Computer generated transcript

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

everybody. Good job. Little part of care in the so light of care is a huge topic. It's an entire specialty. So trying to teo and work out what to talk about, it was a bit of a towns, but really, I think talk about walk by of care is on high. It relates to, um, our practice in the emergency department. Why does it matter? A little bit of a symptom control? Um, in on. Then what about recognizing and of life on the buyers to providing this care on that? A little bit of what we're doing in Kohl's lady with regards to palliative care of the movements. So part of care is treatment, care and support for people with the life limiting illness onto their family and friends. Also, Yeah, lot of carrots, holistic. I'm encompasses physical illness, psychological, social and spiritually Well being. Also on the M is to provide as good a quality of life is possible for the time that person has passed out of care isn't just for cancer, and it's not just that the end of life really is for any life limiting illness. Uh, which is numbness. You can't be cured from, for example, COPD moved in your own disease, that dimension, heart failure or a chance renal failure, any of those kinds of things that should be available at any stage, off life or of that disease to try and improve that person's quality of life. End of life care is treatment. Care on support for someone reaching the end of their life? And that might be in there last year, there, last month's weeks or even days. It's important to note that end of life care is palliative care, but not old. Palliative care is ended. Life care. Okay, so physical symptoms some of the common things that we might country are pain, breathlessness, nosy, a vomiting, anxiety, DeLaria, more agitation, troublesome respiratory secretions and then some disease specific symptoms, such as seizures or ascites, at which will require a specific treatment or intervention as well as the physical symptoms. Part of care can provide emotional, psychological, spiritual support for both patients and loved ones, and I think it's important. Teo, recognize this on address these things with compassionate care where we come now, we also provide support on the multi did a disciplinary team. Assessments have to provide package of care hospital equipment like a hospital bed at home. Uh, I didn't put from district nursing or or positive care nursing for medications, etcetera. So I might win counterpart of care in the emergency department. There are a few reasons, really, that's that I can think off at the first of all is acute deterioration in the patient's symptoms, which require additional control so escalating pain or nose intractable nose in vomiting that kind of thing. Patients may be attending for another reason. Such a a full or an injury or admission for another reason. Require continuing palliative care during their inpatient stay. Or patients may be presenting with a sudden or catastrophic event such as trauma UM, a intracerebral hemorrhage, sepsis, organ failure on require rapid initiation off palliative or end of life care and the D with services under strain patients, sometimes on sure where to turn the needy under pressure. With delays toward admission, we need to be able to provide this kind of compassionate character our patients. Some patients may required Mr the Hospital, while some maybe suitable for management in the community, wants treatment has been initiated or updated while we can organize the social on multidisciplinary team assessment elements. The most likely reason for attendance is probably physical symptom control. Symptoms can maybe a direct result of the disease itself, or is an effect of treatments such as chemotherapy. Palliative medications are used in a number of different guys. Is that maybe one off doses so found? It's easier on the magic I was required Pierre inducing commencing regular medications or early, uh or indeed, starting a patient on the syringe driver. For those who have increasing or high blood music requirements or are a little too tolerant things orally that we also talked about anticipatory medications for patients who really are in the last couple of days off life. We deal with pen every day in the emergency department, acute pain is recognized by a defined onset. Subjective on the object of physical signs heightens autonomic activity in response to treatment of the underlying cause, as well as providing analgesia chronic pancreatis over weeks or months, complete two changes and function personality lifestyle is more multi factorial and more challenging to treat, requiring a holistic approach that to the psychosocial factors as well as physical elements on this is something we're probably not as good up an emergency medicine. Them could be described in terms of ideology UH, no susceptive pin, um identified as ah lesion, causing UH, localized tissue damage, which stimulates pain receptors. Neuropathic pin, which is called but damage to nerves, which misfire either central or peripheral, causing shooting, stopping burning pins and needles. Type in repaired pin pain felt removed from it's colds. Do to handle anatomical origin. Such a You know your typical shoulder tip in and paraneal irritation that we see, for example, with corruption, top of pregnancy or liver capsule pin in hepatitis or liver Feeling. Assessment of being requires an understanding of the disease process of attention to the multi factorial nature of it's presentation. This is the World Health Organization, analgesia Glover, but I'm sure most of you will be as acquainted with just to summarize the heart. To recap. Step one is your mind's. Thin is often treated successfully with simple, non opioid analgesics such as paracetamol, ibuprofen, topical preparations like nonsteroidal jails or light again. That's everything. Step two is moderate. Pin on Theoden of a week opioid such as coding or tramadol, is helpful here, in addition to the elements from step