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does it not make a difference? You can put it up now. Okay? I'll just share my screen. Yeah, let me just share my screen. And that way No, I'm ready to go. There's not any kind of problems. Sure you can see me and everything. Okay, Cool. Yes. Cool. So I can only see my slides at the moment. Yeah, that's fine. So we can see you. Um, so yeah. Hi. Everybody will get started at about five past, just to just to give everybody time to come in. Okay. How do we get started? Okay. Thank you. Okay. My name is Michael J. Harry. Today I'll be discussing D N A C P. R s and I'll be talking about them in the context of this palliative care, a series of lectures. I'm just going to start with this quote. This can be found on the top of the end of life charter. This was It's part of the gold gold gold standard framework and talk it. And I really liked it because it really encompasses kind of my understanding, my kind of understanding, the ethos of palliative care, and it's doing all that we can and encouraging our patients to live well and also die well. The quote is actually from Dame Sicily Saunders, one of the pioneers of palliative care and founders of modern hospice movement. And she was a nurse, social worker, physician, and came came up with the term of total pain, encompassing kind of the physical symptoms of social symptoms and psychological symptoms around death and dying a bit about myself. I'm a GI Be GP registrar in West Essex. That means I'm in my final year of training year Three of three, um, background wise, I have an interest in palliative care, and it's something I've enjoyed from my F one F two years. F three onwards Upwards recently completed a six month rotation in inpatient palliative care as part of my GP rotations currently in the GP setting. I'm one of the leads for the M D T. That means I discussed palliative care patients. Along with our social workers are local hospice, another kind of support teams trying to give the best care possible and kind of integrate as many people in the community to provide support for our patients? And previous projects that I've worked on have been hospital based, including looking at health inequalities for psoriatic patients and seeing if the outcomes are different in if they have cancer or not. Um, during my time in the hospice I looked at, Are we doing unnecessary investigations at end of life and how we can try to reduce those and currently project I'm working on in the community are trying to make sure people, um, people's place of death are where they end up dying and making sure that they're seen by clinicians before they die. So they expected death can be certified and avoid upsetting coroner's referrals. So I'm going to just start with kind of defining end of life care. And I appreciate this series is about palliative care some people might be joining for the first time. So I'm just going to kind of do a little recap and just put things into context, because when I talk about DNA CPR today, I want to put that into context of end of life care. So end of life care. We're talking about people in the last 12 months of their life, so approaching the end, and the reason for that is that why do we think they're approaching the end of life, and that could be because they have an advanced, progressive, incurable condition that could be something like motor neuron disease. Or it could be something like a progressive, metastatic cancer. And it also can be general frailty and coexisting conditions. So it can be many things all together at one time or having confounding factors together. Okay, and that might also, and with the expectation that they might die within the next 12 months. They can also be some conditions where there could be a risk of a sudden death, and that could be a crisis due to that condition. That could be, for example, a an aneurysm, for example, something that can't be repaired but might rupture any time. So again, that that's kind of kind of in kind of put things into context. And some triggers to initiate some discussions about thinking about the future that we normally normally use are the most common is the suppliers cash question. So when you have a patient in front of you are looking through the notes, you kind of asking yourself, would you be surprised if the patient were to die in the next year. And if the answer is no, then maybe we should start thinking of how how we could help them plan for the future and understand what they might want in there last year of their life. Some other kind of triggers could be general indicators of decline that could be deterioration, increasing needs. Or it might be a kind of a natural point where the patient doesn't want any further treatment. And so depending on certain conditions, the markers can look different. And sometimes we use scoring systems. Otherwise it could be just symptoms and signs that kind of indicating that the disease has progressed. The other is specific clinical indicators related to certain conditions for example, developing ascites and liver disease. So again, kind of coming back to the original question of what is palliative care. So again, it's a holistic approach and looking at things, looking at the patient as a whole and in context of usually an advanced progressive illness, the goals are to kind of support the person and the family again. It's not just the person you look after, it's everybody else that's important to them. So a lot of our goals are around relieving pain and other distress. And one part that I really like is a