Computer generated transcript

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

Hi, everyone. Um could someone just let me know whether you can hear me and whether you've heard anything about what I've said yet or? Um is this the first that you can hear from me? Just started hearing me out? Ok, perfect. First we've had, ok, that's fine. I'll start from um the first slide. Um ok, so welcome everyone to teaching things. Sorry, we're starting a bit late. Um, the session will be about an hour but it should be a little bit shorter than that. Um So I'll just give a quick introduction to teaching things if you haven't been before. Um, it's a UCR teaching program which students run for clinical students. Um And today's session is about end of life care. Um Please put any questions as we go along in the chat. Um, it would be nice if this could be as interactive as possible. Um And yeah, we'll start the session now. So today we're gonna cover um the palliative care assessment, symptom control and prescribing in palliative care the last days of life and confirmation of death. So these are all um important skills as doctors. Um, if you've had a palliative care care placement. You might have seen things like a palliative care assessment done before. Um, but all doctors will need to um be good and confident with symptom control and prescribing. It comes up lots in Aussies and prescribing exams. Um And then we'll talk about the last days of life and confirmation of death, which is also an important skill as an F one. So I'll just start with a quick introduction to palliative care because I think it can often be a bit misunderstood as a specialty if you haven't had much experience in it. So, palliative care is an approach that improves the quality of life of patients and their families um in life threatening or life limiting illness. And it looks at caring for the physical psychosocial and spiritual health of the patient. So I just wanted to start with this because um palliative care is a lot about the quality of life and symptom management rather than just the end of life in the last days. And um yeah, so it's life threatening or life limiting illness, which can mean that someone has an illness for, you know, a year or so. Um But the palliative care team would get involved early for symptom management and a holistic approach to the patient. So our case today um will be this one. We'll work through this throughout the session. So the patient is Mister Peter Saunders. He's an 85 year old male. He's on a urology ward, but he's been referred to the palliative care team because of an adequate pain control. He um has uh metastatic lung cancer. Um, and he's not on any active treatment from the oncology team. Um, he's got a past medical history of hyperlipidemia and diabetes. He's on atorvastatin and Metformin and um, he's a nonsmoker uh social drinker, retired teacher. He lives with his wife and is independent. Um OK. So the question is, how would you assess this patient as the palliative care doctor? So if people could put in the chart, the kinds of questions that you'd want to ask him as the palliative care doctor. And think back to my original slide about um the holistic approach that palliative care doctors take. I'm not quite sure why urology is the referring team. So apologies for that. Any thoughts in the chat. If you were the doctor going to see him, what would you ask? Yeah, exactly. So support he already has. Exactly. Yeah, that's really good. Any other thoughts? Perfect. Exactly. So you'd want to take a pain history and exactly explore his key worries and invite questions. Exactly. Great. That's some, there's some really, really good answers. So just kind of um summarize those. So if you have to do this in real life or in an OS situation, these are the kind of headings you want to cover. Um So as we said, you'd want to talk about his current symptoms. So this is his pain control. You'd want to understand um uh what he knows about his condition. Um So his metastatic lung cancer, you'd want to review his medical history and his social needs. As someone said in the chat, um, you'd want to look at other symptom control. So we'll go through the main palliative care symptoms, um his psychological needs. So, how is his mood? How is he coping, what's his support network, Any other psychological input? Um Thinking about the family and carer needs as well and then thinking about his spiritual health, what is important to him? What gives him meaning? Um any faith or belief that's important to him? Think about his capacity and decision making. Um So does he have things in place like an LPA an advanced directive? What's his ceiling of care? Does he have DNA CPR in place? Um And then you need to start thinking about planning ahead. So what are the patients preferences, wishes and needs um who else needs to be involved? So, the palliative care team in the community, the GP district nurses, psychologists, chaplaincy, other spiritual leaders. Um where is their preferred place of death in care setting? So it's either a hospital hospice, nursing home or home. Think about any uh prescribing that you need to do, look at care and family support and um make sure that he's got good follow up and contact details for the palliative care team. Um So, yeah, we want to look at assessing his pain control, but in terms of a general palliative care assessment, these are some of the things