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I'm critical. Key is our is our newest tour. That's a medical search engine. Think you guys also got in med school saying, Continue using that because you get it through. Be any memberships? Well, yet, uh, I was the part membership yourself. Access to our chemical. No clinical going to. Also, you have full access to be FDA learning, which has over 1000 10.4 modules on Also, there's lots of courses of modules helpful for complete Your portfolio is why would you get that one? It's already interactive and kept up. State with practice changes, developments on for each module you do. You can print off. A certificate was proved learning very ready for this perhaps, But if you're thinking about your your specially options already you can use are specially explore. It'll which can have you get that picture of what suits you best. So it's almost like a magic test takes about 20 minutes to complete it. Last course also worked like balance questions. They don't give you detailed report This thing, the tops especially, is important. The answer to go. It was really, really easy to use on. That was a while. You get a special he's, I know it also is a lots of viruses that and grass cancers. So that's our parking at nothing. Yeah, really good center to do just the different stages. So now there may be the year's time, and that's for six months after. And to see how your your taste change on especially sort of suits, you contact the answers you given a nap. Take your time. We have a really good, well being sober. So any time you feel you need to speak to someone about your well being a Services rep. 24 7 on Gilotrif choice of you speaking Teo A peaceful doctor or a counselor? It's a telephone based services deal with it cause it was well, if you for we'll also make sure you speak to the same counselor or peaceful doctors whether this morning singular quarters service completely confidential, free of charge. You know, everybody seven guards with your membership has to use it anytime day or night. I'm putting the most key to all that that I would hope that will you guys use over the next month or two is our contract checking service. Um, you may have heard of it. Save you a lot of time potential. Quite bit money as well. Yeah, definitely the key tool for meters off Have to tell you about today. I don't know. You know, in the next you probably haven't got your contracts yet. You may not get them for another couple of weeks. Still. Well, they should really have it now. But once you do get them, it was set. Sent it to us. We'll check him five working days, comparing it to the model which we negotiate back in 2016 and then again in 2019, Know there any issues we can help get inside? There's not another thing. So I was on purpose, but extra bits could be We've seen this extra bets when you stepped into your contract or the words s changed to mean something completely opposite. What should say on Yeah, we just want to make sure your contract's correct and you're getting where it should be. Sadly, 25 7 contracts we checked last year were wrong wanting for on It's just a matter behind, um but so do join a least until October and get it checked, preferably before you signed it if you signed it. And we can still check any of this wrong. It's wrong. It should never You should never been given a wrong contract. You can still so help in Brexit by that. Yeah. You know, you can also get your road checked as well. So? So we've gone online to weigh you. Just put your writer and France appetizer. It's wrong, but breo is a bit more standard. So it's so she happens. Many problems with that. So just a few figures. It wasn't a few contracts. You take nicely. Check nearly 6000. So 25 cent of those being wrong was just ridiculously high number. So it's to do joined. Get your contract check, preferably for you. So I don't like that. Yeah, um managed almost 21,000 unit doctor cases last year, so we've seen most things before. We need to find yourself needing some support them in any way in facing any issues. Come strict was that and will help you through. We've got great people, every trust. So we got investigations, officers, we got employment is based everything with transferring the UK who knows or a charm who they need to know to to get the inside except on yet we can help sort of support and give you some protection. Also, we check 1006 and read It is relative you Pretty much more standard. Like I said, Should be less this less, uh, room for messing up there. I was going to say that it would on Yeah, that's it. That's it for me. Really say, yeah. As I mentioned, it's a good day. It's join, uh, you've used, like, you walk a little screen or Lincoln chat, you get free Month's free, which allows you to get your contract check your wrote it checked. Get involved in salt the ballot. Hopefully have be October November. Time on in? Yes, source. Look at sort of industrial action that strike action towards the end of the sign. Sign up. You know, already signed up. Get three months, three day contract checks and that's it. Really? For me. Thanks. And I will get one session. Actually, I think gonna hear from empty you first. Are you? Yeah. Thanks for listening on yet. Do you do to join your union? Thank you, Daniel. So, yeah, it's really important to join the B, m and M D u as well, which