firming life and regarding dying as a normal process. It's something that's going to happen to all of us. It's expected, and it's just recognizing a normal, normal, normal natural death is important. I'll come on to that after a goal goals and either to hasten or postpone death. But it's really just to enhance the quality of life and try to positively influence the cause of an illness. And I guess part of me that likes palliative care is the part that likes GP. It's kind of looking after people as a whole and looking at them not just as a person, as a member of the community. So generally just about palliative care. Communication is Sochi and that that's where the patients and their families so talking with our patients, also communicating with other people, other clinicians, other members of the MG, t around the patient and trying to communicate What, what we're deciding what the patient wants with them kind of at the center? Um, one of the kind of buzz words and it's not just a buzz word is the most important part is individualized, and that's that's because we shouldn't have a one size fits all for everybody because everyone is not the same. And actually, everybody has different needs, depending on different conditions. So actually it's about developing individualized plans. And part of the effect of communication is allowing people to have the opportunity to participate in these conversations, actively express what they want and kind of understand what's going on in their care so they can make decisions that's best for them. Um, kind of touched on communicating those decisions between everybody else and the importance of documentation, and I'll kind of come on to that a little bit later. So advanced care planning is a term that we use in palliative care, obviously in GP as well, and it's looking to the future. And it's not always just one conversation. It can actually be a series of conversations, and all of them are kind of looking to the future and thinking What is the trajectory of the patient's condition or conditions and giving a chance to kind of way up what we should be doing and when? So these conversations, normally between healthcare professionals and the patients and just kind of recording what they really want and kind of coming back to the main point of DNA. CPR sits sits firmly in there. So when we're thinking about the future and with death in mind at the end, what what kind of what what does the patient want or what the patient thought about? Okay, so there's It's not so much what happens in that moment, but also including discussions about where it's to happen or what things they would like before that to happen as well and what things they would not want to happen. So sometimes patients can have things like an advanced decision to refuse treatment. So before they become, um, well, they might say, If I was to lose this function, I wouldn't want to be intubated. I wouldn't want to be ventilated or I wouldn't want to go to emergency surgery. So plan's can be started. They can be reviewed and updated as situations and feelings change. I've written plans before with patients, and as things changed, they've decided they felt differently about certain aspects of it, and they've just been modified, and that's the important part that just taken onboard patients, views now, but also as things change so kind of coming to the main topic of the conversation and talking about do not attempt cardiopulmonary resuscitation. It's a source of ethical concern and also legal challenge as well. And it's just difficult because it's it often feels like we're not. It can feel like we're not trying to save somebody's life or we're not offering a life saving treatment, but actually it's not. It's rather using a treatment, and it is a treatment at the right time for the right person. The thing about the tricky part about it is it's anticipating a future event. And obviously, like I said before, it's about not giving something rather than actually giving it feels like that. So it's an invasive process. Um involves putting manual compressions on the chest to try to restart the heart when it has stopped beating. Often can involve applying electric shocks from the defibrillator to try to stop the rhythm of the heart, and hopefully, and I hope it would restart again. You know, in a rhythm that's conducive to the heart beating. Often using medications are involved, and ventilation of the lungs is also needed. Uh huh, and they've been. They were introduced to protect patients for invasive treatments that had little or no chance of success and that still that that still stands. More recently, there's been some concerns about DNA, CPR decisions about them being kind of blanket decisions in the media. There were some reports during coded as well that using a job as a discriminatory factor for initiating discussions, um, in the media at the moment and kind of and following from kind of case reviews of that, there's been a there's there's been a kind of outcomes with thought to kind of attempt to normalize these big decisions. So when we talk about DNA CPR, the goals are to reverse the reversible. And actually, the context of what we're trying to reverse is actually is important. So there's differences with a sudden cardiac arrest. In another way. Is healthy person, for example, the footballer Christian Erickson, who had a cardiac arrest on the pitch where again it was successful versus and our kind of palliative patients where the heart is the last organ to start working in as part of an ordinary natural dying process. For