about the nonpharmacological as well. And then our final symptom that we're going to just touch on is shortness of breath. So lots of patients might become quite short of breath towards the end of life, even if they don't have a respiratory cause of of what's going on. Alongside the similar reassurance that you would give for other symptoms. Patients can find fresh air makes a big difference. So opening a window or getting a family member to bring in a handheld fan and fanning, the patient can be useful. Mouth care can also help if you have a very dry mouth and you're also short of breath, they can kind of exacerbate each other. So, ensuring patients have nice, keep their mouth moist oxygen can be used. If the patient finds it helpful. Some patients will be very distressed by a nasal cannula or a mask, but others might find it has symptomatic benefit. So it can definitely be considered. Then in terms of medicines, morphine would be our first line often at a slightly lower dose than you're using for pain if the patient's already using morphine, and that isn't proving helpful or you're worried about them becoming toxic. You can think about midazolam instead, then alongside the anticipatory medicines themselves, the final kind of part of your prescribing as an F one might be prescribing syringe drivers. These allow us to deliver 24 hours of constant medication subcutaneously to a patient and they're really important at the end of life or tricky to manage symptoms. I wouldn't be expecting you as an F one to be initiating a syringe driver or by yourself without kind of confirming it with a senior. But it might be that you are the person in the team who notices that a patient, a patient isn't on one and can suggest it and, and the consultant, I think that's a good idea. Um The principles are exactly the same as all of the other methods. So reviewing at 24 hours every single day, adding up that total daily dose, using the regular and PRN to create a new dose and then making sure that your PRN are adjusted if you do increase. So hope that wasn't too overwhelming. That's a kind of whistle stop tour of the main symptoms that you might encounter in palliative care. And then I'll move on to new, who's going to speak about other aspects of care, care, dying patients. So, um, when around the time that you might be starting the anticipatory medications that Beth has talked about, you might also go through a process that we call medicines rationalization and this is basically stopping any unnecessary medications. The, the main thing that you're thinking about here is the likely potential benefit from that medication versus the potential harm or distress of trying to continue to give it to the patient. And so essentially, you, you keep going with anything that you think is going to provide symptomatic benefit. And this is a bit of a, it's a clinical judgment. And if you have, if you've been asked to rationalize somebody's medications, which you might be asked to do and you have questions about specific ones, I would definitely just ask somebody whether they think it's a good idea to keep going or not. Ones that you're likely to stop will be things that are kind of chronic medications that are providing long term prognostic benefit. So that's things like statins, BP medications, um, any supplements. If people are on calcium and vitamin D, these kind of things that are useful to a patient in the long term, but in the short term term aren't gonna affect their symptoms, you're likely to stop all of those. And then in, in other cases, it's going to depend a bit on whether the medication is, is likely to be providing symptomatic benefit. For instance, with antibiotics, you might make the decision. And when I say you, I sort of mean the medical team in general, I don't really mean you as an individual, but the team might decide to stop antibiotics because they might feel that there's no benefit to be had from those antibiotics anymore. Or they might find they might feel sometimes if a patient is thought to be septic, sometimes antibiotics will be carried on because the feeling is that it might be controlling the infection enough that it's making the patient a bit more comfortable. Um But it really is a kind of clinical judgment. And I would say if you have questions, as I say, I would ask and some of these, some of these decisions are going to be made through discussions with patients and their family members as well. Because stopping medications can be a very emotive thing for patients and their families. And sometimes medications are continued really to avoid the psychological distress of stopping them. So it might be that the medical team feel realistically that the antibiotics are not helping anymore, but that the patient or their family really want them to be carried on and that ultimately, it's not causing that much harm to keep them going. So I think it's important to have and again, this is really your seniors will be leading on these discussions. But normally there's a flexibility in the approach about what we keep going and what we stop based on what's going, what's going to give symptomatic benefit, but what also might cause psychological distress to stop. And there may also be a bit of a two stage process of rationalizing medications. So you might stop initially, some of those really long term prognostic benefit medications like statins, but keep going with things like antibiotics. And then there might be a point later on where the patient is much less alert, not able to take any oral medications and you might kind of stop another round of medications. The other thing is sometimes if patients are receiving IV medications, for instance IV antibiotics, you might say, and again, this would be a conversation that your seniors would really be having with the patient and their families. But there might be an agreement that you'll keep going whilst you have IV access. But that if the cannula tissues or something similar happens, let's say the cannula is accidentally pulled out that you wouldn't rec cannulate to keep going with that medication. And that can be a helpful kind of conversation to have even at the point where the cannula is still working