you'd want to cover, ok. Obviously, you wouldn't be able to get through that in a kind of 10 minute. Oy, but they're good pointers to have um in the back of your mind when you're speaking to um, palliative care patients. Ok. So the next section is about symptom control and prescribing in palliative care. So, the team have asked you to assess um sorry, the team of assessed Mister Peters and asked you to prescribe adequate pain relief. Um Could you write out a prescription and think about what else you would consider before prescribing? So that's his um background. So think about what you would prescribe him and anything else you'd need to consider before prescribing and just put them in the chart. Any thoughts in the chat, he's already on codeine. How is that managing his pain at the moment? Yeah, exactly. So let's say that his pain is not being controlled well at all. With codeine, obviously, you'd want a bigger history than that, but let's say the codeine is doing not doing anything to help. Yeah. Exactly. So, pain management who ladder or Aor? Exactly. Yeah. Yeah, exactly. So let's move on. So, exactly. Like you guys said, always think of the home pain Ladder. If you're in an OSK station, you're asked to prescribe analgesics, then you can say something like I would prescribe for analgesics according to the who pain ladder just shows, you know what you're talking about. And for anyone that has seen this, um it's basically the stepwise escalation of pain management. So you start with paracetamol and nsaids like Ibuprofen, naproxen, things like that. You then step up to weak opioids, like codeine and traMADol and then you would step up again to strong opiates like morphine, fentaNYL. Um buprenorphine things like that. Um Obviously, if they're in severe pain, you wouldn't sort of start with paracetamol, you would go straight to morphine. But this is a good um framework to have in mind. OK? And then just before we talk about the answer to that case, uh to that question, um I just wanted to talk a bit about opiate considerations. So if someone said in the chart, the next um medication you'd want to prescribe would be m um morphine. Um because codeine is not doing anything to help to the next step up would be opiates. So things to consider when you're prescribing opiates are the side effects that it causes. So it causes constipation because it reduces gut peristalsis and sensitivity to rectal distension. So you need a laxative prescription. Um in some patients, opiates can cause nausea and vomiting. So you don't want to prescribe an antiemetic as well. Um Usually it does improve after 5 to 7 days, you need to check their renal function before you prescribe opiates um and avoid if their eg fr is less than 30. Um you want to consider opiate toxicity. Um This is a bit less than palliative care, but I'm just talking about kind of general opiate um prescribing. Um If someone has an opiate toxicity, as you can see on the slide, those are some of the things you would expect to see and you would prescribe naloxone um as the antidote for that, it's quite a common exam question to kind of see those symptoms and then know that it's an opioid toxicity. So just kind of have those in your minds. Um And yeah, dependence on withdrawal and look at drug interactions for morphine. So if you go on the B NF, that's quite a long list. So you just want to check that as well. So in terms of a prescription, as someone said, you would want to prescribe something like Oramorph um which is a uh um which is morphine um because the codeine is doing nothing to help, you would want to prescribe a dose like 5 mg for hourly P RN. And then the patient could then take the Oramorph um as much or as little as they needed. And then after 24 hours, you would reassess the amount of pr and Oramorph they needed and then look at starting them on a uh modified released morphine um as a kind of background dosing. But in terms of what you would do to start with, this is what you would prescribe. So, with any morphine prescription, you also want to add an antiemetic like cyclizine, um and laxatives um like a stimulant and a softener. So, senna and lactulose regularly um in UCL exams. Uh if they asked you to prescribe morphine, you would just need to prescribe all of these together. Um And it's quite helpful to remember the doses just to save time in exams. But obviously you could look at the B NF for each of these. But I would suggest that you, um remember the doses that's easier for you in the exams and you have more time to do something else cos usually it'll be a bunch of tasks together. Ok. And then you'd also just wanna make sure um that you check the root and that he has good oral intake at the moment. He does. So they could all be oral medications. Ok. So you reviewed Mister Peters the next day. He has used his PR NPR N 5 mg of Oramorph six times in the last 24 hours, please update his prescription. So does anyone know what you would do in terms of the calculation if you could just put your answers in the chat? Ok. Does anyone have any ideas? Ok. That's fine. No worries. Um We'll have a look at what you would do. So, um the patient has basically needed. Um, let's just go back to the question. So the patient has needed 5 mg six times in the last 24 hours. So what you need to do is work out his total morphine requirement over the 24 hour period. So that'll be five times six, which is 30 mg. So he's