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hello and good evening and all. Welcome to the entry it a healthcare once a month. Seriously, December. And when it's really Cooper and I'm be one of the two presenters today, I'm assuming you see my face. I got that right. That should be right. Good. Hello and evening. So this is once a month serious for December, We're covering dying and palliative care, a sort of an overview of introduction to the topic. Talking about some of the really important things to remember in this area today session will be presented by myself. I'm a third year medical student at G Katie Med School. I also previously spent a year work is a healthcare assistant on a ward that come and predominately palliative patients on. We also covered by Charlotte, who get to say hello in a second. Charlotte is an assistance psychologist in Western the community mental health. She's also the mental health lead for Siris on should be covering some of the sudden your mental health topics aspects of this topic. Charlotte, say hello. I, um I think you should be able to see my face, but I'm no 100 sentul. But the cameras on Yeah, nice to be here tonight, but I think they can see my one. Actually, I think it kind of share one at a time. Right? Um, but yeah. So that should be here. This is a little dog. I chose the most Christmasy photos. I possibly good because it's our last, uh, lost presentation before, uh, Christmas anyway, Uh, make the most the session. I say that's each week or session. Pleased to take notes if you want to. They are very good way of helping remember things, and it's still in your brain. But in your long term memory, do ask questions. The morgue, you actively participates. The more you'll remember, the more you'll get out of the sessions on. If you do enjoy any bits or a really interesting the bets, please feel free to email. We're happy to send over for the resources. I put a slide. The end of this one with some extra resources of people will have a look at them. I tried to keep him fairly light hearted, but please do come and get in contact with him or have to talk about this sort of material on sort of fuel people's interest any questions. That's my email address. You probably got it all ready to send out the joining like fire this. You can also follow us on Instagram or on Facebook. At the moment, we are terrible up taking these because I'm the one who basically runs them. And I'm terrible at social Media, but we're doing our best to improve our sort of social media presence. This is where we are on this. Syriza's final, uh, little installment for 2021 will be back in 22 for nutrition. Talked by our wonderful dietician raz on down, we're gonna be a slight different format from 2022. I put them out in the email, that drug for this one, so I won't bother talking about it too much. But we'll be doing two a month every month for next year. So about every Jew, positive and political, I'm dying office. This is quite a emotional topic for a lot people. So please do first fruits take breaks that you need to do anything about that I don't think it covering anything particularly emotional in this presentation, just covering some of some of the broad things that need to take into consideration when working in this field study. Just before you start, There's a really loud noise in the background. Um, I'm not sure if it's your laptop or what. I just thought I'd let you know, because it's quite loud. That's a lot better. Okay, that is my laptop. Trying to explode. Expect to take off. Yeah, does that. I'm not good at looking after my gadgets, so I'm gonna share. I think I've shared the pole, even the in the chat. If you're there, could you please click on it so that we can This I will make it. That should now be sharing on the Poly VI. Um, trying them have these things work. Uh, that's his sharing. Okay, um, so in turn, I'm gonna put up these words one a time. And basically, if you can just sort of think about some of the things these words mean to you, For example, in the first one comfort What? What is comforting to you? What is comfort? What makes you comfortable? Um, it's a word we use a lot in. When did scribing end of life care in particular? But but what? What does it mean? to you bit. It's always in trouble, Polyp. You never know if it's working. Nothing to share that screen got softness is the first one is people. Let me share relevant screen. It's just for me. No, after you got other bits, they want to share. No pain free. Oh, well, we got loads of stuff suddenly pain free pain. One. Something softness understood, Understood is a nice word. Loved. That's beautiful talking. Okay, sure, some good bits come up there, right? Let's move on to the next one. Then the next one is happiness. What is happiness mean? Two people? What makes you happy or share happiness that enough That's actually shared or No, no. I never got to click the right button. There we go. Food, love achievements. That's, um, good things. Anything else? What makes people happy? People. People sometimes make people happy. Two seconds of saving more thoughts through that's one to the next one. Like to like this easily. I'm sure there's a more simple way to activate these, but I don't know it. So next one is suffering slightly less of a the joyous one. What What what do people think off with words suffering. What? What's what is suffering to people? All big, big word pain, loneliness, distress lost. Very good words. Well, we're very happy words, unfortunately, but but very accurately thing in this one here, I think, Yes, I think pain on distress and particularly make you make very good. Damn loneliness. Said, like, a lot bigger there. And yes, I think things are very distressing things. Things that make most people quite distressed. Um, okay, let me move on to the next one. Far this route again because I'm terrible. The next one is dignity. What people think of about dignity was, um, was a respect like that. Like respect, freedom, independence. Both very, very good words Respects in the little bit bigger. I think that's a good sign. Going to a couple seconds for anyone else who wants to pop anymore on there. Yeah, I think again. Oh, um, assuming it's gonna say forcefulness, which is a nice word. Um, yeah, I think again is concomitant stick dignity. Pretty well. Autonomy. A lot brilliant words. Being up to do things oneself independently, I guess, is well, ties into independence quite well. Yes. No, very much. I think a lot of these are very important for dignity here. Um, and then there was one more that I just missed. What was it? Choices? Choices is very true. Very important. Think that patients need to be able to make choices for themselves. And if you can't make choices for yourself, all you really not take the five. Are you able to be dignified? Do you feel dignified? More? And finally, the last one is going to be regret. What sort of things that people think off with regret was a good one already have straight away this heartbreak. So imagine most people do you regret heartbreak. I think great might be quite tough. One to think about things, for it is quite important wanting a disappointment. Yes, I think people do really again. Regrets, disappointment or disappointed by their regrets. But ways failed accomplishments, disappointment, failure, doctor, The sadness. Things were very good, failed accomplishments and quite a lot for that one, didn't they? Um, yeah. So I think there's a really important is very good, actually think products. Um, very, very interesting words for it. Let's get back to the power point. See, I think that's really interesting to see what people thought These words. So these are words we tend to use around around end of life care that we use them around sort of hospital care of lots in in general. And certainly we talk a lot about dignity. We talk a lot about suffering. Um, and I think we talked about about comfort and happiness is Well, maybe not as much we should. I think we sort of think more about the negative. Then we do the positive, Um, but these are all things that are really important. I think everyone's care, whether their palliative, end of life or or just normal regular vacations. So that that's quite interesting to get you off, quite happy to get us thinking little bit there about these. So this sort of builds larger into a large picture, which is who are what makes you you. Here was a bit of a list I put together just a very basic list of lots of different things that sort of come together to make the palace and you are on, and we're going to talk about the shots. Could talk about this in more length of a second with thing called social graces chart. Do you talk? Yeah. So