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Good evening, everyone. Um Welcome to the last session of day one of the M sra clinical topics. Um This last one is on palliative care and Marriott's going to present for you. So I'll turn over to her. Uh big thank you. Before we start to all our speakers and Marriott for giving up their time today. Um Hello. Hi. So um I'm gonna be presenting palliative care today. It's quite a small topic. So we're just gonna cover it in the next half an hour. Um Right. So let's just get on with it. So, firstly, what is palliative care? So palliative care is basically supportive treatment that's provided for. So usually any illness cannot, all illnesses cannot be treated, right? Some of them are usually it in, inevitably ends in that and it's life limiting. So in situations like that where we cannot actually treat it, we all we can do is provide supportive care and we provide the supportive care uh to family, friends and the patient itself and we make them as comfortable as possible. So, what we're trying to do is we are aiming to improve the quality of life of these patients and also provide social support and emotional support to their families as well uh in patients that are uh suffering from lifethreatening illnesses. So, the aim of palliative care is to have a good quality of life in the amount of time that you have left. So this does not necessarily mean that it's end of life care. End of life is usually when it's a part of palliative care. But it's usually when there's only like a couple of weeks left. And that's when we put a patient on end of life, a patient on palliative care can actually live for years on palliative care if everything goes. Ok. So what does it involve? It involves managing the physical symptoms? It uh we provide emotional and psychological support. We give social support. Um We give end of life support and bereavement support especially for the family and friends. And we give um religious and uh social support for their family and friends too. Um So this is just a picture on what it actually comprises. So what people actually usually think palliative care is, it's just preparing for that, but it's actually not, it's a holistic approach that includes a lot of different aspects of care that we can provide. Uh But for the sake of this exam, we're only going to touch upon the actual symptoms that can be managed because the questions and I'm sorry, are usually based on the symptoms that occur in palliative care. So, these are the various symptoms that are usually seen. Um, pain is one of the most uh common symptoms that we absolutely should control because it plays a huge role in the patient's uh, in, in lessening the patient's suffering. Um, few other symptoms that can be seen are increased respiratory secretions, anxiety, dyspnea, um, nausea, vomiting and restlessness. So, what we're gonna do is we're just gonna try and go through different medications that are given a little bit more detail on your vomiting as well as pain management. Because again, usually the questions in I'm sorry, are based on pain and the nausea and vomiting, right? So let's start with nausea. So, nausea is usually divided into six sections. There are six causes of um nausea that are seen in the care. So the number one reason why patients usually have nausea, vomiting is because of reduced gastric mortality. So, like I said, pain control is one of the most important aspects and we usually control the pain with opioids, opioids. Um while they're very good for managing pain, they do cause a lot of other symptoms like constipation and nausea or vomiting. And so one of the main reasons why opioids cause nausea or vomiting is because of reduced gastric mortality. So, um in reduced gastric motility, basically, the serotonin uh receptors, the five ht four receptors are inhibited and the dopamine D2 receptors are excited. Um So in the situation where there's reduced gastric motility, we give prokinetic agents which are metoclopramide and domperidone, which act on the local region, um, which basically increases the gastric mortality. So, we, one main thing to remember at this point is that we absolutely cannot give prokinetic agents if there's bowel obstruction or perforation. Uh, mainly because, uh, or if they've had a gastric surgery, uh, mainly because if you give prokinetic agents in an obstructed patient, there's a chance that you can perforate it because you're increasing the mortality of the intestines. Um The second one that we're coming into is chemically mediated. So, usually chemical mediated uh s chemically mediated nausea is associated with either hypocalcemia or chemotherapy. So, hypercalcemia is most commonly seen in bone tumors or METS to different regions, different bones. So, um in this situation, we give Ondansetron, which is a five ht three inhibitor. So, Ondansetron works on the central receptors to reduce nausea and vomiting. And uh one thing we should absolutely remember is we should correct the whatever metabolic abnormality is there. Like if there's hypercalcemia that needs to be corrected as well, which would automatically improve the symptoms. Um The third type is virosa, which is just due to constipate constipation. Um Again, it could be due to opioids or um other causes of constipation and we give cyclic in this situation. Levosin can be used as well. Fourth type is because of raised intracranial pressure. So, because the central chemo receptors are um stimulated, uh due to adly seen usually in cerebral meds. Um we have uh patients can present with nausea and vomiting. So in this situation, cyclic is recommended. So, cyclic, like we saw is an H one receptor antagonist. So, lysine is