needed 30 mg of oral morphine in 24 hours. And then what you would do is you need to convert that to a modified release. Um morphine and the way that you do that is divide his overall morphine requirement by two. So essentially what you're saying is that he needs 30 mg over 24 hours. You would split the dose. So he would have a BD dose of 15 mg. And that's what you can see here. So you can give him 15 mg, BD. And then it means that the patient has a good background um morphine dose rather than taking the P RN when they need it. But you're giving him the same amount of morphine over the 24 hours. You also need to prescribe Oramorph P RN with a modified release um prescription and you would pres you always prescribe 1/6 of their requirement as their P RN dosed. So this would be 30 divided by six, which is 5 mg. Um And therefore, if the patient is still in pain with the modified release um tablets, um they can have some P RN doses as well. Does that make sense to everybody? Let me know if there's any questions in the chart and obviously you'd continue his cyclizine, senna and lactulose doses as well. Great. OK, we will move on. So everyone's happy with that. So, um with opioid prescribing, you also need to know about the opioid conversion table, this comes up a lot in your prescribing exam that you're doing final year. Um It's a table that you can find on the B NF. So I recommend people having a look on the BNF and um making sure they can locate this table, you'll find it in the prescribing and palliative care guidelines on the BN F. And essentially what, what it tells you is the equivalent dose of different types of morphine um by different routes and what the equivalent dose is to 10 mg of oral morphine. So um if we look at the top one, for example, it says that codeine, oral codeine 100 mg is equivalent to 10 mg of oral morphine. Hopefully, that makes sense. And it essentially allows you when you want to switch someone between opiates. Um how you would give them an equivalent dose but with a different morphine drug if that makes sense. So I've just got some questions on the side if you could just put in the chat, what the answers? Two, those questions will be. How do we limit or regulate his maximum dose over 24 hours to avoid over medication? Um So do you mean with the modified release? And then the Oramorph dosing in the previous question. Yeah. Ok. Um Let me just go back quickly. So essentially you shouldn't be overdosing because the P RN dose is always gonna be four hourly. So they shouldn't just be having as much as many 5 mg tablets as they want. Um Your main concern is about pain control rather than over medicating someone. Um which is why you after 24 hours, you switch them to a modified release version and then give them the P RN Oramorph if they need it. Um The other key point to know is that you can't increase someone's um background morphine by more than a third or a half depending on your hospital um in the next 24 hours if that makes sense. So say someone used that P RN or a morph. Um So, so this person is on 30 mg, let's put, let's put it this way. This person's on 30 mg, say their requirement in the next 24 hours was um 90 mg overall. In that 24 hours, you couldn't increase their background dose from 30 mg every day to 90 mg every day because that's more than doubling the dose. So you can only increase it by a half to a third of their current background dose. So yeah, that's a really good question. Hopefully, that makes sense and I haven't complicated that anymore. OK. Uh Let's just go back to this one. So um if everyone could uh work out these conversions. OK? OK. I'm just gonna go on to the answers just for the sake of time. I'm sure you can all do this. Um So 30 mg would be equivalent to 3 mg. So you would divide it by 10 because 100 mg is equivalent to 10 mg. If you were going from oral morphine to subcut morphine, you would divide it by two. Uh If you're changing subcut morphine to subcut oxyCODONE, it's equivalent. So it'd be 10 mg. And if you're going from oral codeine to um oral oxyCODONE, you would, it's always best to convert back to um what the equivalent oral morphine is and then convert to the drug. You want it to be just makes it a lot more straightforward. So 60 mg of codeine is 6 mg of oral morphine and then 6 mg times two thirds is 4 mg of oral oxyCODONE because 10 mg of oral morphine is 6.6 mg of oxyCODONE. Oral, you'll have all the slides afterwards. If you wanna go over that again, you, you can OK. So we'll just go through the other, other palliative care symptoms. Now, um so first one is pain and the second one is nausea and vomiting things to consider when a patient is nauseous and vomiting in general. Um is what is the cause of their nausea and vomiting. Um rather than just prescribing antiemetics and not actually thinking about um what's causing it. Um Make sure that you add apr n antiemetic to your prescription in case the one you prescribed doesn't work. And it's better to switch between antiemetics rather than adding them on top of each other because they often have different actions. Um So that's best practice. And could people put in the chat? Um uh We'll skip the first question, second question. What antiemetics? Um Do you know? So we just put them in the chat. We'll go over the first question later. Don't wanna run out of time anyone put some examples in the chart. Nice, great. OK, so we've got some good examples