here. I'm so I suppose he said at the beginning that I'm joining a my role in Iraq. Chest is an assistant psychologist within our community mental health team. Um, within kind of the psychology profession. More generally, we use this model the social graces quite a lot. We use it to the kind of Well, Oh, yeah, I took a little bit. So it was a model that was developed by some people burn, um, in 2013 on. But it's called The Grace is because if you look around, all of the words kind of put together spells out a very long form of the world graces. But it's often just told me to jail. I see. Yes. Um, and yes, it's an acronym. Basically, to define different characteristics that can make up to a person is, um and it could be with helpful to reviews. Gonna, when thinking about suppose yourself when thinking about others on your relationship to others. Um, and we can think about kind of which of these elements of the social graces affect you, and I'll read them all out. So gender, geography, a race, religion age, ability, appearance, class, culture, ethnicity. You think about education, employment, sexuality, sexual orientation and spirituality. A lot of theory it's that make it races. Um, and when you kind of put them together, we can we can think about which of these affect us. Um, which was I mean, to be honest, that they all affect us. Every one of the social graces effects us in some different way and kind of forms. Um, part of our own identity. Onda kind of kind of link up together, um, and Intersect form who we are with people. Um, but some of us, some of them stand out more. Two more to us than others at different times in our life. Um, I suppose what? Whilst we're thinking about palliative care, there are probably elements of these that would stand out more to you, I suppose if you were at the end of your life or if you were supporting somebody who was at the end of their life. Um, but we can also think about how these might change in your work life. And for example, you know, your your gender. I always I'm gonna think about about gender. The service. I work in a compression I work is very female dominated eso gender plays a very difference. Um, part, um I suppose my work life as opposed to maybe my personal life. I mean, they they hold a different kind of holds a different value in those two different spaces. Um, so, yeah, the social graces. Essentially, they make up who we are today. Um, they they form our identity, and it this could be a tool to help us think about different parts of our identity. That really important to us on D. What? What can you do with this model? You might be wondering, Um, I suppose we can think about yeah, the the dominant categories at any one time. Um, which of these elements of the social graces impact on a daily basis and which kind of most important to you right now? Um, which of thumb? Kind of less important to, you know, that's also important. Say, um I think what What could be really good about this model is that even if two people you know might might present it was quite similar. Um, all these elements of the social graces will mean different things to different people, Um, and kind of will eat, You know, different elements of these will hold more strongly. And 22 different individuals. So, yeah, why? Why am I bringing this into this teacher about palliative care? I suppose I have spoken about how these are important to us as it's professionals that also in our personal lives. And it's really important to think about how these you know, how these impact somebody when they're at the end of their life. And I suppose one that stands out to me is religion, religion, spirituality that cannot be really important to people when it comes to the end of their life on B can use this model to kind of help us think about our patients and the people you work with on to think about what's important for them because they won't always be up to tell us on D. Yeah, some people at the end of their life might not be able to kind of tell us what's important to them. Um, but we might be able to use their families a swell to kind of help support those discussions. But we can use the social graces model to kind of explore, um, the things that are important to people towards the rent their life on Do also, you know what was important during her life as well. And it could be kind of a tool for discussions. There are two of the kind of reflection and on exploration, I think it's something we're gonna come back to Towards the end of um, yeah, um, thank you that you stop cameras against this for me again. So, uh, that's never good. Announced me again. Have bladder. So, like I'm flying away. So it's a social graces. A good way to sort of think about what makes up a person who makes it the personality. Other bits that we really sort of think about is what it is. Important thing about this from your own perspective. Because obviously every individual you are an individual. The patients who look after will also be individuals. What? What do you enjoy? What do you think? You couldn't live without other elements of your life that you, you know, really, really strongly attached to on what matters the most. You said the big factors that make your life enjoyable on the life that you want to lead. Um, as it won't remember. This is the same for everyone. Other people have similar have interests. They might be the same as yours. But when patients are very, very sick when patients are coming towards the end of their life, these are important factors for them, particularly patients, maybe with illnesses that are making them unable to enjoy the things they used to do the things they enjoy, Um, which can be quite debilitating. So what is it Will matter when were suffering. What when people are suffering is still important for us to remember that they are people. Just because they are they have X y Z disease. They are not the disease they have. They are still a person who is is going through something. Um, they are put you in a sort of a very not tacky. What's the word? Cliche had way. Human is a collection of bones, flesh, blood, viscera, etcetera. But a person is in a couple the things that shape thumb things that they care about, the things that matter, the things they do, the way they influence the world around thumb. It's important to sort of be respectful and mindful of that when you're looking after someone who is potentially coming to the end of the life or just going for a really, really rough time. So moving onto actually what is palliative care? A lot of people seem to believe that palliative care actually is the same as end of life care, or it's care for those who are dying. It's not specifically, um, as defined by different dictionary. Dot com is care for terminally ill patients and their families, usually provided by organist Health Services. Mayoclinic. Despite a specialist metal care focusing on providing patients with relief, um aims improve quality of life on, not preserve life. And then it just website again also says that it's more about improving quality of life and involves physical, emotional spiritually Can. I think if we bring all three of these definitions together, it's the best encompasses what my experience of palliative care is in particular, which is the palliative care is not care of those who are dying. It is care with the aim of luck, improving quality of life, so it doesn't necessarily mean that person is going to die. In some cases, it could be sort of care during someone else. The treatment plan. The bases care about the intending of cure. Obviously, that does come a lot into care. Towards the end of summer is life, but it could also be that you have a palliative care input during someone's cancer treatment when they're still expected to make a full recovery or a palliative care and put into some of the long term condition on basically about managing quality of life, improving quality of life and some extent rest, giving them a rest from curative treatment. But we'll talk more about that in a second. Um, actually, what I just said, I think on a slide put here Good examples. We pain management. Pain management is a vital element of palliative care, and it's it's always good to be one of the priorities. Really, pain is terrific. It's debilitating on We always have to do the very best we can to control it and deal with it control of nausea or vomiting or other symptoms, and signs that we want to bring under control to improve the quality of life. You could also have surgical palliative care, so you can a palliative surgical procedures. These could be things like removing parts of tumors. You might have to remove the whole thing, but we can remove some of it in order to give back more