to just kind of lay the groundwork for what you will do if it stops working. Ok. Mhm. Thank you. So then to say a little bit about observations. So the normal thing that is done at the end of life is that you stop your standard observations, the ones that are done to provide you with the new score and instead you start what are called comfort observations. And this is where a nurse or a healthcare assistant will go in and regularly assess the patient for any signs of discomfort So they'll do things like, look for pain, look for, um, shortness of breath, look, look at the mouth, all the things that Beth has talked about and assess the need for any of the anticipatory medications or any of the non pharmacological methods to manage those symptoms as well. And I think this can be a really helpful thing to let patients and their families know that you're going to be doing because when you're having these conversations about kind of approaching the end of life and making these changes in a patient's care, it can feel like a lot of stuff is being taken away. So we're withdrawing lots of medication. And I think it's really important to emphasize the things that we're still doing. And this, I think it can be really comforting for patients and their families to know that we're still actively treating, not actively treating, we're still actively caring for the patient, we're regularly assessing them so that they know that they're not sort of being forgotten. Thank you. Next slide. So a little bit about hydration and nutrition here. So this is hydration and nutrition at the end of life is a really big topic and could be definitely a whole hour on its own. But I'm just going to briefly go through the options. So what we have here is kind of these are the options in general terms for how we can deliver hydration and nutrition. So the first one is oral intake as is tolerated by the patient. And that's sometimes called taste for pleasures, for pleasure. The second one is subcutaneous fluid. The third one is IV fluid and then the final one is NG feeding or peg feeding. And I actually should have put TPN in there as well. So I'm gonna go through these again and just say a little bit more about them. So the first option here, oral intake as tolerated is where we encourage the patient to eat and drink as much as they can, as much as their alertness allows. And we accept that they're not going to really meet their nutritional needs. But that's a natural thing that happens at the end of life. And we're focusing on comfort and pleasure. So we're encouraging patients to eat whatever foods they fancy and things that we know that they like and to drink as much as feels comfortable. And we may at that point be accepting that there's an aspiration risk. But the benefit to having a bit of oral intake is greater than the risk from the aspiration. And that's probably the most common way that we deliver hydration and nutrition at the end of life. And as patients become more drowsy and less alert, their oral intake will decline. And it's really useful to kind of preempt conversations with patients and their family that this is completely normal that at the end of life, our need for food and fluid goes down. And that, and the the main thing is to keep them comfortable and to just um to focus on mouth care because we know that that is, that's the kind of the main discomfort that patients have is feeling that their mouth is dry. So the second, the two options, the next two, subcutaneous fluid and IV fluid are ways that we can provide artificial hydration, subcutaneous fluid. So just like you can have a syringe driver, which is a little needle that sits under the skin and delivers the medication. You can also have a similar set up where there's a, a small needle that sits under the skin and delivers fluid very, very slowly. You really, you can't deliver, um you can't deliver it fast at all, but a a really slow delivery of fluid into the subcutaneous tissue and then IV fluid, as you all know, is just in, into a cannula, the decision to offer these is again, a clinical decision that I wouldn't expect as an F one you'd be making yourself, they would be decisions that your seniors would be making. And again, it's a sort of risk versus benefit decision based on how uncomfortable the patient is, how dehydrated they feel. And the risks of providing the fluid because the risk is that the fluid goes into the lungs or into the peripheral tissues and isn't actually hydrating them. And one thing we know is that subcutaneous fluids and IV fluids don't improve the symptom of thirst. So, whilst they might be getting some fluid into the bloodstream through this, the, the, the main thing that we're focusing on at the end of life, which is their symptoms are not improved by this. But again, it wouldn't be your decision to make. It's just something to be aware that they are, they are ways that fluid is delivered at the end of life. And then the final option here, which is feeding peg, feeding and I should have put TPN on there. These are things that would not be introduced at the end of life. But the relevance to end of life care is that sometimes they would be withdrawn. So if patients have come in with a preexisting peg or TPN or they've been started on N feeding during their admission and then they've deteriorated. At some point, the decision will be made to withdraw those. And that would be a decision that your seniors possibly with the help of the palliative care team are having. Thank you. Right. And then the final thing to say is just thinking about the patient kind of more widely in that as a whole being is thinking about spiritual and religious care. So Beth talked earlier about involving the chaplain and it's always worth asking patients if they are religious and if they would like to speak to the chaplain, the provision will be different at different hospitals, but they're normally multifaith chaplaincy, which means that whatever the faith background is of the chaplain, they will support patients of all religious backgrounds and they can also be helpful if they don't have a representative of that patient of the patient's faith within the chaplaincy team. They can also