will protect you from any litigation. Once you start working as a doctor, uh, I'm just gonna play a small video from the is. We don't have the representative year, but they just sent the videos. So just shut my screen now. Okay, good. Share my slides for my presentation. All right? Yeah. So welcome, everyone. Uh, again. So today's talk is, uh, part of the talk of our f y, once a Bible guide on DNA, CPR and verifying death. So my name is hands a definite or I'm with junior doctor working in the West Midlands today. Uh, this talk What? We're into a hostess Talk over an hour, so feel free to put and questions in the chat box, and we'll try Answer it at the end of this talk. Also post the feedback, uh, link for the feedback form in the chat box. So do you feel out the feet bathrooms? Because it does help us improve our talks. But you also get a certificate of attendance on filling this out, which you can use for your portfolio. Because this talk and count as a non court thing, our when you as part of your f Y one, you're uh so let's start this talk now. So today's content will cover DNA, CPR, respect, forms of discussion about respect, forms of family members and patients. We also have a small section on verifying death and how to document verification of death, and we have a summary at the end. Okay, so CPR CPR stands for cardiopulmonary resuscitation. So what does that mean? That means when you do repeated cycles off chest compression and artificial ventilation, basically to mimic the action of the heart and the lungs. So that's usually done for patient, where their heart or their lungs is not working. So it's ah, manual effort. It's a mechanical effort you do to mimic the action of the heart and the lungs to preserve oxygenation to the brain until you get Ross. So Rosky is a common term. You're here when you do your LS course, it means return or spontaneous circulation. So that means when the heart and the lungs have started working again. So basically, uh, you do CPL to take over the action of the heart and the lungs until you maintain a return of spontaneous circulation as opposed to what many people think. CPR actually has a very low success rate. So the actual success rate of CPR for patients in hospitals is between 12 to 15%. Uh, and that's compared to a survey done where most patients for CPR was successful in 75% of cases. So CPR has a low success rate, and the success rate is actually even lower if performed outside of hospital if performed by by stand on the street of the success rate is around 7%. Yeah, so it has a very low success rate, and C. P. R is quite a violent process. As you can imagine, you're jumping on someone's chest and you're doing compressions. So in, uh, there's the risk of injury to the patient as well. There's around in 9% of cases. You can get broken ribs, broken sternum. Uh, you could get internal bleeding and you more for axis, both at around 3% of cases. Eso quite violent process for patients. And as you can imagine for all the patients, CPO can actually cause more home than good for them. And it's I've also put this point about dignity of death. So if you're going to consider CPR for someone, it's important to think about whether you want this patient have a peaceful death. So if the patient's going to die wherever jumping on the chest, women within the last few minutes off their life would be best or just to leave them comfortable and die peacefully. So these are important factors we need to consider when thinking if CPR, uh, is necessary for patient. So now we go into DNA CPR, the C P O. Stands for Do not attempt cardiopulmonary resuscitation. So usually some patients and hospitals will put up the CPR, and it's a decision made in advance. It's made in advance before a crash goal. So then you know which patients you will go on and do chest compressions in which you want. Um, and it's a legal requirement for a patient to be involved in making this decision and to be informed off this decision, which is made on their behalf. Uh, however, the Lord does say that you don't need a patient's consent to put a DNA CPR, so basically what that means is that at the end of the day. It's a dog doctor's decision. There's a huge responsibility, huge misconception that people think a DNA CPR decided by the patient and the family members. That's not the case. It's decided by the doctors and the team looking off to them. But it's always good to have the patient and the family members in agreement with this decision. So when would you consider putting up a DNA CPR for someone, or even consider the question. So if you have a patient who you think is a risk of dying or they've been diagnosed with a terminal illness, Uh, you can also consider it if you get an advanced directive from a patient. So that's when the patient tells you in advance. I don't want to be resuscitated, uh, in the future. If anything does happen, and you would also consider putting a DNA CPL. If you think the risk of CPR outweigh the benefits as we talked about earlier, CPR is quite a violent process, especially for older D patients, where you think it won't benefit them to do CPR with the low success rate, you would actually put up the CPR, and it's good practice to start the discussion early on with the patient. If you anticipate there's a risk of them dying during this hospital's day, no matter how small the