functionality. Maybe to a limb. It could be something that improves life expectancy, but mainly it's about things that will make their life better, even if you can't necessarily, uh, save their life or prolong their life. Um, I think that's quite important to remember. Does it always involved dying? Importantly, Stream here know palliative care is not the same as care of those who are dying. Um encompasses everything. People who are dying, people who are undergoing prolonged peer problems, periods of ill health patients of lifelong conditions. Um, and it it could be used along side curative treatments. Or it could be used in place of curator treatments. If there if there isn't a way of curing a condition, palliative care can be ways of helping manage that. Helping give people back mawr control on more quality of life, so that must have thought of it. Bases a palliative care is the quality of life. Minutes. Um, there we go. Palliative care is focused on quality of life and symptoms control rather than cure with that, I do want to mention hospice care. So as this, this diagram I stole from a a hospice charity from think it's from the UK, and I thought it was just a really good way of encompassing What is different? What is the same? What is the difference between Paris of care and hospice care? Hospice care tends to be that for those who are dying, not necessarily actively dying or talk bit more active. Dying is in a minute, but these are patients who have a life expectancy of about six months or less. On there are no they are not able to be cured. There is that we are not actively trying to fight to the disease that is, is bringing their life to an end. Uh, and in that case, these are normally specialized places where patients go so they can have nursing care and nursing input so they can have regular medical care. They can have basically people to look after them and support thumb on, try and give them as much independence as possible as they come towards the end, as opposed to that palliative care Is there any stage of disease? Like I said, you can have chronic conditions, so lifelong conditions where you have palliative care inputs. These are things that not necessarily like limiting, but they need that sport on the to overlap quite heavily says about optimization of comfort and independence. Reducing of stress is giving support to some of these graces were talking about earlier, particularly emotional spirituals, sides and symptom relief. So management of pain management and nausea, the six things so four that's quite important to highlight the difference, but also the similarities. Um, talk about respect, so respect is a word. We sometime actually come across it quite quite often if you're working in palaces care. But respect is basically rest. It's giving a break from care. So response is often when a patient who had a person who has very extensive care needs normally at home is able to be looked after by other people to give their usual can care support network a break. So, for example, if you're being looked after it home by your wife or your husband, this would be someone else coming to look after you in order to give them a break, and it's important to remember that little carriers Michael staff need a chance to have some time off. So whether this is for a couple of hours, then go out and have a coffee or meats, Um, friends, whether this is a couple of days so that they can go away on a holiday or looking sorts and things out, the rest bite is basically someone else taking over. The care needs to give a break, but also giving a break to the patient, because sometimes it could be very emotionally stressful and demanding and strenuous on a relationship to be completely reliant on one individual on one network. And it's good to have a break t reset on, Get back into yeah, go back to different set up. Um, it's also useful. There's a really good use of respect for Typically you need to make changes to the environment. So so if patients care needs change, for example, or they have repairs need doing well, then you just changes in the home or in the place where they're being looked after the patient going somewhere else for a while. In order for that improvement repair toe happen so then come back into the environment and have a a better time there. Um so different types of rest biters is paid carers or care broke, paid can break. So usually this is normally a couple of hours. Or you could know we have, like, a network of care is in a particular cared for at home. You might often need regular carers, Um, and it's normally gives their regular care teams and partner Children, friends, whatever that might be. A chance to have some time away normally a couple of hours while someone else does the care roll. You don't have things like day centers today. Centers are normally places. Pay careful people go to for the day normal. They're open sort of a 9 to 5 kind of day. Uh, there are staff there to help provide the care needs on this last care is the chance of work or rest or just balance bit more. They're caring, role and their their life. You don't have residential care Central rest fight, which is sort of day and night. These are normally for a couple of days on does a really good chance for things like improvements of repair work to happen in the normal environment or for the care to have a holiday, perhaps, or if the care has to go into hospital. Perhaps, um, the problem is perfectly in the UK there aren't many residential rest bite centers that they're quite few and far between and difficult to get hold off. Which therefore means we much off. Quite often, it's used the final option, which hospital hospitals don't tend to offer. Respond care. They're too busy there, too, full. But in an ideal world, we would have the ability for at home care persons to come in to hospital for a period of time to allow improvements and repair at home for that person to return back. We do do this, but normally it's Dunmore on the sort of emergency or urgent basis that person's developed a new infection that person's really unable to manage home. They have to go into a hospital for a period of time for something to change at home. Uh, before they could be able to go back out there and put it in Okay, repair it has that been damaged. Report care equipment, things like hoists or, if there's a change in care needs. That person is now needing a higher level of care that you previously had. Often that person ends up in hospital for a little while while that can be implemented outside of the hospital. Personally, I'm a big, quite fan of an idea that hospitals should be able to offer that routinely, it should be something that people can arrange for the hospital, for them to look after someone for a period of time in order to optimize, optimize their drugs and optimize their meant. Their management's getting to be reviewed by various doctors or various physios and mental health teams, etcetera to sort of optimize the individuals care before they return home. Unfortunately, the health service in this country is just far too busy to be offered routinely, though it is something I I wish I could be. And I'm hopeful in the future that might be an option. That being said, let's move on to the end of life care portion. So end of life care. There are a lot of things that come together and a really important to focus on. Opposite of the management of symptoms, generally an end of life care treat active treatment. So the attempt to cure or better this condition is withdrawn. And it's more about symptom management, which again, as we mentioned, a palliative care is normal is happening in palliative care. But normally palliative care if you have curative medicine happening is, well, curative care. That's what happens alongside in this in end of life. K u normally won't have cured care occurring at the same time. Um, at the end of end of life, we need to focus on what is it basically, on this slide, the big one I'm going to highlight, actually is after death. So actually, end of life care needs to have a focus on what happens after someone has passed on. We're gonna talk a little bit more about that in a second, says a lot of elements that come together. It's important to remember that it's not just about the individual who is coming to the end of their life, but the people who gonna be left behind. So the family, the friends, in some cases long term care is because they can get quite emotionally attached. The people they've been looking after on these air important people taken to count consideration. Um, end of life care is care For someone who is actively dying, actively dying seems like a weird concept. But basically this means that they are. They