example, a patient with metastatic lung cancer. And here on the slide I've got CPR is not of pants here for all people going through ordinary natural dying. It's a treatment, so it's not something that's going to work for everybody. It's not going to reverse natural dying when, actually, all of the other body functions that have kind of stopped or dysregulated before that have stopped functioning. So one of the tricky parts is of of DNA, CPR. It's almost like the default in the hospital now the hospital that if someone was to someone's heart, was to stop breathing, we would try to attempt to restart it. But again, kind of coming back to the process is if it's part of the expected part of dying for for whatever underlying causes, causing it. Trying to restart the breathing and circulation is wouldn't wouldn't be appropriate. So we kind of come to the point of making those decisions beforehand of why they're not appropriate and how we include others in that decision making process and the last line they're kind of not put put. Putting DNA CPS in place is are there to ensure that patients die in a dignified and peaceful manner. So why can't we restart the heart? So So again, with CPR, we're trying to manually restart the heart. That's because it ceased to have an output that could be because it's not beating due to the electrical activity or it could be due to cessation due to the underlying process. Is so again, just kind of a bit about CPR. In general, it's about putting manually trying to compress the heart from the outside from the chest by putting compressions down at a rate of around 120 BPM, and even the best compressions get about 30% of normal function. Uh, the goal is to get the patient to attach to a defibrillator that is trying to initiate shock through the heart with the hope of restarting in the correct rhythm. So around 20% of cardiac arrest do two abnormal rhythm problems, and those are the ones that are most likely to be effective for a survival. However, 10 to 20% survive survival for people whose heart stopped for other reasons, so it's considerably lower. So we just need to put why has this stopped into context of the patient and kind of into our individual patients who were thinking of now DNA. CPR carries burdens and risks, and these need to be taken into account when we're making decisions about our patients and if they would be for CPR and not for CPR. So some of these outcomes can be damage to internal organs, rib fractures and adverse clinical outcomes. So, for example, something we don't always think about. But patients often end up in I. T. U and often have been their brain have been starved for staff of oxygen for a considerable amount of time during the downtime of the arrest. And they might have an increased physical or mental disability, which, which might be a result of the arrest and just to keep in mind as well. When CPR is not successful and we started in the heart and in restoring circulation, it may mean that the patient dies in an undignified and traumatic manner, often in a place that they might have not wanted to have died so kind of coming to. When do we normally consider? Consider, um, DNA CPR, And it can be when the patient has capacity. They just decided it's not something that they want and it's something that that they want us to document and they want want us to document that for the future? That but sometimes I'm kind of when we were thinking of palliative care. It's normally number two when CPR is judge very unlikely to be effective because the patient is dying from an irreversible condition, but also when we think about the patient's future. 20.3 is when it might be successful in starting breathing in circulation. But it might not be seen as clinically appropriate because of the potential poor clinical outcomes. And actually, it might lead to a condition where the patient might not think it's acceptable for them. So why is this a difficult area to discuss? Well, it's an emotive subject. Talking about death can be quite difficult, and it can be something that doctors shy away from themselves. You don't want often. We think we don't want to upset the patient. Maybe we think it's not the appropriate time, and and it's a literary life and death discussions. Um, it can be difficult because of understanding of patients and families what they think it means. Um, there was this slide captures a bit about a recent poll about by by Compassion in dying, and it showed that most people didn't really understand how how we kind of come. Clinicians come to the decision about it, what it really means and what their rights are and what's given what's not given when people are for not for CPR. But the good caveat to that is people actually do want to know, and they want to have the discussion around this or at least willing to have the discussion. So that's around 77% of people polled would be willing. Only 6% actually said, Oh, I wouldn't want to talk about it at all and would be surprised a lot of people actually thought about it or being part of these discussions in the past for somebody else or even thought about for themselves. So just highlighting a few common misunderstandings and by kind of knowing some of these misunderstandings, it kind of aids us in how we explain things to patients and kind of gives us some tools really, of knowing how we can best hold these kind of conversations, advocate for our patients, but also express what we think we should be doing okay. So I think one of the top ones that people have to often feel they have to opt in or decide that I have to think