risk, Um and then I put this one's about respect forms I go on to speak about respect form in a minute, so respect forms are a new form has been introduced in the UK, so it's now available in a lot hospitals across the UK, and it prompts the condition to have a discussion with the patient about CPR, but not only about CPR about the ceiling of care. So what level of care you would give a patient. So this is the format of the respectful. So it's a one page document and this is the front, and this is the back, and it's quite self explanatory. But we'll go on in a minute to work through the different sections of it and how you fill out a respectful so respect it stands for recommended some replying for emergency care and treatment. So it contains a summary of personalized recommendation for patient's clinical care in the event of a future emergency. So if anything does happen in the future, let's say patient has called your pulmonary arrests. The respectful is usually like it's a piece of document, which has recommendations of what to do in in the event of this case. It'll it'll guide you. And why is that important? It's because, as you might imagine, patient my deteriorate out of hours. So it's good to have a document from the clinician's looking off to this patient, usually during the day. And you know this patient better to give advice about what to do or what level of care to give this patient if anything does go wrong, because they are in the better position than your if you don't know this patient to make a decision about it. Respect form also allows, uh, us to take into account of patients preferences, but also the clinical judgment off the doctor's looking after them from day to day and respectful remains with patients. So even on discharge from the hospital, the patients take the respect for with them on. They bring it to the community, whether it be the nursing home or sometimes you even have respect forms started by GPS. Eso. Then when they do common hospital, they should come in with their respectful or least have it on the system. So respect forms, like was day with a patient for life, but that, having been said, you can reconsider the decision made on the respect form. But, yeah, the respect form stays with the patient wants it's made. They should carry it with them when they come talk to you again. So respect for months, I said, it prompts a discussion between the clinician and the patient and their family members just because of the format of the the The way the respect form is is formatted. We'll see that in a minute. And ideally, all patients should have a respectful, but it's more red relevant for those with complex health needs. So for those who you think might need a mechanical ventilation, for instance, or CPR, because on that respectful make and then see whether they would be suitable for this treatment, So now we're gonna just work our way from a respectful uh, this is a respect for my filled out for and imaginary patients again, I apologize for the small print, but I'm gonna We're gonna work through it together. Uh, so at the top of the respect form, you have the patients preferred name. So this patient wants to be called John Doe, and they're full name and the energy just number there. Date of birth is well, and the address it's important or respect forms not to put patient, identifiable labels, but to actually fill out all these sections in full. This just avoids making a mistake because, as you can imagine, making him putting in a respect form for the wrong patient, uh, can be quite detrimental and that you have a little box where you write the date at which you're completing this respect form. So the first section of the respect forms is a summary of relevant information for this plan. In this section, as you can see, it's all self explanatory, tells you what to put it, says put the diagnosis off this patient. And that's also where you would put the background, uh, past medical history of this patient's a relevant pasta medical history, which would prompt you to make the decisions which you'll put below. So, for instance, for our patient here, John Doe on this admission, let's say he was diagnosed with advanced metastatic lung cancer, So I've put advance metastatic lung cancer. Uh, he also has a background of dementia, heart failure, COPD and severe frailty. So these that's his list of a past medical history, which is relevant. That's why we would make the decisions, which will come to, uh, below in this section. You can write about organ donation on other stuff, but that's not really important. So I've just left this blank, and in a lot of patients, you're Yeah, it's actually left blank. So then we come on two section free and Section four. So these are the two most important sections of the respect form in section feet. So that's where you have the patient Preference is. So that's when you would consult the patient. But that's given if the patient has capacity. So on the foreign, you have prioritized sustaining life, even at the expense off some comfort. So that's usually in this category. You have patients where, for instance, CPR or even a mechanical ventilation where you want to give them treatment, even if you you agree that in my course home to them and at the other end you have prioritized comfort even at the expense off sustaining life at this so this far and