given in the situation uh to reduce nausea and vomiting. In palliative patients, we can also give radiotherapy in the case of cranial tumors because that would um reduce the edema in the brain and inevitably reduce the nausea and vomiting and the symptoms. Um The next step is ve vestibular, which is due to the activation of acetylcholine or histamine uh one receptors. H one receptors. So again, because cyclizine is an H one receptor antagonist, that's the first line treatment. Alternatively, we can give metoclopramide or chlor pericine. Uh last time it again, cortical, uh this is usually due to anxiety or pain or fear. And again, it's H one receptor is getting uh activated. And therefore we give an H one receptor antagonist as one of the main treatments. We can also give a benzodiazepine because this would alleviate the anxiety and the pain that the patient has. Um So these are just, so we're just gonna go through a few questions along with the whole presentation. So if you can just look at it and answer right. So I can't see the screen, I'm just going to, right. No, that wouldn't work, right. So if you can just try answering the question, I'm just gonna give you like five minutes and we, uh we're just gonna move on because I can't see the screen and present at the same time, which is a technical issue that's been going on since the beginning of the day. And we're really sorry about that, right? OK. We're gonna go on to the next slide. So what's the answer for this? Um So 77 year old man and diagnosed with glioblastoma, he and he is under the palliative team, his pain is well controlled. Um However, he is complaining of nausea, what would be the first line antiemetic to prescribe. So, in this situation, we would give psychosine because um that would help with the nausea and the the option was radiotherapy but, but it's not the options. So this is the next question. So this is a patient, a 65 year old man with metastatic lung cancer. He is admitted for the management of hypercalcemia. His pain is rolled but he complains of nausea, what would be the most appropriate medication prescribed? So, uh if you remember Haloperidol is the answer here. If you remember um in situations where there's hypocalcemia, either Ondansetron, haloperidol or Ibuprofen is given right? So, co coming to secretions, uh secretions is a huge of palliative patients face and it's just, it causes a lot of chest chestiness and there's a lot of discomfort associated with it. So, um these are all actually anticipatory meds that we prescribed in palliative care. So, in secretions, we give hyos butylbromide, which you would know probably as bosco. So this is an anticholinergic which inhibits the acetylcholine receptors and this causes uh inhibition of the parasympathetic system and it just decreases all secretions. So, in palliative care, we give it to reduce the respiratory secretions, but it is also used in general for patients in irritable bowel syndrome. Um So another symptom that we often commonly encounter is confusion. Um So what we do is we can either give Haloperidol or Levo promazine to just uh make the patients comfortable. So, haloperidol is usually given because the confusion is usually associated with agitation and restlessness. So, um Haloperidol which is an antipsychotic reduces these symptoms. Um Yeah, Levo Levo Mezepine as is a sedative. So, again, it's more to do with the restlessness and agitation and confusion which we want to control. Um Right. So coming on to breathlessness again, a lot of patients have breathlessness as a symptom and the anti me that we give in this situation is either Midazolam or morphine. So, Midazolam is a Benzodiazepine drug. Um and it works on the Gaba receptors and it just, it reduces the breathlessness, it makes the breathing easier. Uh morphine again, does the same thing. Um it works on the central nervous system and reduces the breathlessness. But something we should remember when we prescribe morphine that it does have a chance of reducing the respiratory rate. Um So hiccups uh and all the symptoms that we usually encounter and we give chlorproMAZINE for the treatment of intractable hiccups. Um Haloperidol gabapentin can also be used. They work on the central receptors by reducing the receptors that cause hiccups. Um So for constipation, which is mostly associated with a large number of these symptoms are associated with a large, large uh giving a high dose of opioids. So senna is a stimulant, laxative uh doxy is a stool softener. Both of these are most commonly used in managing constipation in patients with uh any lifethreatening condition. Uh Right now, coming on to pain, pain is uh a very important topic in palliative care. Um Usually we start treatment with morphine if the patient is not in renal failure or does not have any sort of renal issues. And we give usually oral modified release morphine and we give immediate release just for breakthrough pain. So that would be just prescribed as APR N basis and they can take it when they have increased pain. Um So if there's no other comorbidities, what we do is we usually prescribe 20 to 30 mg per day and see if the pain can be controlled and they'll further be reviewed by the palliative care team to see if the patient is comfortable and if not, they keep increasing the dose. So um when we give modified release morphine, if say you give 30 mg per day, um we divide it by six to get the dose for the breakthrough pain So if you give 30 mg, the breakthrough pain would be five mg um again, so nausea would, can be there. So we prescribe antiemetics with it. Um Constipation is another thing that's commonly seen with opioids and we give um senna dot Usually, uh patients given morphine