about if I want this or not, or that they have to make the decisions for themselves when often it is a medical decision. But we obviously want to include everybody in that decision making. Often some people think that not for CPR means not for anything at all, as I've kind of captured before and not understanding that may again. The forms clearly say it's before one. We're talking about one specific treatment. Often people might think they're being left to die being written off and that that needs more discussion. That needs to be showing that actually there is compassionate care going on. We are thinking about you and the future and what's best for you and CPR being worth ago. So there's a There's a mismatch between public perception of how successful CPR will be so around. The general member of the public on survey kind of in studies are showing that around people believe 75% of the time it is successful and that's quite far off from around 20% which we know is true, and that's in a kind of a specific population that generally quite well. And I've kind of encounter this a few times already. When people said, Well, if you're dead already, it can't hurt to try We should just give it a go because it couldn't hurt. So that's something that I've definitely come across having these discussions before and again why? And from a doctor's point of view of healthcare professionals, Why do we shy away from this discussion? So definitely can say time and competing demands would be one of the big ones. Um, how well we know the patient and the family. Do we have a report with them? Do we feel like I can be the one to initiate this discussion? I think this is one that I've certainly noticed in the hospital. And now where I'm in GP practice as well that thinking it may be this decision is it lays with another team. For example, I think cancer patients are kind of a key one where people often think we need to discuss it with the oncologist first. Or maybe the GP should be the one to discuss because they know the patient better or the war team could discuss it with the patient, given they're looking after them during an acute admission and in adequate training and support, is one of the big ones around that as well, obviously, concerns about patient autonomy. You don't want to feel you're taking away anything from the patient. So from my experience, I've kind of encountered this one recently as well, thinking that it's the decision of another team and I that's one thing that is quite difficult. And actually, sometimes the patient thinks this as well, and it it can. It can be tricky, or sometimes we differ decisions until you see the oncologist for the decision until the future. But often in palliative care, there's a window when an appropriate window of having these discussions so kind of coming on to some of the rules around DNA CPR. So who can initiate the discussions? It can be. It can be anyone that kind of any great, but again, it should be. When you have enough information to hand about the kind of condition you've got enough time to discuss it with you and you can kind of seek advice around this as well. So when we come to the rules is that is there a medical decision in regards to a treatment? However, it's a decision that shouldn't be made unilaterally. It should be part of an M D. T. So that could be a discussion between colleagues in an individual team, but also between other teams, for example, working together with oncology, seeking those opinions. And what do they think, or including the GP as well? What do they think? Knowing the patient's baseline actually other kind of confounding factors? One of the key part is kind of around doctors' health care professionals involving the patient in the decision and communicating decisions to them. And that's really one of the most important parts having good conversations with them, with the patients with the next of kin involving them in the decision making process. Okay, and there's only on very rare occasions would you make such a decision and not kind of include the patient within that, And that's if it's going to cause physical or psychological harm. And that's on. I haven't so now encountered that, but again, some patients don't want to discuss this, and they kind of alluded to what they want in between the lines. I've only briefly touched on it. But if there's a if, if you're putting the patient at the center and kind of understanding what they want and really taking interest and allowing them to understand and talk normally kind of come to an agreement with them about them understanding you, you understanding them. However, if there is a disagreement, the GMC does have guidance around this, and it's all about reaching a consensus involving an advocate. You can seek a second opinion from somebody else, and it can also form as part of the case conference or local radiation within the hospital Trust so integration with advanced care planning. This is about a one decision amongst many different decisions. DNA CPR was often seen separate, but actually it kind of sits really in the center and actually talking about the n a. C p o c. P. R. Is part of advanced care planning, Really, Is this kind of synergistic effect kind of. It's the overall goals and care and combining everything together and knowing what the patient wants and wouldn't want it all kind of sits together now some kind of trust in areas use something called a respect plan. That's a recommended summary plan for emergency care and treatment that's quite far reaching, including a lot of these decisions