is what you want To keep your patient more comfortable. You don't want to start like any invasive procedures, and you want to give them a dignified death if ever it comes to it. So in this section, you should usually circle somewhere between these two. So it's like a timeline. Most people will either circle one or the other, but you can circle in between as well. If you think, uh, you want both for your patients, like you want a balance between both. So for John Doe coming back to our example, John Doe, who has advanced metastatic lung cancer, uh, were prioritizing comfort because, as you might, you guys might have noticed. Yeah, he's quite a cold patient would have advanced dementia. He was born in 1932. So now we come on two section for off the respect form. So this is the most important section. So here, as the clinician filling this out, you would sign in one of these two boxes. So again, on the foreign focus on life sustaining treatment as per guidance below so life sustaining treatment. So if you're planning on doing CPR for this patient, if you think there will be a candidate for ventilation, invasive ventilation or I t. U or at the other end is more symptom control. So that's again keeping the patient more comfortable. That writes. So as we discussed earlier this John Doe, we want John Doe to remain more constable. So I've signed here, in this section here, focus on symptom control. So the next part of section full is where you would specify the ceiling of care. Stealing of care is quite a common term. You'll come across as an F one, doctor. That basically means what level of care have we decided? We will give this treatments or where there's the limits. Stop s o. As I said, it's ah, by law. It's a decision of the conditions looking after the patient to make this position, not the patient, but it would be good to have the patient and the family members in agreement with that. So coming back to John Doe, we said, uh, we've decided as the clinician looking off to him, hey would be forward based care and treatment of reversible causes. The wart base care is, uh, we would treat him for anything we can treat on the ward. So anything like a chest infection or UTI and those are reversible causes a swell eso. He wouldn't be a candidate for it to you Escalation as I've said. So what basic means if he does get it every rate and does need I to you, we wouldn't send him to I too, because I've given his core mobilities and his age. We don't think it would be best suited Fight to you. And then in this section, you should also write your decision about CPO. Whether you think this patient would be a candidate for CP or not. So for him, which said not for cardiopulmonary resuscitation and not for invasive ventilation either so invasive ventilation would be in the form off a CPAP or bipap. Yeah, so it's good just to write a summary off potential treatment. You could give the street at this patient and where the limit would stop. Just so, uh, someone else looking at this respectful knows what treatment to give this patient. If they do the table right, and then at the bottom off the first page, uh, the front page, you'd sign. So, uh, for John Doe, we said CPR should not be attempted. So I've signed here again. I put my signature so these forms are quite self explanatory. It waas you can see it says clinic clinician signature. So I just signed that. So now we go into the back of this form a Section five. It's basically asking you this this patient have capacity. So because John do has of, uh, advanced dementia, we said he doesn't have a capacity, so I've circled new. But if your patient has capacity, you would circle. Yes. And does he have a legal proxy? Uh, John Doe for in this case, huh? Yes. So I've circled. Yes. And then in section six, that's asking you who was involved in making this decision. So in part A If the patient husband mental capacity, it's usually this patient. Uh, so you would take both a few Patient has mental capacity for taking part in the discussion about respect, form and ceiling of care. But if your patient doesn't, if they like mental capacity, then you would take it. So for our patient with tic party, and then it also ask you about to list the details off anyone who's been involved over than the patient in making disposition because our patient does not have capacity. I've put down the name off their next of kin. Jane Smith, who is John Doe's daughter? Uh, Port seven of the Respectful is where you'll need the signature off the clinician filling this out. So in this case, this has been myself. So you put your grades. I'm an F one, my name GMC number and my signature and date and Time I two, which I completed. Disrespectful. And it's also important to know that a respectful miss, only valid if it's counter signed by a consultant or a red ST free above. So that's a register or above. So as an F one f two, uh, just feeling out of respect for money by yourself wouldn't be valued. It will need to be come to sign by someone. But the reason I'm teaching the you this today how to fill out of respect for me is because in the majority of cases, as you might imagine, your seniors won't have time themselves to fill out their respect form, so we'll give you to fill it out, and then they'll just count to sign it at the end. So in this case, I've put down the name of an imaginary consultant. Doctor