there. Um So I just wanted to bring your attention to this really briefly. Um cause I think it just helps you understand um nausea and vomiting a bit better rather than just blindly prescribing any antiemetics. And I found this quite helpful when someone showed me this um on my palliative care placement. So nausea and vomiting can be caused by many different things and it has a pathway in the brain um with different receptors and so you target different receptors with the different antiemetics. Um So you have the um vestibular system, um which can lead to nausea and vomiting and the uh gut. So that's another main one, the stomach and the small intestine can obviously cause you to become nauseous and vomit nu- nauseous and to vomit. Um the vomiting center in the medulla which basically um looks if there's any, uh, blood products which should cause nausea and vomiting. So it's basically, uh, senses the blood as it goes through the medulla. Um, and yes, I think that's, that's the main ones. Um, ok. And so different, um, antiemetics, as I said, um, act on different receptors and then depending on the cause of the nausea and vomiting, you can select the antiemetic that you think will be most helpful. So, just quickly to run through them, cyclizine is an antihistamine. It's most helpful if the patient has to raise ICP mechanical bowel obstruction, vestibular dysfunction, or if you're not really sure, it's quite a safe antiemetic to prescribe. The next class is dopamine antagonists like domperidone, metoclopramide and they help, um, if the patient has gastric stasis or gastritis, you wouldn't want to give it in a, in a bowel obstruction. Um, because it essentially stimulates the bowel. And so you'd make the bowel obstruction worse. You'd also avoid it in anyone with Parkinson's disease. Um, because uh of its dopamine antagonism, um, haloperidol is used in biochemical causes of nausea or vomiting and also for postoperative patients, something like uh levomepromazine, um, is a broad spectrum antiemetic. So you wouldn't tend to use that until you've tried the others. Um And if they don't work, then you could go to Levo promazine, levomepromazine and it's used mainly in the palliative care setting. Uh, it's also quite sedating. Um, so you wouldn't, you don't tend to see it very regularly except in palliative care. And, uh, finally, Ondansetron is mainly used for chemotherapy induced, um, nausea and vomiting. So, this is quite a good table. Just have in the back of your mind be before you prescribe. Um, just have a think about, um, what you would select for that individual patient. Ok. Um, the third symptom we'll talk about is constipation. So, can anyone give me some, um, causes of constipation? Yeah. Medications. Exactly. Think outside of palliative care a bit. I think it's, um, more helpful to think about these symptoms generally. And then we can focus on the palliative care bit afterwards, but it's good to be able to generally assess a patient with these symptoms. Yeah. Really good. So, medications dehydration, immobility. Yeah. Nice. So, yeah, exactly as some of you said, um, also always keep bowel obstruction in the back of your mind. Um, metabolic causes like hypercalcemia and things like hemorrhoids and anal fissures as well. Ok. And in terms of palliative care, um, obviously, patients are often on medications like opiates, um, and often have poor intake are dehydrated and immobile. Um, so they are a high risk group of patients, um, full constipation. Um, so generally you would think about constipation, you would think about conservative methods first. Um, like diet mobilization, hydration. Um, not so helpful in palliative care, but I just wanted to mention that, um, and then think about your different groups of laxative before you prescribe them rather than just prescribing a random one. So there are three main types, bulk forming, stimulant and softeners, bulk forming. Um are things like Asperula Hulk. Um And uh they can take a while to work. They tend to take about seven can take up to 72 hours to work. You need to make sure the patient continues good fluid intake. Um And yeah, they're often given kind of um first to try and stimulate peristalsis, retain fluid and the stool et cetera. Um The next group is the stimulant laxative. So things like senna um don't give them bowel obstruction because um they stimulate peristalsis and you wouldn't want to do that in bowel bowel obstruction because they might perforate. Um And you would prescribe senna um as we saw earlier, um you could prescribe it with the opiate prescription and the final class is the softeners. Um So things like macrogol lactulose fossae enemas, they work by drawing fluid from the body into the large bowel. Um and they are often used presurgery um before you have colonoscopy and chronic constipation and you could prescribe it for um with your opiate um prescription as well. And then you have some mixed uh laxatives which work by multiple um mechanisms. OK? In palliative care. So, I just wanted to draw attention to the um nice guidelines. They have a really good palliative care section and in terms of constipation management in palliative care, they um recommend first line giving a stimulant. And if the bowels still haven't, haven't opened within 3 to 4 days, you would add a softener. If they're unable to take oral medications, you would prescribe a suppository. Ok. And then finally, in terms