one on come on, too high of the importance of the multimodal approached Jones Easier on. You know, a little bit of lots of things are more effective than lots of one drug. Most patients will have tried step one and possibly step two before they present us or a pain. Relief is the preferred first step. Um, pain relief is important to ensure plasma levels of the drug remain consistent, as opposed to dozing just when pain gets unbearable on attention to the underlying calls. For example, in Lindros, mobilization of that fracture or or injury well will help to reduce the pin, stepping up the ladder to the next step. If the pain not controlled by the current therapy Step three then is severe, been and really the mainstay of off treatment of this level is the stronger opioids Analgesia. Okay, so there are a wide variety of opioids available, but morphine really is the gold standard for the first line that we should be using. It's available in a number of preparations, both orally, Aunt Parentally as well. Oxycodone is another option, which is better in impaired renal function on some other drugs such as a fentanyl, which we can use most safely and acute renal failure. Old a big reference of this point to this book somewhere you may have seen or have a copy off the physical palliative care guidelines. Hamburg. And but there's an excellent Frito Access palliative care text book or reference guide available of this, um, websites. Or if you direct your phone at the ER codes, then it would like you to the book. Okay, so we have reference guides like this. Specialist help is available in ours from Are in the hospital McMillan, the palliative care team who can advise on at dosing or choice of allergy six and specific situations on Out of ours on call palliative care consultants. Three. Sweat sports Really, That's really after discussion with with the eating consultant. So it's being shot from this, uh, online resource that just what should we do in this side? Is the opioid conversion at tables on? But this is important because when the patient has mark state on one treatment school, for example to normal, 3500, which is really the strongest thing that we prescribed routine leak. Then we're gonna have to look at how to convert that to the next step. Orel Conversion Summary off The important drugs that we might encounter Morphine is about 10 times as opposed to this coating, so you're taking regular Kokomo it tablets in a day. 240 mg of coding is equal or equivalent to 24 mg of oral morphine. Um, the oxycodone is about twice as potent as morphine, so 10 mg of oral morphing will be equivalent to 5 mg off or lock school no Similarly, a 2 to 1 ratio and some cuts. Morphine. Oxycodone, 15 mg of stuff got morphine is equivalent to about 10 off diamorphine. Sub cut 15 mg of sub cut morphine is equivalent to 1 mg of subcapital. Sensible, um to convert or more thing to sub. Couple more thing for someone. For example, if you can't tolerate or lint ick at 10 mg world to five subtypes and the same with obstacle, and then there's just the dye morphine, fentanyl as well. So we've started someone on a stronger, almost sick What's the next step from there so, or a morphine solution? A dose of 5.5 to 10 mg? I could be given regularly. So every four R's and elderly patients or patient zero bit naive you might good. I'm Teo, a dose of 2.5 regularly in additional to breakthrough or PRN doses. Then what we do is talk up the total number of doses the total number of milligrams over 24 are, and that could be consolidated into a sustained release preparation. Like MST eso say the patient has taken a total off 30 mg of more finger over 24 hours. We could give them MST 15 mg twice daily, and then they're breakthrough. Your PR and juice should be about six off that. So that would be then 5 mg off or or more thing as a breakthrough. Patches, fentanyl patches, for example, or the Butrans patch is another option, but I'm not gonna cover them. So this stage nose is another common, particularly symptoms, particularly malignancy on the causes air many and varied so gastrointestinal. We have delayed gastric emptying mechanical obstruction with a tumor, for example, constipation was, ah and side effect of a lot of the drugs, or indeed, some other treatments on then, for example, radiotherapy to the album to central nervous causes, such as a space occupying lesion in the brain causing wrist intracranial pressure, Um, and also testicular um, dysfunction, causing sea sickness type symptoms. Some metabolic causes like advanced liver or real failure on then pharmacological chemotherapy is well known to do this certain under the Arctic on anti convulsants and indeed, the opioid. Just once we've just prescribed before some of the common, um, thematics that we're using their goods in palliative care. Um, but our it's like using is the first I got to come to you. Understanding, because of nausea, is crucial in choosing the correct antimatter on the same principle applies, you know, as required teo regular doses on them to put a pound potentially that continues syringe driver infusion if if required. So 16 is a histamine antagonist with some anticholinergic activity, and it works on the vomiting center in the brain. On on the vestibular system. On the dose, as we know, is 50 mg up to three times a day, or a maximum of 150 daily. Medical promotes is a dopamine antagonist, and it's particularly useful because it's prokinetic so the like. So you're delayed gastric emptying on the dose is 10 20 another grounds three times a day. Just need to be careful with these ones with extrapyramidal side effects, particularly in younger patients, which could be quite troubling. Leave him a promising is palliative care sort of Swiss Army knife off antiemetics on it has action on serotonin, dopamine, anticholinergic. Histamines are sort of broad spectrum on the, um attic, and it's a good choice for someone who's come in with a multi factorial presentation that, such as your palliative cancer patient to have maybe disease