Brown is also can't assign the respectful. And in section eight, you can list emergency contact details with this patient S O James Smith, Who's this patient's daughter and her telephone number s. So that's, uh, this section is used, usually in the event of If there's a harmful event of this patient, it's quick access so they can use this section to contact his next skin to form Gentleman. Okay, so now we move on to respect form discussions. So I'm going to give you some tips about discussing respect form. Uh, so it's important to give the both the patient and their relatives time to process that diagnosis. So let's say, coming back to our example of John Doe, for instance, if someone's just recently being diagnosed with, let's say, lung cancer, you want to give them time to process this. In this information, you wouldn't jump in straight away and go to them and start discussing respect. Former As you can imagine, it's quite a grim process, so just give them some time to, like, process information. Maybe a day or two if you have time to spare and you see the patient is stable and it's important to start the process early on because that gives the patient time, uh, to broke, to process the information, to consult the family members as well and to think about the future. And if the patient has no capacity, as was in our example, you should consult the next of kin, so at least make them aware off the decision has been made. But again, as I stress, it's good to have the patient's family members and the patient in agreement with your with your decision about the any CPR. But at the end of the day, it is the clinician and the team looking off the patient who makes this. This is a decision about seeming of candy and a CPL. So now, quickly, I'm going to, uh, run through a D and C P r forms, so I've never I have not personally filled one out, because usually if your hospital will have a respect for respect, forms have now replaced the any CPR forms. But I'm just running through in case you do come across it by doubts you would eso the any CPR forms actually easier to fill out that, uh, respect forms. But it's basically the same thing with the patient details. Here, patients name the the energies number, their address and the GP practice. And then in this section, you would take whether you think this patient has a realistic, uh, chance of surviving if CPR was done. So for our patient, John Doe, I don't think a CPR would give him a realistic chance of survival if if it was performed. And you need to say why you think so? As I have said here because he has severe call mobility is such a COPD heart failure, frailty an old age, and then the rest of this's DNA CPR for ms just take box. So it's just have you discussed it? Ah, with the patient, Uh and, yeah, has their individual been made aware off this, uh, discussion. And then here you would sign and again get a consultant or Reg to come to sign. So, yeah, it's basically the same principle as a respectful. So now I'm going. I'm going to quickly run for an example of how I would discuss, uh, ceiling of care and have a respect for this discussion with John Doe's The Water. Just so you guys have an example, Yeah, but so in front of me before I started discussion, I just have some information about our imaginary patient. Just so have it all that And so we have. John Doe is a 90 year old man, and he was recently diagnosed with advanced metastatic lung cancer. On this admission, he has his past medical history includes dementia, COPD, heart failure and severe frailty. And his next of kin is his daughter, James Smith. Eso. The decision about his ceiling of care was made by the team looking after him, which was led by Doctor Brown, The response responsible consultant. Let's say risk for respectfully consultant, for instance. And what have we decided for John Doe? So we've decided that he would be for war, base care and treatment of reversible causes, and he wouldn't be a candidate for cardiopulmonary resuscitation, so cpr he wouldn't be a candidate for invasive ventilation. Know a candidate for I t. U escalation. I either. So for him, we just want to prioritize comp it, so I'm just going to run for an example. Uh, so just pretend on bringing the patient's daughter. Hi, there. My name is Hamza. I'm one of the F one. Doctor is working on the respiratory team. I'm one of the doctors looking after your dad. John Doe. Is this Jane Smith again? I just confirm whether she's next of kin to a patient. And let's say Jane says, Yeah, she is. So Jane, would you mind just telling me what you know so far about your father's diagnosis? So let's pretend Jane tells me that she knows her father has been diagnosed with advanced metastatic lung cancer. All right. Thank you, Jane. Yeah. So, as you know, where your father has, we recently found out that he has advanced a long cancer. But the reason I'm calling you today's I just wanted to have a discussion about the ceiling of care and something called the Respect form, which we put in place for your father. Would that be okay? So, again, off the patient or the family member, whether it would be the ideal time to have this discussion with, um and let's pretend Jane says, Yeah, she's happy to have this discussion over the phone right now. So, Jane, as you is your where your father has been recently diagnosed of advanced lung cancer