are going to pass soon. Someone could be. Don't determine to be dying if they've been told that tumor in your abdomen, that will end your life. But it's going to be about two years, so they are dying. But they've got two years in which their quality of life can be good and it's a long way off. It's something that no immediately going know immediately. Gonna have to consider. End of life care tends to be the last few days, potentially in the last few hours of someone's life, it's really heavily focused on looking after yeah, symptoms. We don't want them to have any pain. We want it to be as dignified as possible on trying to think about what that person will that individual wants. In their last few moments, Um, yeah, as I said, involved removal of stoppage of treatment that could be curative, particularly because sometimes these things cause nasty side effects, and if they're not gonna work, you don't really want to cause their side effects and and cause further suffering. Um, and it's and said it's really important because it a family, friends and those around thumb because there it's really important to help them in this early stage of the grieving process. Um, an important question. And it's important question. Everyone needs to sort of think about themselves. And for those close to them, is where would you like to die? Do you want to die at home? John? Try and hospice in hospital. You know, there's a lot of places out there. We don't always get a choice, but we can at least know let others around us know all wishes so they could be best. Uh, we can try and meet thumb. Um, that's a really big question. It seems scary with people are very scared about death on. It's unfortunate because actually having that conversation convene so much to those around you and to you when it comes to those final moments. Taking away concerns. Um, 2016, almost half of deaths, 46.9% were in hospital, so that's actually gone down from previously in 2004. So few of people pass away in hospital, Uh, but still nearly half of a lot of people. And that's not necessarily well, I don't know. I personally wouldn't want to pass away in the hospital. I wouldn't want my final moments on this Earth to be in the hospital. I would rather that be somewhere at home somewhere in my my own space, Um, roughly a quarter that occurs in people's own homes and roughly a quarter in care hose resentful nursing homes. And then about 6% were in hospice. Um, and hospice is can be very nice. That you can get some very nice hospice is that could be very welcoming. That could be very comfortable. Like what do you get? Some very good care homes. So it is important. So think about what you would like, but also then what that individuals care needs are, um, generally, we're trying to reduce the proportion of death in hospital because not many people want to die in that environment. It's quite a uncomfortable environment is quite clinical, and people don't tend to find a very peaceful, so it is important to think about where would you want to die? Where were those around you, like to die. I know it seems a bit scary, but having that conversation is very, very beneficial. And they're one is what would you like after you die? And again, I know that seems a bit morbid, but it can often bring a lot of closure to those around you because they can be confident on be, uh, yeah. Be confident that they are making the right decisions for you. Once you passed a big one off, he's buried versus cremated. Some people want to be buried. Some people want to be cremated. If you do, where do you want to be buried? Where would you like your ashes to be afterwards? Do you want awake? Which is a bit like a so I don't really describe it like a very somber party versus an actual party. Happiness versus sort of memories. More sort of thing. Would you like people to do to celebrate? Remember you. Do you want them to? Maybe you don't want anything like that. Would you like to be in a church? Would you like it to be in a funeral home? Would you like it to be completely non religious? Would you like it to be in accordance with certain religion. The last one, actually I think is really important to remember is the nation of body some people donate their body to science is I certainly have benefited from this in minutes. People who don't get their body often have their body donated to medical schools so that we can use them for learning in the form of Cadavra two sections, things like this. So do you want to donate your body to benefit the next generation of doctors? Do you want to go for scientific practices? Sometimes bodies could be used to practice medical procedures so the other people could benefit from them. Um so there are a lot of things to think about, actually, for what happens after that moment and by knowing these and writing down or sharing the people close to you, it can really help them in the grieving process because they now know what you want it. They don't have to try and guess they'll have to make it up. They go along, they can go. This is what they wanted. And I can rest assured that this is what we're going to do for them. The last visit was the will and testament. It is important for people to know what you wanted to happen to your belongings. Um, because otherwise again, it's it's sort of guess working it could be very stressful for people after you pass the try and honor what you would have liked on this. Well, you lucked out assistant dying. This is a bit. I'm going to get into this a bit more. Please let me just check the you in a second. Nothing in the queue and eight. Okay, so it's just a dying just dying, something I'm oddly passionate about. Having worked in the palliative environment. It's something I I'm strongly, actually, I'm actually quite in support of sister dying that off. Some people have their own views on it, and I fully accept that there's actually a a A pole went around a couple of years ago around doctors and medical schools, asking people's views on assisted dying on The overwhelming result was that was a neutral one. A lot of people have said yes, that lot of people said no, and overall, there wasn't enough to differentiate whether it was a good idea or a bad idea. Among the medical community. But the overwhelming result was that people probably were in favor of it but didn't want to be the individuals who carried it out. They were very, very few physicians who said Yes, this is something I would want to be a part off. But they were sort of generally in favor that it would be happening somewhere else. It's an interesting thought, Um, sometimes called assisted suicide. There is a difference to your sister dying in assisted suicide will talk about in a second, um, the basis, the process of helping people to bring their life to an end where they have more control over the end, and it's often used in people are very advanced health problems. It's currently illegal in the UK There's a 2015 vote on got shot down in Parliament with roughly a quarter of NPS in favor and three quarters against Um, there are some organizations in this country. They're trying to push for it to become legalized. Henry Marsh, who is ah, quite famous author, he wrote a couple of books. I think I'm gonna recommend a bit later on. I know he's quite heavily involved in this movement, he wants is in favor of assisted dying in the UK um, within Europe. Several other countries do have some form of city assisted dying. Switzerland is very famous for it. For Dignitas, it was the sort of first organization that sort of supported people. Teo pass away. Um, more recently, the Netherlands and Belgium, they probably the most. We'll talk a little bit about what is legal and what's not legal in certain places, but they're some of the most strongly in favor nations. Luxembourg, Austria, Germany of all got the glow storms. As to the Scandinavian countries, Um, so what is a sister dying? There are four main forms at the extreme end. So this is Ah, this is you, Frasier. This is patients who have their life. Life ended directly by a doctor. So that is effectively taking a cocktail of medications. Injecting them on. The patient will pass away. So this is only legal in the Netherlands and Belgium on actually. Interestingly, both of these nations recognizes for both minors under 18 on adults over 18. There's a lot of controversy in both the country's still around it, but they do support this. This is patients who potentially can't they wouldn't be able to do it themselves are given, uh, effectively you financed by a physician. There's a lot of legislation around it. A lot of stuff has to be done before that. Patients allowed to have that procedure carried out there to have psychiatric assessments. They