related elements a swell, a skin therapy and that kind of thing. Yeah, on the dose for that is 6 mg Oh, really? Or 6.25 mg sub cut too early as required, or in a continuous infusion up to a maximum of 25 mg today polyp area. All could be useful. Um, well, in certain circumstances, and it's another dopamine antagonist, Um, I could give smaller doses of it 1.5 mg once or twice a day, so you'll notice that I haven't mentioned that one anti emetic in particular. Uh, which has it's place on That's on dancer from Yeah, it's something that we use frequently in the emergency departments and what I suspect. A lot of us don't really know what awful lot of weight it eso just into the comments there. Does anyone know what the licensed indications for ondansetron are? Yeah, so he knew. Induced nose involvement. I'm not a general. Okay, so there are two licensed indications and metagenic chemotherapy on post operative nausea and vomiting. Eso were all using this drug off license every day. And on that has there a couple of significant things about number one That's really not the most effective drug for what we're giving it for. Remember to you know, we're using it for indication, which it's not licensed for a prescription. Well, down strong is that serotonin that works on the serotonin receptors. Now, some of the common side effects are constipation. Also, that will be it rarely prolonged. QT interval. So does anybody check patient CCG before they prescribe one downside from Has anybody, uh, discharge patient on dansetron when they come in with nausea? Uh, from constipation. So just a little little thought provoking. Uh um points there based on that. So, yes, it's useful. And it may be useful in combination with some of the other treatments that particularly for those patients presenting on chemo now here, having intractable nose involvement. As I said, some patients with significant allergies like requirements or anti emetic formance or those here on a pill to take medication or early that may require a continuous certain striver. So this could be a combination off analgesia and thematic sedative and a cholinergic for respiratory secretions on opioids, which we're putting in. There can also be useful in treating breathlessness because the lady will shortly possess to off the similar experience drivers as part of an end of life care projects that Lisa and I have been developing. So how do we know when somebody is dying and what should we do? Do we see they're dying patients in the emergency department? We probably see this more than we think. So, for example, 78% of people with dementia but Warm or Edie attendances in the last year of life, indeedy attendance has increased closure of the patients where to death. So have a think about the Alzheimer's patient that, you see he's been referred from the nursing home for monitoring off their challenging behavior for IV fluids because they're refusing to eat or drink or refusing to take their medications. Um, this patient is dying of Alzheimer's. They're entering the final stages of their disease on with her excellent talk there from the cool talking about the, uh, the treatment of Alzheimer's and high we should, or dementia and how we should approach it in the emergency department. These patients probably need palliative care, not unnecessary admission, invasive investigation on aggressive treatment with IV fluids of medications and biotics and things. So we should instead perhaps be looking at what's important to them ways apart from potent sedatives to treat their condition. Um um, address. This is a more holistic patient center to broach University. Edinburgh. Have this useful tool coat spect or supportive? Um, palliative care indicators to this is used to identify objectively those patients whose health or condition is deteriorating, and that may be approaching the end of life. So you can see they're some of the general measures on sound admissions. Deteriorating performance status with limited reversibility that dependent on others with loss, uh, persistent symptoms despite treatments or that patient is actually asking for palliative care or is choosing to stop or not of treatment has some specific disease related markers. Such a counselor, you know, deteriorate function due to their counselor or two fails for council treatments. Um, some of the organ failure diseases you see there you know a good few points as we've already raised in the in terms of dementia as well and then neurological conditions. I want to draw your attention in particular to this box because I think this is very important crucial in managing patients approaching the end of their life, such as stopping unnecessary medications. Unless that medication is having direct benefits to the symptoms that they're experiencing. You know what really is the point of being on a statin, for example, or, you know, anti hypertensives. Or, you know, there's things like that palliative care in boots, communication patients and their family. Regarding that current and future treatment, having these conversations early in advance of significant deterioration is important. Now we're gonna tell the way better by DNA, CPR and I, and then a new name is doing a dedicated talk on the n A, C p. R. And dying matters later on. I'm good record keeping of these discussions and communication with those who will be involved in care Later. That insure joined up uh, continuity of care. If the patient is admitted to hospital, they will have the benefit off are palliative care colleagues expertise as well as the care of the inpatient team. That said, we should get the ball rolling on. If we identify a patient that is likely reaching the end of life, convey them to the accepting team. There's still some things that we should do any D, such as insuring their symptoms or controls insuring they understand the situation will establish what their wishes and goals are regarding their care. Do you think we do this well? Do we advocate for our patients? We need focus on their quality Has