sometimes try to find somebody for you, but also for patients who, who aren't religious. There's also kind of other ways to look after the patient as a whole being. And I think as an f one, this isn't necessarily your job. But one thing that you can do, which I think is a really nice thing to do is to speak to the family or the next of kin, whoever's visiting and ask them if there's anything that they want to bring in that they think would be nice for the patient. So I've got some examples here of that. They could play music, they could bring in photographs of loved ones. They could bring some depending on where you work, especially if you work in a sort of hospice or a palliative unit, you might be able to bring in pets. Sometimes it's possible for patients to be taken outside and that can be really nice. And all of these things are just ways that we look after the patient as a whole being rather than just as a kind of set of medical conditions. Ok, I think that's everything that we have to talk about. And so I can see a few questions in the chat. So if you have any other questions, please feel free to post them. So somebody has asked here, um can an existing Dnrar be refused later on? So I think what you mean by that is if the patient is in agreement at the time that the DNA R is put in place and they then change their mind, can they kind of then refuse it? And basically because it remains a medical decision, they can't kind of say, oh, I actually do want to be for CPR and then they would have automatically have the DNA R removed. It might be that they do kind of change their mind and start to express that they want to be for CPR. And at that point, you would, you that your seniors would need to have a conversation with them again, it's a medical decision. So ultimately, the medical team's decision would still stand, but it would involve some further discussions with the patient trying to understand what's changed from their perspective, why they've changed their mind and kind of going from there. Um And somebody else has asked, do we need to memorize formula for converting dosages from MST to syringe driver, morphine drugs. Do you want to answer that, Beth? Absolutely. I mean, so I, I would, I would say no in terms of memorizing, um II, I personally don't memorize any of the, the conversions. So I think what you're referring to is the fact that um for example, five mg of oral morphine is going to be a different strength from five mg of subcu morphine. And so it might be that if we're going from kind of oral to subcu or, or going from one route to another, we might need to convert it. So change the dose by timing it by a certain number. I use an opioid conversion table. So um you can find them, I use a palliative care guideline in the northeast that has it in it. But you can also Google opioid conversion chart. Um, and it shows you a, a very useful table that will generally tell you, you know, if you're going from this to this times by 0.5 or, or something like that. Um But, but I've never memorized it and I, in a way I think I probably never will because it means that you're always making sure that you're getting the maths right when you do convert. But I don't know who is that? I agree. Yeah, I think, um, I don't know about some of you might have learned them for your, for your finals and certainly for postgraduate exams, sometimes you have to learn them. But in practice, I always look them up because I think even if I think I know what it is, I just want to be sure. So I would always look it up. Yeah. And then somebody's asked, what are the common modes of death in patients with functioning defibrillators, eeg, active icds in situ. Um, so I, I have no idea. Um, I think what you're asking is, is they have a DFIB in place. If they have a cardiac arrest, then they'll be shocked. So, what, so kind of, what do they die of if, you know, if, um, if the DFIB is working, I, I wouldn't be able to tell you. Do you have any ideas? Beth? No, not, no, not, not. If the DFIB is working, I think, no, I, I think you might need to ask like a cardiologist or, or someone who knows in, in terms of, in terms of the DFIB itself and, and who might, what they might die of. Yeah. But I think, um, that raises a good point, which is, if you're ever looking after somebody who is end of life and you know, that they have a pacemaker, it's important that the pacemaker is deactivated before they die. So normally where I've worked before the card, the cardiac physiologist can come and kind of properly disable it. But if it's, if the patient is acutely unwell and you're worried that they might die before that process can happen and you can normally get magnets. And I, I would speak to your palliative care team about where you get those from, but it's like a, it's a big magnet like this, which is basically taped over the pacemaker physically taped to the chest and that deactivates it whilst you're waiting for the kind of proper deactivation to happen. Great. Thank you very much. I think we've answered all the questions. Um So, first of all, I'd like to say a massive thank you for taking the time and presenting this session, which is highly invaluable. I personally, when I was left, one started off with acute medicine and definitely, if I, I would have loved to have this session before I started my F one basically. Um And so thank you very much for your time and words of wisdom. I'd also like to say thanks to the audience for coming and listening and we really appreciate your engagement with our, with our speakers as well. Um Also, finally, I'd like to ask if we can all, if sorry, if the audience members can all um complete the feedback form. It's the same feedback forms as for all the other survival webinars. Um If you can complete it, that will be highly valuable for us and the team so that we can create something similar next year um and find ways to improve our sort of service to you really. Um But yeah, if there's all this, is there one more question? No, if there's no more questions, then I think you can call it a day. Great. Thanks. Thanks very much. Thanks, everyone. Have a nice day. Thank you very much. Thank you, bet and thank you. You see you soon. Bye.