can usually have drowsiness as well. Usually it's transient and we can just keep them at the same dose and it'll just pass. But if it's not and if it's constantly there, we need to adjust the dose and decrease the morphine dose or add another opioid. So, in patients with CKD, because morphine is metabolized by the kidneys, we cannot really give morphine. So, oxyCODONE is preferred, technically a stronger painkiller and it controls the pain very well. And if there's severe chronic kidney disease, again, we wouldn't give oxyCODONE either, we would need to move on to other options like buprenorphine or fentaNYL or a fentaNYL, which is just a derivative of a fentaNYL. Um So another thing that we should remember is that when increasing the dose of opioids, suppose the pain is not controlled with 30 mg of uh modified release, morphine, we increase it by 30 to 50%. So we would give another 10 mg. So that would be around 30%. Um So another thing to remember is that if there's metastatic bone pains, in addition to the opioids, we add bisphosphonates or radiotherapy. Next, right. So this is just a picture I found online actually and it seemed like um so one of one of the most important questions that comes in the M sra is like exam is how to convert it. So they will give you a dose of oral morphine. And suppose the patient cannot tolerate it because of say nausea or vomiting. And we need to change it to subcutaneous. What would we do? And how do we change the doses? Or a patient who is on oral morphine develops kidney issues and we need to give oxyCODONE. So what dose do we convert to? So this, I found it a very helpful picture. So oral morphine is supposed 10 mg of or uh suppose 20 mg of or M is given and you wanna convert it into subcutaneous. So you divide it by two. So then it would be 10 mg of subcutaneous. Again, oxyCODONE is the same thing. If you give 20 mg of oral morphine and you're converting into oral oxyCODONE, it would be 10 mg of oxyCODONE. So that's the equivalent dose like that much would get the same effect um for codeine. Um if you give 20 mg, uh you multiply it by 10 and that would be 200 mg of codeine over the day. Uh traMADol again, you multiply it by 10 alfentanyl and methadone is not really that commonly asked. But if you're giving a fentaNYL, you divide it by around 20 buprenorphine. Again, it's a little more harder to calculate. So you have to multiply by, you have to divide it by 1.7 to get the same dose equivalent fentaNYL is again a little more difficult to calculate. But um the same dose of oral morphine would be needed to multiply would be needed to be divided by 3.6. And you would get the dose of fentaNYL. It, it's just the same thing but tabular form, right? So um this is for BNF conversion factors that are given for transdermal preparations. So, transdermal fentaNYL 12 mcg usually is approximately 30 mg of or um and transdermal buprenorphine around 10 mg equates to approximately 2, 24 mg of oral morphine. So we're just gonna answer a few questions now, right? And please put it on the chart um for an 80 year old man with lung cancer, bony mass, the palliative team to assess his analgesic needs. He currently takes 30 mg of sin twice daily. Although his pain is controlled, he has been extremely difficult to swallow and they've decided to switch it to subcutaneous morphine. What would you ideally give? Right. Ok. So um we're giving 30 mg twice daily, which would actually be a 60 mg dose. And like we saw earlier, if you want to switch to subcutaneous, we're gonna divide it by two, right? So like we divide it by two and what would be the an it would be 30 mg, 30 mg is the answer. So uh 60 mg of subcutaneous would be converted to 30 mg of subcutaneous. So 67 year old disease stage four and metastatic prostate cancer presents as his pain is not controlled with cocodamol. Which one of the following following opioids is appropriate to use given his impaired renal function. Uh Please do try and put the answers on the box even if it's guess right. So chronic kidney disease stage four is quite severe and it's quite, quite advanced. So, in this situation, you would give buprenorphine over the rest of them. So 65 year old mathematics is admitted for the management of hypercalcemia female. Hello. Right. A 65 year old man with metastatic lung cancer is admitted for the management of hypercalcemia. He's currently taking slow release morphine or 90 mg BD to control his pain. Uh along with his regular naproxen and paracetamol. In admission, he complains of pain in his lower back. He has known skeletal meds. What would be the most appropriate medication to prescribe for his breakthrough pain? Ok. Right. So 90 mg BD again, would that would be 1 80 mg and that would be divided by six and that would come up to 30 mga. Um So moving on to the next question, a 71 year old woman with metastatic brain cancer comes to the surgery with her. She is known to have bony pelvis and drips, but her pain is not controlled. Sorry. Uh She is on paracetamol, Diclofenac and MST 30 mg BD. She is using 10 mg of oral morphine solution around 6 to 7 times a day for breakthrough pain. She has already tried a bisphosphonate, but this unfortunately has resulted in myalgia and arthralgia. What would be the most appropriate next step to be taken? Um Again, I'm just gonna put, give you like two minutes. I can't really see the chat at the moment. I'm so sorry. So we would go with D um which is increase the MST and give radiotherapy. Um switching to Oxy oxyCODONE is not really gonna be beneficial here. Um The other options don't really make sense. Radiotherapy is something that helps in uh when it comes to body meds. So yeah. Thank you. Right. Thank you so much. Any