have to have reviews from multiple doctors. They have to have very extensive medical reporting, but ultimately the answer comes down to. They have a lifelong condition that is impeding the quality of life, and they're of sound mind to make a decision that would rather die. Then a doctor will be able to administer the cocktail of drugs to bring that about. By comparison, physicians assisted physician assisted death is very similar. It's using the same sort of drugs. It's using the same sort of procedures and has the same sort of legislation around it. The difference is that the individual has to administer that medication themselves. So normal it'll be set up viral cannula with a pump, and basically a patient presses the button and ministers the medication and ends their own life. This is legal is slightly more countries, with Germany and Switzerland both having made this legal. This is what happens it Dignitas. The difference is that for patients who are severely disabled, this isn't effect. This isn't possible. They can't press that button themselves, which is the difference. It is something that Belgium, in the Netherlands, that sort of written into taking into account for allowing a physician to administer that medication. You don't have passive euthanasia. It's a passive. Even a zero is something that's recognizing it. A lot more countries. And this is basically withdrawing all life, all life, all medical things necessary for living, so that involves medications that involves fluids and that involves nutrition. So basically, we're not going to give any IV fluids. We don't give any, uh, extra nutrition to this patient, which is going to let them pass away. Importantly, the pain relief is not withdrawn. Another symptom control, then the medication is keeping them alive, will do have drawn. This is also legal in Austria, Finland, Sweden, Norway, as well as Switzerland and Germany, and honestly, to me, seems a bit brutal. I I'm not a big fan of the idea of passive you for nasal because it does involve basically just allowing someone to pass in what I would refer to is quite a cruel way they do it in this pain free and supportive instance is possible. I'm not necessarily the biggest fan of it, but that's my personal opinion. The last one is withdrawal of life saving, life sustaining treatment. This is the same as passive euthanasia it with the exception that we will continue to give nutrition and fluids so the patient will stop having medication that's keeping them alive. And I'll just be given their water and their food will intravenous nutrition or one of the nutrition they're having, Um, and they're allowed to pass. And this allowed in various different levels throughout Europe. Their forms this legal in the UK on does basically withdrawal of treatment to allow that to pass. I I think I'm slightly more in support of that than passive euthanasia. I don't like the bit of that sort of dehydrating or starving people to death. I know it doesn't really work out that way, but I can't get past that in my own mind. You can make up your own decisions on it. Here's a little map about what is legal in which countries in Europe Like I said, Scandinavian countries in Austria in have legalized passive euthanasia. Um, only the Netherlands and Belgium have allowed euthanasia as well as physicians. Sister death. But physician sister death is also available in Switzerland and Germany, so quite central block that there is discussion in other countries. And, oh, Francois, a big discussion about it, the moment about bringing some of these things into into law there. I know we've had that discussion over here before. Scotland were talking about having it legalized in Scotland alone on that one got shot down, unfortunately again in Scottish Parliament since, ah, it's a field. It's an area that is likely to continue to expand in the next few years because a lot of countries is starting to have this discussion as to whether or not it is something that they want, something that they support. Because I felt like that's quite a lot of heavy informational. We do have a question in the chat. What type of care would you advise of a person's addicted to something and can do anything to fulfill it? I'm not entirely sure what the question. What type of care would you advise that person is addicted to something and can do anything to fulfill it. I'm not entirely clear on the question. I'm afraid, um I'm wondering if that goes back to something like this. Um, I please, if you please, do feel free to clarify that question because I'm not entirely sure if I'd be answering correctly. But generally, I think Charlotte would be a better influence on this one. And if you do have addiction, that's still comes in the mental health care, um, patients who have issues basic before any former sister dying patients know we had to have a for mental health review worked up by normally two different individuals. I think in Switzerland is by two different doctors who specialize in mental health. I think the Netherlands and Belgium allow other professionals who aren't doctors. So they allow that Saikat psychologists, um, or therapists to have ah do that review on generally, If someone has been found to have addiction issues or something like this, they would not be allowed to carry on to the next step Until that is proven to not be an influence. I don't know that. Answer the question of five completely missed it. Feel free to retyping, and I will answer it again in a couple minutes. If I'm if I've completely missed the the ball that that was kind of wear out what I was thinking about in terms of that question, I suppose I go down. The more psychological support and side it sounds like, Yeah, that person wouldn't need some support professionals to kind of and help support with that addiction. Um, there's clarification. So, for example, for drugs, Um, this poor major in this category. Yeah, I would say I would say that. It sounds like would need, like, a logical supports. Um, from A from a mdt sports kind of medical support, if they are kind of physiologically addicted to a drug, otherwise kind of psychological support. Tell them with that. Yeah, generally, these, um, any pharmacist dying, It's generally you need to make sure that the individual is of sound mind to make that decision. Anything like an addiction can possibly be argued that they're no longer of sound mind. Is that have to have a lot of investigation into that and support before they could make a decision around a sister dying? Um, yeah, I don't know. if that answers, I'm hoping. Answer the question. If not, we'll come back to again in a minute. Um, this is the bit more I'm gonna hand over to Charles, actually, so is this is very much the mental health clinic. Ah, they go like said there. Any questions, please put them in the chat, and I'll have a look at them while Charlotte's talking. Thank you. Um, so, yeah, taking up? I'm taking care of yourself. Um, I suppose this is thinking about things more from, like her conditions upside because working in this well, I mean, just working health care generally is really difficult. And we we go into these professions because we're kind of you know it and empathetic people. People who want to help people who want to kind of make a difference. Um, they involved in in someone's care. Um, way start crazes very empathetic people. And that where when there's so much kind of I was we see so many different things. We're we're part of systems that where that where there's a lot of suffering and there's a lot of pain that kind of that can take its toll. Um, and when we surrounded a working in healthcare systems where people are dying, always supporting people through you, that that time of their life or towards the end of their life, that's gonna have a massive kind of impact on you is a person on both professionally but also personally as well. Um, you want to switch to the next life? Ready? Thank you. Um, so I'm bringing back my favorite model of the day, which is the social graces model. Um, I started this presentation by thinking about social graces in terms of us and then in terms of people towards the end of their life. Um, and the thing is that matter. I wanted to also think about this in terms of why Why do some patients and why do some people we care for kind of hit home more than others? Because, although, you know that I suppose this isn't even just in terms of, um, end of life care. This is just what you know, working people more generally, they're always gonna be some people. Um, that will have more personal impact to you that than others. That's that's just not true. Um, and I suppose we can use the social graces kind of models. Teo, think about you