together, however, and the good thing about it contextualize resuscitation zones in terms of all the goals together, however, that's a topic on its own. So coming back to kind of centers of kind of palliative care and what we're doing, we're putting a person sent care kind of right at the forefront and understanding what what kind of we're doing and why we're doing these things for for our patients. So what understanding for the patient, what matters to them, who matters to them, understanding what information they need and kind of personalized contact with that patient, knowing it's specific for them and the last kind of topic. Nothing about me without me. This is kind of this is from one of the government white papers, and it's about giving everyone a say over their treatment and care. So come in to initiating these discussions through the next kind of slides. I'm not going to give, like a blueprint or kind of what you should be saying and what you shouldn't be saying, but I think it's all about having a conversation. And when it's a conversation between two people and you genuinely care about them all kind of doing it right, it generally goes a little bit better, and you might make errors in what you say. Or maybe something doesn't come out quite right. But I think my experience finding that if people can tell you're coming from a good place and you've got the best intentions that you could kind of model your way through. Even if you don't know exactly you know you're not exactly using the right word. So I don't think using a specific stock phrases are important here. It's about just being genuine and really taking an interest in the patient and before kind of having a conversation about DNA CPR. It's good to make sure you're putting it into context for the patient as well, so they know why you're having this discussion so important. Things that I always recommend is making sure that you've allowed enough time in GP. You might have 10 minutes, 15 minutes. If you're a trainee conversation, you can't keep the conversation like this just to that amount of time. So I would say organize a double slot, and if it's in the hospital, it's not a conversation you can have quickly, just before lunch and get a form done. You should allow the appropriate amount of time for a patient to kind of have a discussion with you. The other part is having all the information needed. So when you're kind of putting, when you're having this conversation about that with the patient about their circumstance, you should understand the circumstance enough for a medical point of view. And that might be just looking at a few of their most recent letters from each of their teams. Or it could be just the last couple of water and entries or scans that they've had. I always like to have a warning shot that could be like explaining what you want to be discussing with them, or I would like to have a conversation with you about future care planning. So thinking about the future and also when we're initiating these discussions, asking the patients when you normally make decisions that are important, you normally involve anybody else and and would you like them to be present? I find having a kind of opening and just keeping it kind of general is quite important. So and asking questions to patients like How much do you know about your condition or using the phrase of them? What is the specialist explain to you? So far, I'm thinking here when? When patients under neurology and they've got a life limiting degenerative condition. What do they know? What what is their understanding of that kind of prognosis at this time? Sometimes patients are a little bit reluctant with this part as well. Sometimes, but asking opening questions are kind of helpful here and kind of asking patients well, how much do you want to discuss the future and how much? How much do you want to know what's likely to happen? Or how much do you not want to know and again saying and just other things as well as like, look into the future? What matters to you? This kind of really kind of put things into context, and in GP, we always say, Give people the golden minute, allow people to talk and just just listen. And actually, once they've told you what they how they imagine how things are going for them. You can kind of lead on to the next part of the discussion with with that in mind. So some people say, Oh, I just want to be well, I want to pay pain free I've had patients say Actually, I know that I'm going to die. But I just want to be alive long enough to see my daughter get married or my grandchild graduation and things like that. So actually, it's quite important just to listen and actually put into contact someone's illness with their social situation as well. So as part of kind of what you it's about having Once you started the conversation, you started to think a little bit like What do you where Where do you see yourself being cared for? How do you imagine your last day is looking? Where do you Where do you imagine you're dying in the hospital at home? Can talk about actually, when the time comes and you die? What? How do you imagine that to be? And I think it's just great to just be open, allow people to kind of talk and kind of going and asking patients as well. So we've talked a little bit about what CPR is, but actually from a medical point of view. But maybe asking the patients as well do you Do you know what a cardiac arrest is? Do you know when what normally happens towards the end of life as well? And maybe keeping keeping that in context and may be asking questions like, Do