and he also has a background of advanced dementia COPD heart failure. And he's quite frail as well. So, uh, the team looking after him, which has been led by Doctor Brown, the consultant, and we've decided that in the event if something does happen to your dad's, such as if his heart was to stop beating, we wouldn't jump on his chest and start CPR. S O c p r. As you, as you might imagine, is quite a violent process. Uh, it involves can have several ah harmful effects such as broken ribs. Uh, and it's only actually successful in around 12 to 15% of cases. And we don't think your dad would benefit from CPL. That's why I just wanted to have to discussion with you to make you to see if you would agree with our with our decision. Also, uh, because your dad is quite frail and your COPD is well, we don't think he would be the best candidate for I t. U or invasive ventilation, which again are both home for procedures but that having been said, we would still treat your dad, uh, for any reversible causes. Oh, and eso anything, for instance, like any chest infection or urinary tract infection, Anything we can do on the ward, we would still give your dad full treatment on the ward. But we're just saying we wouldn't jump on his heart in the in. The case of his heart was to stop beating, or we wouldn't ventilate him if his lungs were to stop. Would you agree with this decision? Uh, Gene, And then let's pretend Jane has agreed because she knows her dad is point free land. Or, uh so then I would just think the patient and then I would, uh, documents my conversations. It's really important to document your conversation with patients or next of kin regarding respect form. Uh, you'd be surprised. A lot of patients actually don't want CPR or their family members, because if if you do explain it, well, that it's a violent process, and it has a low success rate. A lot of patients coming to hospital actually want to be kept comfortable. Especially uh, the older patients you have. You have severe comorbidities s Oh, yeah. So it's quite important Have, uh, a discussion with the patient and the next of kin. So this has bean our section on respect form and DNA CPR. So Well, now we want to the next section of our talk, which will be on verification of death. And I'll also run through how to document verification of death. So as an f one, doctor, uh, verifying death will be a common scenario. You'll be called to the wards to do so who convey if I death usually so all doctors can verify that. And sometimes you can have some. In very few cases, you can have some specialist nurses you convey if I death is well of a patient. But most of the time it falls to the job of the F one to do it. So some tips went verifying patient's death are usually I you I allow some time before I go verify the patient step. So I deviate least half a now hour to 45 minutes after a cold, uh, by the nurse because, as you might imagine, like the patient is if the nurse knows this patient is dead, uh, there isn't There's no pressing need to do it straight away, especially if your own call them or important jobs to do. But also allowing this time to pass makes it easier for you when you go verify this patient stuff. So if you go verify someone and they're freshly dead, there might still be warm. Uh, they might. You might still hear some gurgling or some of respiratory sounds, and you might. This might make you untrue about whether this patient is dead, whereas if you leave, if you wait for, uh, around half an hour to 45 minutes or even longer, when you go verify the death, you'll be more sure of it. And it's important to allow thymus well. So what's allowing this time? You can give family members time to grieve by the bedside, Um, and to spend time with their loved ones. Yeah, one important thing to do is to check with the nurses called you, whether it's the right patient and whether this patient's in the right location. When going to verify this, that the last thing you want to do is walking into the wrong day at one in the morning, thinking this patient is dead and then being startled to death when you actually have mistaken the patient for someone who's alive. So, yeah, make sure it's the right patient and it is in the right location. Yeah, and, uh, given that we're still in the cove, it pandemic, so this could not be more relevant. Don't forget to wear your PT to work to go verify death. Uh, so just protect yourself a swell, important things to carry with you when going to verify someone steps. So you'll need your status scope and a torch so you can usually carry a pen torch or I usually just carry my phone with me, and then you can use the torch on there. But I'll come to that in a minute to tell you why you will need his to equipment. Okay, So how how will you verify someone's death? So there's no fixed way of doing this? Uh, what I mean by that is you can do any of these steps in any order, so there's no order of doing this one first. And this one second, everyone will. You're all develop your own personal style of doing it. So what I usually do uh, the first thing I do when I walk into the room is I just see if there's any response, the voice and touch. So, uh, the same as you've been taught in I'll s or airless. I usually drop the patients shoulder and say Hello. Hello. Can you hear me just to see if there's any response? And if there's no