have to think about why that might be, um what kind of elements of the social graces? They're things that kind of resonate with you particularly like, Does that person maybe remind you of somebody in your life? Will? Maybe they've had a similar kind of upbringing to you. They may have faced similar struggles in their life. Um, they won't be a similar start trial to our religion to you. And that might be why, maybe they hit home a little bit more. Um, I suppose this isn't a tool to kind of think about how to to cope with it, but it's more of a tool to think about how to just think about it, to reflect and to explore. Um, some of those kind of emotions that that this worked brings up for you because it will bring up things for everybody. Um, especially when we're when we're in health and profession. I have me we can use. Yeah, we can use social reasons model to think about what's important for the person and how that kind of matches up, um, to you as a condition in two years. Ah. Is a health care? Um, yeah, a commission with in healthcare in healthcare provider. Um, and you know, some Sometimes if lots of the social graces quite similar that that would make sense that you would supposed build up more emotionally invested in that person's journey and then otherwise. So, yeah, just bring it back to my favorite model of the day. Vices, Um, next light, please. I think he, um but also, I kind of wanted to talk a little bit about that of looking after yourself when you're working in such a such a difficult profession where we're kind of giving constantly and I feel like a sexual social media has glamorized the idea of self care, and it's often put out there that, you know, have nice bar. But two handles on, or something like that is self care, which is this kind of element to it. But really kind of self care is is an ongoing It's not going lifelong process. It's not just kind of one event that happenings once in a while you know how it's often made out to be. Um, it's kind of it's consistent things within your life um that you that you do and the prioritize to look after yourself. Um, and this is kind of important for a number of reasons. Um, I don't talk about a supposed to passion fatigue, and we'll go into these careers because we want to help. Um, well, for going is very sympathetic people. In some cases, what kind of baby like our baseline and 30 is supposed higher than the rest of the population, Which is why we go into what we going to work, career like this where we're kind of constantly giving, um, but kind of at some point, this is empathy. You know, it will naturally take a hit, and it will kind of everything flow throughout your career based on a variety of different things. But, yeah, compassion. Fatigue is a really thing when you're working in a ah helping giving profession on. But I think there are There are studies that kind of like track when when this happens on for lots of, you know, for lots of people on, I think the most common point that compassion pretty can kind of hits is in, like the first few years after qualifying. Um, or graduating or whatever it is for your your profession. Um, yeah. What? Why is this, Um why? Just compassion. Fatigue kind of hate us. I suppose when we're we're constantly giving on been caring for others, it's natural. That is difficult to keep that up. 24 7, you know, seven days a week with in your career. Um, we're working pretty difficult environments, and they're kind of things that can speed up that process, like shift work, which happens a lot with in healthcare. We work really long hours and naturally, that could be really tiring. That can kind of speed up that compassion, fatigue sometimes. Sometimes the cultures that we were working to be really be difficult. You know, sometimes I could take it of the blame culture, Um, within the been health health care. Unfortunately, um, and acting kind of speed speed things along a little bit, but it's important to remember that actually, when you're kind of compassion does wax and wane, it's it's not, You know, um, it's the environments that we work with in, um on some things that you kind of I suppose I want to go into What? What? What to do about that? Because, as as I said, a compassion will, um, yeah, wax and wane throughout all time working health care. I think that kind of things that help it comes back to your self care. And it's not those singular events, um, that are often kind that cell care is made out to be, um, those regular important tasks that we kind of prioritize in our lives on go that we need We should practice my life, um, to kind of help us better best, both professionally, but also personally. Um, so I think I've got got, like, a little points that are not the points that are on this diagram and that kind of eight points that are really important to to think about. Um, it's a first. It kind of value our own AIDS on. But we put so much, so much kind of effort, and it's supposed sarosi into caring for the needs of others on. We often like that for ourselves. Um, so I think learning to kind of notice kind of assess where we're at and kind of value and respect our needs and parrot eyes. Looking after ourselves is really kind of the first step in self care on and often a step that we can we can definitely look, elect, when we're constantly giving, um it can also be good to suppose refocus. You re focus your thoughts. Um refocus. Oh, like, uh, priority of our thoughts. Um, it could be really easy. And it really starts Supposed to focus on the things that haven't quite gone so well. Well, I think often not people who have come into this profession on back chew a li high achievers. And we're quite hard on ourselves on and provokes on the things that maybe didn't go so well, actually focusing on the rewards and focusing on you know why we went into this career in the first place on day, thinking about those moments of success and where things went well farther yourself. Or feel if your client so your patients and just refocus that your that your frame of thoughts on is something you know? No, we're not gonna fix everything, but it is one like to run out of the box. And as to looking after ourselves, I think it's also important to, I suppose, recognize the hazards and the difficulties of the work that we do eso I can't by identifying the the stresses in our in our work life and and kind of mentally preparing yourself for that there are lots of kind of, but worked very emotionally demanding, you know, area work on. We see lots of distressing experiences on do might witness that you might hear about them, um, often were working kind of difficult, physically difficult working conditions on deck spirits and lots, lots of physical exhaustion, especially if you're on your feet all day or were working in a ward. Um, so just recognizing, um, noticing, um, the hasn't said your workplace. And if you could know, too, so that's the first step towards doing something about it and also really important to kind of take care of your body. Um, look after yourself physically eso making sure that, you know, having that had take taking time to kind of have enough sleep. I know sometimes I could feel like a privilege, but yeah, taking time to rest on and look after yourself physically, and it's important to kind of know overlook that kind of biological Pedro basis for a mental health within self care. Um It's also exposed really, really important, too Supposed not sure those relationships you have within your life, Um so kind of cultivating supported network around you both in term there, but that work. So with your colleagues with your mentals with the team around you because of the people that they do, they do the same job as you. They're the ones who they understand what it what it's like on understand the work that's going on, so kind of leaning on them. Also kind of cultivators supporting environment in your personal life as well, eh? So with family with close friends within a significant others where possible Because that the people heal likely go home to everyday or kind of, you know, speak to outside of work and ensuring that you kind of got supportive support of people around you in both your work and your personal life. Um, another thing I think it is another part of self care that is often overlooked is come setting boundaries. Um, that could be boundaries between your work life in your personal life, which has become a lot more difficult with cave it on working from home. Um, that kind of a Z much as possible. Trying to leave work at work and home home on I realize that that can be a bit of a privilege. Um, but also scheduling breaks. Making sure you're taking your brakes and leaving work is close to one time A Z