you know when we do CPR and usually who we try this on and again? So the answer's probably will vary. And actually, by offering it explanation of either way, based on the information provided before it starts to stimulate a discussion now saying, saying things like, Would you want CPR? You often get like if you got no, that's a great answer if it's matching what you believe and what the patient believe. But often when you when they say I would want to be that often, that leaves you kind of in a difficult situation. But but not asking, I mean, it doesn't mean that the situation is not going to come up. So asking what what people wanted allows for that natural discussion and asking people, have they been in these discussions before for someone else, then I would kind of go on to explain what it normally involves the outcomes. Finally, you kind of explain what you think would happen if we attempted CPR and the person that you have in the conversation with and what the outcome would be based on their health. And I think that's really important. Part is, they're individualized Part is putting that into context of what their condition is so again, if it if they have already have failing lungs, if they already have failing kidneys, if they already have multiple organs are not quite functioning. The likelihood is that these things would lead to the heart stopping so kind of explaining that is often helpful. So and then kind of coming to that is kind of put it into context. Like I said before and highlighting allowing a natural death so explaining, we know that over time your kidney, for example, your kidney function will deteriorate and come to a point where it will cause electrolyte abnormalities. At that point, they might cause the heart to stop. That would be the natural process, and at that point we won't want to intervene. So explaining that natural process and and emphasizing that the decisions that we are making are in regard to once the heart has stopped and all the things that lead up to it. And but the other point there is just to say, Actually, we need to make sure that you know that we're going to reverse if you want us to try to reverse all of the other things to stop or try to delay that point, okay? Or focus on a good quality of life for you and symptom control. So in the time before, we'll try to make sure that all of your symptoms are kind of control. But ultimately, once, once the heart stops, we won't try to restart it. These conversations are quite a minefield. You actually find that they can be smooth. Actually often there's a lot of discussion back and forth between the two, especially with relatives, and actually that that's the good part as well. It should be a conversation, but coming to the end of it. Hopefully, I normally ask the patients or the relatives to kind of summarize the conversation back to me and say, Do you understand why I'm making this decision for a treatment for you on your behalf and understand if they understand what their feelings are around that, invite them to ask further questions and again summarize when it comes to objections, trying to hurry the conversation, to finish it or it doesn't help. Listening to the concerns and attempting to address them through conversation is really the mainstay of discussions now objections, usually around understanding. And maybe if people are not understanding or objecting, maybe you have an understanding clearly enough. Or maybe you need a bit of extra help with this kind of conversation as well, or people need a bit more time. And that kind of kind of takes me back to the point of just involving others in the conversation as well. So communicating with the next of kin is really important. For example, if you're making decisions for pain, there's lots of different circumstances and nuances. If you're making decisions for a patient that doesn't have capacity and you're doing it in their best medical interest, it's really important to communicate your decisions with the next of kin so they can understand they can advocate for the patient so they know what's going on. Also for future planning as well. If you're making decisions for a patient, how they envisage, they're kind of they're they're last weeks or months of their life and obviously, where they're going to die. It's important to convey that to other people so they know what their wishes are and they can be honored. And there was an interesting case a couple of years ago. It's called the Tracy case, and it was about a patient with metastatic lung cancer. And actually, it went it become a legal case because actually, it wasn't a contention of the DNA CPR decision. It was actually the family just weren't involved or weren't weren't aware of the decision. And they it was actually in regards to kind of the right to family life. And so, actually it's important. It's It's not just from a legal perspective, but it's just important patients and their loved ones to involve everybody so coming on to how we document this. So I think it's, um it's an age old saying, and it's kind of something I've learned from, but you have to document things, or else it didn't happen. Now advanced care planning can be documented in lots of different ways. Different places, depending where you are. So it could be part of a specific document such as respect. It could be within the patient's notes so it could be in there GP records. But in regards to the specific part of that advanced care plan decision of the one decision of DNA CPR, it needs to be on this form now. It can be different versions of this form at