questions? I am so sorry. It's for all the difficulties today. Um We tried, it was a great question, right? So I hope you join us tomorrow as well for the next few sessions. Um We're gonna be covering uh gastro um Yes. Uh We're just gonna send out the feedback forms now for the ent as well as the I think somebody asked a question. MST stands for. So it's basically the modified release one, it's morphine sulfate tablets and in the table tablet form the morphine, which is available. So it comes in two formats, modified release and uh immediate release, immediate release is the Oramorph that's usually most common in UK that will immediately give them pain relief. That's why you are using it for uh breakthrough pain and modify release is over. It works for over a few hours. Usually you give BD dose because it works well for around 12 hours continuously. So Zoloft is the most common one that we use here. So essentially you put patients on Zoloft that will give them slow release over like over the whole day. And whenever there is pain at the moment, you want to manage that pain and that would be breakthrough through or. So this is just basically over the 24 hours you have to see because sometimes those patients are not able to ask for the pain. Uh Most uh good number of palliative patients who won't be much awake, much alert or won't be able to talk. But you do want to give them good quality of life. So that would be through modified release. And that's the same reason you do next day. Yeah. Yeah, I'm done. If there ha anybody has any other questions, please do let us know. So I've just send in the feedback for the ent and I'm just gonna send in the palliative as well. So the uh the recordings would be available after a few days guys. Uh After we are done with the sessions, uh we'll make them on, on the medal on the FT SS East Midlands uh platform. So make sure you follow it. Plus there is some catch up con content there. Uh I think there's already a CST uh webinar which is present for all those who are applying for CST on the application exam, the interview, what to expect and what to do after it. And that's for palliative care. Please do fill the feedback forms uh that are from her as well. So we are sending a whole uh feedback form for the whole day and you have to actually fill up those feedback forms to get the attendance certificates. So that's a me generated feedback form. So once you fill it up, you would get your certificates after the four days are over. So probably in the next two weeks. Yes. So there are two feedback forms, please. One they would be separate for each presenter and then the one you can fill it for the whole session. Uh It would be really appre appreciable if you will fill the individual one so that we know what we can improve. I know there were a lot of technical issues this time but we can patients. Uh I try to cover the topics that are most commonly uh in this, but well, there's a lack of time. There's a whole lot of specialties that we have to cover. So ation of time and it is the period when people all the way on for the first revision or doing. So this session clears the doubts puts the basic concept of all the and the main idea is how to differentiate between scenarios and the collective will be uploaded before them. And the attendance certificate of the metal one, you will feed back, put your feedback into the metal one. Then you will get the certificate, there will be dates mentioned that which days you have done the card. Um the 2nd and 3rd, meaning the cardiology and you want the ophthalmology. Is that what you're talking about? I think so. Right. I'm just going to the all the feedback forms have been put up in the chat. Uh I think you'll be able to search in the chat or otherwise I think put it there at the end. Yeah, we'll put it all at the end so that you have all of them do let us know what went well and how we can improve on the presentations. So next time we can do better, right? So that's the um OK, I'm going to just send all the feedback forms uh back to back. So anyone who wants to fill it up can fill it up uh cause I feel like a lot of people have missed on the feedback forms. Thank you. Thank you, Mary. Uh Yes. So individual ones and the male one, please. So all of them I think I know there's a lot of work for you guys, but it, they are quick feedback forms. It won't take a lot of time, just a few minutes. So the metal one will help you to get your attendance certificates. So the second one's oft and I'm going to just, I think ent and palliative you already have and I'm just gonna send rest as well. Um, it will be sent to you. You've signed up for the, um, whole teaching and I think it'll just be sent to you. Here. It is. You were also ready to get it from your email. So you can either fill it up here or you can fill it up via your emails. I think it would be quick if you just lift up here. So if I holding this right, uh in the initial poll, I think there are 30% of the uh candidates who are applying for co surgical cleaning. So as I was saying, we do have that uh co surgical training webinars and if you will look, go through the teaching thing, uh there are some presentations for surgical interviews as well tomorrow, I think if I'm uh remembering it, right? Thank you so much guys for this. We'll be just up for a few more minutes and then will end the session and, and again, I would apologize for all the technical issues that were happening today. Thank you guys for attending. Um See all of you tomorrow. Hopefully just a reminder for tomorrow. We'll be starting at 9 a.m. not quarter past nine. So make sure the first session is due to start at 9 a.m. Ok? I think we can log off the session now. Ok.