of symptom management, um, other symptoms in palliative care that you might come across is breathlessness, um which you would manage with morphine prescription um secretions. So that's when you have fluid in the upper airway. Um And you would prescribe hyoscine Butyl bromide. Um And if the patient is quite agitated, you can prescribe benzodiazepines like midazolam. So, yeah, these are really cool things to know. Um in palliative care meds and palliative care prescribing. Ok. So the team are now ready to discharge um, Mister Peters from the hospital under the community palliative care team. The consultant asks you to please prescribe anticipatory medications for him to go home with. What would you prescribe? Does anyone know what would be included in anticipatory medications? Have a think about some of the medications we've talked about. Ok, don't think we're getting anything in the chat, so we'll move on. So, anticipatory medications are um given in the proactive management of symptom control of palliative care patients. Um So that if any of these symptoms do occur, the, the medications are there for them to use. Um This is an example, prescription of an opiate naive patient, obviously, if they were on opiates already, um then morphine prescription would be different cos they'd have a baseline requirement already, but this would be, um, a prescription for an opiate naive patient. So you'd want to think about analgesia, an antiemetic, an anxiolytic and an anti secretory. And then there are all the doses there, but you can see, you can find them on the B NBN F as well. And in anticipatory medications you'd want the route to be subcutaneous, um, in case the patient couldn't take them orally. Ok. And then we're just gonna talk about syringe drivers and then I'll just talk about these, um, just in the interest of time rather than going through the task. So, the palliative care team has starting Mr Peters on a syringe driver because he is nearing his last days of life. Um, and he's asked you to write and the, your consultant has asked you to write the prescription. This is on a different admission to the previous one we talked about. Just for clarity. Can anyone, um, answer those questions for me on the slide? So, what is the syringe driver? What are the indications? And how would you complete the prescription? This is also quite a common exam, um, prescription. Do you have to write at UCL at least? Yeah, exactly. An infusion over a certain rate. Yeah. Does anyone have any advances on that? When would you give a syringe driver? When would you start selling on a syringe driver? Ok, let's carry on. Um, so a syringe driver is essentially a cutaneous subcutaneous infusion over a 24 hour period. It looks like this image in the corner. Um Essentially, there's nothing special about a syringe driver. All it is is the medication is all put into the syringe and then the subcut needle is attached to the patient. And over the 24 hour period, you set the rate and then slowly um the machine kind of uh pushes the syringe so that you get that syringe worth of medication over the 24 hours. Um, it just means you're not injecting someone constantly with subcu uh injections indications for a syringe driver are if someone's requiring two or more doses of any one of the anticipatory medications in a 24 hour period, and if they're unable to take all medications that need replacing like modified release opiates or antiepileptic medications, for example, you can put other medications of course, other than uh analgesics into the syringe driver as long as they don't interact with each other. Hopefully, that makes sense. And in terms of writing a syringe driver prescription. So for the infusion, you need to write cutaneous subcutaneous continuous subcutaneous infusion by a syringe driver, made up 24 mils of water, a rate of one mils per hour. And then you would write the drugs that you want to add to the syringe driver and write the dose. The doses are the amount you need in that 24 hour period. So if someone is needing 60 mg of morphine in 24 hour period, you would write 60 mg as the dose um and make sure that you convert it to the subcut um equivalent. So if that on oral, you would divide that dose by two and then that's what you'd put in the syringe driver. Um And then again, with other drugs like cyclizine. So the prescription for cyclizine is 50 mg T DS. So you would put 100 and 50 mg in the syringe driver. Do you see what I mean? Um The syringe driver is usually filled with water because things like saline can react with uh cyclizine. So, yeah, usually they're made up with water. Ok. So that is everything about prescribing and symptom control. Hopefully that's all made sense. Um Any questions or have a look in the chat. Oh, yeah, when unable to take by or? Yeah, exactly. OK. So the final thing we'll talk about is the last days of life and combination of death. So just a couple of things um kind of the foundations of this. So you have the priorities of care for the dying person, which is one of the cornerstones of palliative care um helpful just to have a read of that. And um look at the principles behind patients in the last three hours or days have skipped this for. Now, you, you can see the slides later um in terms of recognizing death. So this is quite an important skill for doctors on any ward. Um patients will uh deteriorate more rapidly. Um And uh on a daily basis, patients