most a quantity of life? Probably not, not much. Much of the focus of our practice is on preserving life or the quantity of life as a boost to quality. It's easy to get caught up in a busy emergency department in treating what we know we can treat on. There's a certain cognitive dissonance on Dem, maybe reluctance or embarrassment or awkwardness on our parts toe have the's difficult discussions in the day time consuming some time is limited. It could be difficult to build a sufficient report in such a short space of time to have a meaningful conversation about such a serious subject. Patients and their families were understandably stressed. Worried may show away from having these conversations at the time, but if we've planted the seed, is that at least when our colleagues and the Ambition team revisit the subject later, then they had a chance to think about it and reflect a little bit. Yeah, does medical professions we can All I are anxiety or awkwardness or embarrassments to get in the way of these conversations when they're required. I know needless delivering a talk on the CPR, but I felt was important in this subject to reiterates it in the context of palliative care. DNA CPR is misconceived by the majority, probably of the public on the concerning proportion of health care professions. CPR is not a treatment for ordinary dying. The N A. C P. R probably should be friend as protecting patients from an inhuman, inappropriate medical procedure. Ideally, this conversation to be hard when a patient as well, um, can consider it not when they're breathing their last or when they have deteriorated suddenly were making Mr Station in an emergency. So there's another key. Our link to the above poster. If you're interested in in Twitter or kind of formats, the hostel have the conversation that has some more additional resources. So chat a little bit about a recent case that has prompted us to have a thing about Hae Remanage and of life care in the evening on Elderly Man presented to the department with a life changing diagnosis. In other words, he had a large bleeds on the brain. Ultimately, we established that he was nobody in the last day or two of his life. Um, his daughter, who was an experience nurse, felt strongly that her father would want to die at home, and she wished to take him home and care for him and his final arson days. Unfortunately, this was not simple. Is helping him into the car or ordering an ambulance to take him home. Arranged was for maybe for a last minute conversation with the palliative care team, about quarter to five to get him home with the appropriate referrals to district nursing community of palliative care of RCP as well as his own GP to insure ongoing care that could be provided after discharge. The out hog nature of this arrangement was concerning on a little weight had everything in place that we needed. We felt that pathway which is still on draft. But I'll I'm happy to show you for staff to follow in. This scenario should arise again. So what we've produced so far is Ah, um pathway as I'm going to show you The loud comprises this section on decision making Recognizing the end of the need for end of life care. The importance of documenting these decisions bit about ensuring adequate arrangements are in place. Such a referral to district nursing on divorce tp palliative care, hospice community team. If the patient is already know one to them on things like social care package, it requires there's a section on anticipatory or strings driver medications, un insuring that the appropriate prescription charts were strings driver charts, husband completed on the medications and supplies dispensed. And then just a final check s. Although this isn't the prescription she eats. Just making sure that we have documented what we have prescribed in the rationale on who's making these decisions. We will understand the patient home with all of the medications. Concern will sharps. It's actually needs as well as comfort pack. So you know, toiletries and other things with the records. We have some information booklets on end of life care and palliative care as well. Some useful numbers such as district nursing and Mark You're a nursing teams through the out of Ours GP dollars Community Palliative Care Hospice team, which can be referred to through their own GP if they're not already open to them. Patients in their elders could contact that team if they're already knew in service. And then if the patient's being admitted to hospital the hospital, McMillan, part of Claritin, could come and see them. Um, they're very predictable and very happy to come and help us with patients here in the eating. Uh, all of these organizations have websites on be useful resources on their websites with regards to palliative care, couple of dust, additional things. So this document, the R P M G guidance that for the management of symptoms in the last days of life, I've already pointed you towards this part of care uh, adult network guidelines on If you didn't get the opportunity earlier there, stay the link again for that. I really can't. Stress are good resource. This is and once again have the conversation. So, in summary, pie of care is a treatment, care and support for people with a life limiting Ellis for their family and friends. Uh, palliative patients in the d. We need to recognize we need to address these issues symptom control, including pain relief, nausea, or be always an antiemetics. We've covered a bit of a prescription in terms of symptom control. Recognizing the end of life is important. I'm not straightforward. There are barriers to care and having these difficult conversations on. We've talked a little bit about how we should think about that. Um, we talked a little bit about what we're doing in terms of breathing End of life care in cause, lady at the minutes. Yeah, that's me. I always take any questions or comments from anybody. Great. Thanks. So much done. And that was a great talk. Please, Just to get some help is what about it? Really