different places, but it always looks quite similar, so just kind of talking through it. Um, it's not difficult to fill in if you've had the right conversations and take taking the right things into context and often in some hospital trust. These can be electronic important parts that it has to have the right person's name on it and actually keep in mind for the communities, have the right address on it and as well as the date. Often the first box is around capacity. Does the patient have the capacity to have the conversation? And if they don't, you're really kind of summarizing why you're making these decisions and who you're communicating them, too. And if you're finding that they do have capacity, then documenting what? What? What have you included in this conversation? So this brings us onto box two, which is summarizing the main clinical problems. Why? You think CPR would be inappropriate, unsuccessful or not in the patient's best interest? And that could be, and that's often coming back to what medical conditions do they have? Okay, why? It wouldn't be in their best interest. And that could be they might. After speaking to them, they might end up with the quality of life that wouldn't be acceptable to them. Something to keep in mind that when we talk about quality of life and what's acceptable, it does vary between people, and we shouldn't assume that what might not be acceptable for me would be unacceptable for someone else as well. So summary of the communication with the patient or the advocate. If the decision has not been discussed with the patient or the advocate. The reason why so again, this is the box where you explain what you discussed with the patient now, Yeah, just under explain what you've explained to them. So what? They've explained to you as well, Backwards as well. So what is their take on this situation on this medical decision that you're making and again same. The same goes for the summer of the communication with the patient's relatives or friends. Um, Box five kind of comes in. Who else has been involved in this decision so often? It's not. It's not one person making a decision, even in G p, where I'm largely on my own. And I would normally discuss this decision with maybe one other GP or I would be having this discussion, maybe with somebody else that's looking after the patient. But sometimes it could just be myself. And obviously you're signing who's made the decision. Who is reviewing and actually is it an indefinite decision? And in palliative care, it usually is so kind of just kind of wrapping up and putting things together, just a summary, really. So there's five steps for persons centered TPR decision making that healthcare professionals need clear, accessible tools, information, guidance and training to enable them to explain what CPR is, what it may cause, why it may cause more harm than good for a particular person. So conversations about what matters to the person, including CPR decisions, should be everyone's responsibility in healthcare must take place at the earliest possible opportunity, which is one of the fundamental things that we kind of encourage urgent need for better public understanding of what CPR is, how CPR decisions are made and the fact that the DNA CPR decision only applies to CPR touching this before but highlighting one of the important it's record keeping. An information sharing must be improved when the decision about see cars made it must be available across healthcare setting to prevent inappropriate resuscitation attempts, delays accessing appropriate care and treatment and people suffering traumatic deaths. Um, and discussions about CPR must not take place in isolation from person's wider priorities and wishes. So just kind of finishing up on sharing this information once and communicating. We've kind of highlighted communicating with the patient themselves, but actually what we we need to be better as well is communicating between other healthcare professionals and different different teams. So that could be with the ambulance service that could be with the GP themselves. It could be with the hospital specialist so you could have these conversations, but everybody needs to know that they're being had. Thank you. That kind of comes to the end of my slides. Brilliant, Thank you. That was That was really helpful, very thorough and lots of really good tips there. Does anybody have any questions? I think we've got some, uh, some nice feedback in the chat. Somebody said there is such an interesting presentation. Thank you. You're welcome. It's really It is an interesting topic, and it can be done in so many different ways. I saw some really good other presentations and mind bleep and looking at kind of DNA CPR, but in the context of treatment, escalation more, more in terms of acutely and well patients. But my focus really is about palliative care. And that's what the series is about. Thinking about the future, asking patients what they want and what they want their death to look like at the end. And having that conversation is appropriate at that time. Yeah, absolutely. Does anybody have any Any final questions? No. Okay, well, we'll leave it there, then. Thank you again, Michel, for your time. It's really, really brilliant. I'm going to pop in the chat. The sign up for next week's session, which is with some of the chaplains from hospital. Both Michael and I have worked in, um so that should be really interesting thinking about the role of chaplaincy at the end of life. Yeah, I have a nice evening, everybody. Goodbye. Thank you. Thank you, Nina.