possibly can, um, and learning. Learning to say no. A swell, um which can feel very confused. Very difficult, especially, is we're often people who go into helping progression because we want to do that on a natural tendency Is to say yes. Um, but that can have kind of secondary consequences, but for us and for our own kind of help mental health wellbeing. And so I kind of monitoring, monitoring went when you're saying yes and maybe trying to consider saying know when things are feeling difficult? Um, I think, but table points he'll be talking for a while. Um, I think another element of self care is kind of sustaining those kind of healthy escapes from work. So kind of having things outside of luck, um, allow us to kind of separate are professional self from our our personal self on, but it's is easier in a profession where it takes so much, and it's so kind of unrelenting Ondas often a lot of competition. It's easy to allow our professional self to become our identity. Um, thus, I suppose I say that work in psychology but also, you know, working around people who more on the medical side of things. It's a really demanding and difficult career to get into, and that can often lead us to make our I space make a career. Ah, whole life, Um, but it's important to kind of value that time away from work on a way from your career. Um, kind of having having other hobby easel friends you see outside of work. Because when when it gets difficult, when our professional life gets really hard, the bigger part of your life, that is, the more of an impact it's gonna have on your kind of your mental health. And I think of it like a pie chart. I like my charts for some reason, Um, but the more of the pie chart you're working your career takes up. Um, when things get really hard, the more of an impact it will have on your mental health. If you can kind of break that my child up into different elements. So, like I said earlier, like relationships with friends and family and hobbies and time away from work, the more of those other bits that you have, the more kind of balance weekend we'll be having all I It's well, um, and the last thing just been shown much meal. Um, e selfcare could be seeking professional help would need it. It's, you know, well, and good to say, you know, have a bath, do some copies, gets you sleep on that sometimes that's not enough. We work in professions where things like PTSD. And I suppose it could just burn out a really, really, really things. Um, you could have a math an impact on, you know, I'll mental health in our lives, which then has a knock on effect your patients as well. Um, but mental health kind of mental difficulties within helping professions are really, really, really um and often people who work in mental health in the last people to want to seek help. But it's important to remember. Like I said earlier, noticing, um, assessing where you're at and actually things do feel too much seeking compression help because that's okay. They can often be a lot of shame in being a professional who seeks help out and for yourself for multitude of different reasons. I could probably do a whole talk on that, Um, that it's important that you look after yourself, if anything. So, yeah, it's been looking up yourself one for yourself. Exactly. So you can kind of do your job a swell and look after others. That and that's it for me. Thank you. Make my face back again. So, yeah, I think it showed Very Yeah, just basically reiterate that is very important with golf yourself because we don't look after ourselves. We can look after anyone else because we become the patients. So I'll finish all the materials that I just couldn't go through. Some of the questions here. These are some bits of put together. I didn't put the hair on the March book in Here was terrible of me. Um, there's Henry Marsh book as well. That is very useful. Google him. It'll come close to home one of the home as a second one after that as well. Um, that's that's a really, really good books there. I'll put his name in the chat in a second when birthday comes areas really good. It's about a doctor who is the doctors or memoirs from when he got diagnosed with cancer. On eventually is sort of experiences with coming towards the end, Um, being mortal, a very, very popular. But again for a very good book, Uh, and then actually two films that we've been made to watch at University Wit, which is never tops and film, in which he betrays eight lady with terminal cancer diagnosis and the Children's act, which is where the top PSA again. Because every Thompson this fabulous portrays a judge passing judgment over a young boy refusing medical care. So these are, um, really, really good resource. Is there a way they're not sort of textbooks? They're all quite good, fairly straightforward, sort of reading. Watching um, I'll put ah, in the chapter ones are really worth having a look at Henry Marshals. Um, that's all from us. Have you got any questions? Any more questions? I'll read a couple of ones that are in the chatter. A couple of really good questions here. Um, first one is what you do in a country where it's not possible to support end of life care, know into like it a sister dying. Um, and simply the answer is that a lot of questions have a lot of countries have made it legal, you know, allowed to support someone to go to a country with the aim of ending their own life because it's still believed to be assisted. Murder all suck you shin. Similar to this, however, I know for a fact that Switzerland and Netherlands both say they will treat foreign nationals as much as one of their own nationals. So basically, if someone can get to those countries, they could be assessed on potentially go through with assistants doing their own life in these countries. But honestly, they have to get there under their own steam because anyone found to assisted them could be prosecuted in the home nation, which is something I'm not a big fan off again, but unfortunately, it's a state of play at the moment, and hopefully in the next few years that that'll improve on. We might see countries being a bit more open toe, allowing people to help the relatives there friends to get these other countries. The other one, I really wanted to read out waas Mental health diagnoses. So for a person with only mental health problems such as depression, who've had years of therapy, medication, etcetera, on be completely sound mind that they wanted to go in their life, would they be allowed to have sister dying? And actually, there was a case a couple of years ago that was quite low profile in the Netherlands, in which someone who had treatment system depression, it was assisted to end her in life. Likewise, this is, I think there's another case over that I couldn't find the link to. But there was one treatment resistance. Schizophrenia on these patients being allowed to do in their lives, being assisted in their lives in the Netherlands on then, apparently recently, there was a case for the Canadian courts, which now means that which has now allowed to be illegal for Canadian services, which assist with dying to accept patients on mental health diagnosis alone. So patients who have mental health problems and the physical problems were able to apply through that, and it's been a couple of really interesting studies lately. One of them, looking at certain personality disorders on certain conditions such as depression and psychosis. On whether or not they are, they should be eligible for a sister dying on. Generally, the research is sort of saying that it's in favor of those conditions being treated the same. Any other sort of physical illness, uh, toward the Requip for girls to assisted dying, which is really interesting. It's sort of on the very much on the edge of sort of research knowledge at the moment, So I can't really say much more. That's really interesting to see this. How much sister dying cost? I have no idea. Actually, um, that's a really good question. I just genuinely don't know. Um, I have no idea. I can't even start thinking about ballpark figure because also, there's no as a foreign national, you wouldn't be eligible for ah, like national insurance and stuff like that in some of these countries, like I know Switzerland to treat their own nationals free of charge. But they don't treat for nationals. I have no idea. That is a really good question. Um, I don't know. Whatever the cost is a ticket to Switzerland. Plus, I don't know. I'll look that one up. Actually, I really don't know the answer. Um, let me get my final slide. I think because it's quite a heavy topic, I've been through a walker. Crackers are meant to be the cutest animal in existence. I think it was a nice sort of lighthearted