response, I then go on to check any response to a painful stimuli. So painful stimuli, zinc and use or super orbital pressure. So just a prime pressure above just around the orbits or stone or rub. So again it needs to be painful because you want to check if this patients that that do, applying some hard pressure Super orbital e and on doing the stone or rub just a check of there's any response. Next I going to check the super very light reflects that. That's when I use my torch, my pen torch on my phone, so I'll shine the light in the few bills just to see if there's any reaction to it. So if the patients that they're people's will usually be fixed, dilated, they will not be any pupillary life reflexes, then I go on to check peripheral and central pulses, and this should be done for it, least a minute. So I go on to check both some people. Just check Central Post. But I just checked both, just to be sure. So the proof hope all's. I usually check for radio and so central posts. You can check the corrupted or the femoral pulse again. A central pulse. If this patient is dead, so do press a bit hard just to make sure, because sometimes the carotid or the femoral pulses. If you don't press hard and you're quite superficial, you might not feel it, especially if it's a week ago. So do press hard just to be sure that there is no poll. So press for a minute and feel. Then you should listen to heart sounds and breathing sounds for two minutes each. So for heart sounds, I usually listen over the different valve areas for two minutes and for breathing sounds a swell just at the back of the lungs. UH, two minutes. Sometimes you might think you're not. You're here like some artifact, but on doing this, you on doing on verifying a few death, you'll become quite fun, familiar with what's artifact and what's actually hard sounding breathing sometimes usually, uh, if the nurses have called you to verify death, the nurses or the X rays are quite good at spotting someone is that is dead. So, um, in 99.9% of cases, if you call to verify death, this patient is dead. But just be sure. Just run through these steps, to be sure, and to cover your back as well. And once you've completed this examination, it's important to check the time because the time of death will be the time to which you have, uh, certified the death. So the time at which you have finished running through these procedures, not the time at which the nurse thinks this patient might have died. So the legal time of death is when the doctor or let's see the specialist nurse has finished examination. So why is important to know the time? Because your document this in the notes and also in the death certificate of whoever's filling it out at the end. Eso here I've just given an example of how I've documented my verification of death when imaginary patient uh, at the top. I have patient, identifiable details because this will be in the patient notes. So the patient's name and the hospital number these are both made up, but sometimes in But in most cases in hospitals, you'll have patient, identifiable stickers just at the top. I've written in the, uh, the date and the time of which I'm documenting in my name. So my name in my position, f y one and why I'm documenting so osteo verified patient's death. Uh, so then I go on to write this steps I've done and what I found. So for this patient up, I've noticed absent responses to painful stimuli, and I go on to specify super orbital pressure, and sternal wrote absent peripheral and central pulses. Uh, this patient's pupils of fixed dilated and there was no pupillary light reflex and absent breath and heart sounds at the bottom. I go on to say the time of death. So the time at which I finished running for these procedures. So it was one in the morning 10 minutes, boss one in the morning and is usually good. Just a good practice to write a rest in peace at the end because this will be the last documentation and sit in this patient's notes so no one else will go and document in this patient's notes after, uh, and again, as with any legal documents of sign it with your name and your GMC number. So this is just done with verifying death and how to document very find it. Uh, so this is the end of our talk. So, uh, just summarize. We've gone through DNA, CPR. We've run through respect for Ms and how to fill them in. I've run through an example of how to discuss respect form with patients and family members. And then the second part of this talk was about verifying death and how to document verification of death. Just a reminder. This talk is part of our f Y one survival guide, Webinar Siris. Uh, so we've already done quite a few about talks already. Uh, I forgot to say this talk will be recorded and will be available on the mindedly YouTube channel for you to watch again, but we have to upcoming talks. So our next talk well beyond preparing for one cause and common bleep scenarios for every one this will be delivered by my colleague doctor. Anyhow, change in on the 14th of July and now last session will be on managing the deteriorating patient on and this will be run by a med originally eso both important talks preparing you for life as an f one. Uh, mind a bleep is also running in person courses which are free in Liverpool, London and Sheffield and from previous years that it's been shown to have to receive good feedback. So