might express the realization they are dying, they might withdraw socially. So they might be less conscious or um uh less kind of talkative or chatty and withdraw into themselves. They might be um confused or agitated or restless. They might be seem more fatigued or weak. They have poor oral intake and they might have altered breathing patterns like Cheney Stokes breathing have a look at that on youtube if you're not sure what that is. Um And yeah, they might have poor perfusion or mottled skin. So it just a couple of things that you need to consider. Um it will be different for each patient. Um But try and, you know, uh if you don't get placements with your palliative care team, try and find them in the hospital and spend the day with them. Um And it's really, you can't really kind of appreciate this, I think until you see it uh on the wards. Um and then considerations um in the last hours to days are the patient's comfort. Um, mouth care because they're not, they don't tolerate um fluids. Um just in terms of uh food and fluids, um patients have very uh little need for oral intake. So you shouldn't worry if they aren't eating or um often people wonder whether they need a um IV fluid bag, things like that. But, um, patients at the last days or last 1000 of days, um, have very, uh, low requirements. Um, so it's normal not to do that. Um, consider symptom control. So we talked about all of that already stop any unnecessary medications. Um, so if patients are still on things like statins or any kind of longer term drug that, that they don't need to take, then stop their prescriptions. Um and consider whether they need medical inter interventions like blood tests. Um And whether there is an actual need to do that or whether you're just distressing the patient more um discuss with a senior um discuss with next of kin family and loved ones and consider fast track discharge. So this is where patients can be discharged home um very quickly so that they can die at home. Um Yeah, just something to bear in mind. Ok. So the nurse comes to the doctor's office and informs you that um Mister Saunders is not showing any signs of life. She asks you if you could please come and assess him and then his brother Philip is in the side room. This is quite a common task as an f one doctor um to go um and confirm death. So there's a few steps that you need to go through um before you see the patient. So make sure that you review their notes, confirm who the patient is, um what their background is what their status was and was the death expected. You need to confirm that the patient had DNA CPR in place, the C that CPR has failed or a life sustaining treatment has been withdrawn. Make sure you introduce yourself to family and friends. Um and obviously offer condolences and explain that you need to confirm the death and that they can either stay in the room or leave. Um And especially in exam settings, just make sure that you do do this and don't kind of rush into the actual process of confirming the death. It's really important. Um So in terms of the actual confirmation, so make sure you wash your hands, confirm the patient um inflammation, check their wristband. Um and then for a minimum of five minutes, you need to assess for signs of life. So you need to assess um their respiratory effort. So also take the chest um check response to verbal stimuli response to a trap squeeze. So pain response. Um and then if they, they're on ecg monitoring, you'd want to check that you would palpate the carotid pulse. And then as I said, auscultate for breath sounds and auscultate for heart sounds. So you need to do that for a minimum five minutes. Um then you need to check the pupil reflexes, you can check the corneal reflexes and motor response to s orbital pressure and then recover the patient and explain um what you've um anything to the family um that you need to, that you haven't explained already or if they can come back in the room, that kind of thing and then you need to document. So who is with the patient, the date and time of death at which all the criteria is fulfilled? Um Document, all the criteria is met and make sure you sign print, name, grade, registration bleep, all of those things on the documentation um in sy stations, really make sure that you do that because you do get marks for that. And it's very easy to forget when you're in the middle of your documentation. Um And then next steps would be to inform the nursing team, inform the next of kin, inform the your seniors and consider need for a death certificate or referral to the coroner. Um So yeah, that is just a summary of the process that you need to go through. And as I said, it's quite a common task for an F one to have to do. Ok. So that's everything that I wanted to go through today in terms of end of life care. So we've talked about the foundations of palliative care medicine, how to approach palliative care assessment, prescribing in palliative care, recognizing death and certifying death. So, um yeah, let me know if there's any questions from any of that in the chat. Um And I hope this has been helpful for everybody. Um If you could fill out the feedback form as well. Um, and, yeah, I hope that's been helpful. Sorry if I fall, fall at all. Um, it's been a long day. But I hope, yeah, I hope that's been really helpful and make sure you come back to the next teaching things next week. Same time. 6 to 7 on Thursdays.