wait to finish, uh, safety Accession. I said the, um I've said the feedback on for this in the chat I'll share it again because the feedback is really useful for us guys. Please, do you keep it coming? Because it is really, really important for us, those of us so we can improve ourselves. Teachers and serious keep making high quality content or better content for you guys on that also so that we can prove our experience in teaching when applying for three jobs in the future, which I know sounds a bit selfish. But it is something that we have to, uh, consider how much you Yeah, I've just had a giggle eso you some of the not the dictators website. But then we did a study that showed the average cost office sister dying in Switzerland is about 10,000 lbs. I'm not sure if that includes kind of getting there or not. Uh, I think I think that doesn't turn of getting that potentially. And what's the number? Sorry, about 10,000 somewhere. So on average, 10,000. But those interviews going for anywhere between 521,000 have a sister in Derek. And I think what's important to consider is Well, is that actually over half of the population in the UK is about 68% actually of households in the UK have less than 10,000 lbs and savings on. So it's a financial cost. Um, is that 80% of wrenches, um, have less than 10,000 lbs? Um, savings, something that's an important Uh huh, Yeah, I don't like that. I don't like the idea that you can charge to help someone die. Well, that I suppose the only rich people have the privilege of potentially ending suffering, and I mean, it depends on where we stand on the fence for that. But if you kind of maybe even I, you've support with this is I in some way, I suppose that basically, there's this little language people allowed know, suffer. That's that's no something other final But I have to admit that doesn't sit well with me. The idea that someone might make profit out of people end of their life. I don't really like, yeah, make it as you wish individuals watching. Also, the one last question here is a good question. Which is, what can you do to help a person who was wanting to die? But it's legal in the country there, in on their it? Yeah, so basically, in the UK, we have question rules on it. They can withdraw life saving medication that is allowed thing that used to be called the liver, poor care pathway and the guy updated. I climbed all it's called now, basically withdrawing off medical input in order to allow someone to pass the way. It's meant to be more pleasant for them than, uh, the alternative lighting and carry on for a longer period. I I would argue against no having worked in this sort of field. I'm quite in favor of assisted dying and the being legalized and having the right mechanisms in place to support it. That's my personal opinion. I respect everyone who doesn't have that opinion. You know, I just thought that I understood the belief that if it's the less cruel option, foreign inevitable end result, then I think it is for the benefit of the individual in the family around thumb. Um, obviously, people can argue whichever way they want it on that one. I'm happy for everyone you know, so long as you've considered it sufficiently. I'm happy if everyone's have their own opinion. I'm just glad for people to have considered it sufficiently. What could we do to help people? Alternately, it goes back to palliative care. It's symptom control. It's helping them in a ways we can't have the highest quality of life possible. I think I haven't sold palliative care as well as I'd like to in this session. Actually, palliative care can be incredible. Um, you know, if you change your mind set as a medic as a nurse, as whatever role you might be in if you change your mind set from, we're trying to save lives and prolong life to. We're trying to improve quality of life and with focusing on people having good life's well as good a life is they can palliative care is incredible. It's such a amazing specialty about, you know, balancing pain relief and symptom control, getting people to go home and, you know, giving them the opportunity to spend as much as they can, living the life they love or spending time with people. They love being a big toe, you know, say goodbye to those they love. It's an incredibly rewarding, incredible field. Things like pediatric palliative care is incredible. A. Well, I've met people. I say this every time I have to talk about palliative care because it was just the most amazing job in my mind. I was spent specialist nurse whose specialty was roller coasters, and her job was basically working with young people who were have life limiting conditions. People who had a couple of years left to live, potentially or work going to make it very long into the adult lives. And her job was to sort of work about trying to get them to get a theme parks and work out what medication to take, how to balance the medications. They're symptom free, but also still able to experience what's going on. So they know, you know, numbed by the medication. Get them to go to these these incredible experience is just to give them. You know, that amazing day out attention the best day of that young person's life in some cases, And he can have, um, that is an incredible, incredible thing to be able to do. It's a really, really wonderful field. It's provided you go into it with your head's in the right direction. You're thinking about it in terms of yes, my patient is going to die. All my patient isn't going to get any better, but it's my job to do everything I can for this person. Was that parameter in place bars and really answer so much question here? What can you do if someone does really want to die upon asleep? Palately accent, Symptom control. Improving the quality of life, mental health support Try and improve their mentality around it. Try and and do what you can there and ultimately, sometimes we are just limited by what we have. Sometimes, unfortunately, by Lauren and resources available that there isn't a noxious Teo, I fully support someone in the way. Maybe we would We would like to um, but like I said, uh, let's not Let's not focus on the negative end of this session. Obviously, there's a lot of negativity in this area. Is a sad area is very sad area to think about, but, um, that think about it is also an incredible area. Palliative care can be one of made an amazing specialty. You could do amazing things. I'm making massive, massive difference. So I think that's a really important thing to going knowing. Yeah, like I said, uh, resources. I was gonna put Henry Marsha's named Henry Marsh. I think that's I spell it, Um, really amazing books, like was, um when breath becomes a routine one of the ones that was on my list. I think they have one that's on my list. Being mortal really, really good reads anyone who's looking at getting into any field of healthcare. They're really interesting breeds toe have to have right and really good resources that potentially could discuss that interview. It's going to be a hell of a Nintendo you if you end up talking about palliative care on end of life care, but they definitely would give you a lot of insight and a lot of a lot of knowledge around the area, off working and healthcare and one of the sad part of working in health camps. That could be very, very good resources for you to have your your fingertips when you go into a sort of an interview for an application scenario, Um, with that, I will give that's this cool. It's I'll give, you know, 30 seconds for any more questions. Please feel free to email me if anyone's got any other questions afterwards. Um, but yeah, any other questions, please feel free to put in the chatelaine. Mail me more than happy to answer them. I'll say massive Thank you to Charlotte for help tonight. Really, really useful. I think having that mental health input on this sort of session, I think, is invaluable. This sort of topic is something that's often really quite poorly covered in most healthcare courses. No, as really important to have a 90 about because it is a big part of any area of healthcare. One anyone wants to go into there will always be patient to a palliative. There'll always be patients who are end of life. Unfortunately, I'm seeing no more questions here, so I'll say thank you to everyone who came here tonight. Thank you everyone who's attended. Thank you for everyone who's ask questions. Thank you. Everyone is given feedback. Um, I hope everyone has a wonderful break. A shame. Assume everywhere. You have a break over the winter. Don't use some of some description before the next term. Um, and see well in January for nutrition session. Thank you very much. Thank you very much. Charlotte's Thank you. Bye.