be sure to check out the mindedly Facebook page and their website or these free courses which you can sign up. So yeah, I just put up the cure Quote for three sessions. Feedback forms on filling out the feedback form. You'll get a certificate of attendance and you can also put this in your portfolio. So please scan the QR code are just posed to think in the chat box as well. So you guys can fill out the bathroom and these do put out your questions in the in the chat box now. So then we can run through the with a Q and A section. So I just stopped sharing my screen, so I put the link for the feedback form there. Uh huh. So I'm just going to run through the questions. So put your questions in the chart and then now allowance of them as we go along. Uh, so Salmon has asked Can available requests from the patient overrule They're respectful. Know? So, uh, if a respect for ordinary CP off decision has been made by the team, the patient can Sorry, I'll just charge my laptop. I don't want to run out of Yeah. So the patient or their family members, they can make a request for a second opinion. A second opinion from another clinical team. But they can't. They have no legal say in this decision. But as I said, it's always good to have the patient and the family members in agreement. But yeah. And then Sunday, I was also asked, Can it be filled? I But by next king, should the patient laugh capacity know? So the the respect form is filled out by the doctor. So it's filled out by the F y y Y Y know whether Let's see yourself if you're feeling out the respect form, um, like, if the patient lax capacity, capacity absolutely. You should consult next of kids or pretend there the patient to inform them off the decision you made and try to see if they're in agreement of this decision. Alina has asked, Would you get the patient to market a long section free scale themselves? I know you would. You would fill out the feedback form. You would just have the discussion with the patient or the family members and document this discussion. But it's again. It's the clinical team that fills out the respectful, the patient lot of the time. The patient doesn't actually get to see the respect form, so they'll just take your word for what you've told them. They only get to see the respect for me. They're being discharged from hospital, and then you give them to respect to take on, because the respectful, um, as you can imagine will stay in the patient notes so that they won't get to see it. Uh, so far as our Sorry if I've missed this, but is that DNA CPR form filled in first prior to the respect form, So know what? What I mean is, if you're filling out of respect for you, don't need to fill out a DNA CPR form. The respect forms have now come in the UK to replace the n A. C p R forms the most of you will never actually see a DNA CPR for respectful of common to replace those. Yeah, but I've just run for an example, just in case if you do, uh, the few hospitals, if they are that are not using respect forms. But to my knowledge, all hospitals in the UK has now started using respect for me. It So any more questions, guys? So Alina has asked, Would you fill out a new respect form on each admission? So that's a very good question. So as I mentioned, a respectful more stay with the patient. So if you're discharging them, you will discharge them with this respectful, and then it's a comment hospital. They should come in with their respect form, so you wouldn't really fill out a respect form. Uh, boy, patient is, uh, they have one already in place and you agree with this decision made from their loss respectful, but that having been said in actually in practice for a lot of patients, you do fill out you do actually go on to rewrite the respect form because their respect form has been lost. Oh, yeah or that, or they didn't bring it with them on this admission. But another reason you could go on to fill out a new respect for me is if there is the case where something else has happened, let's say for a patient who's comment and initially on their loss admission, we thought they were fit and they were candidate for CPR. But then they come in, Let's say, 10 years off the and the situation has changed. Now, this patient, you think, wouldn't be a big placebo your anymore, Uh, so you would now fill out a new respect form because your decisions have changed. But for most patients, if the respect form is still with them and you agree with that decision, you would just use the same respectful any more questions at all. Thank you. I'll just give it a few more minutes just to see if anyone's typing anything. All right? I think that's all the questions we have. So, uh, I'm gonna end this talk now, so just remind if you want to really watch this talk. It will be on the YouTube mind the channel, and we have further talks coming along. Teo, Be sure to tune into these two these thoughts either. But more importantly, I wish you guys, although best for, um why one common yours like it will be. I'm sure you guys will do great. We've all managed for it. It's initial like it is like a big step. But think of it like now you guys are working. Uh, you'll start earning now, and it's quite uninterested job. And that's why we're all in this profession to help people. So all the best for your why one years now? I hope this talk is being useful to you. Thank you.