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Good evening, and welcome to the mind beep Palliative Care Webinar series. My name is Beth, and I'm one of the palliative care Khalid's. I'm really excited that this evening we're going to have clear Greenwood joining us. Uh, now we've been having some technical difficulties, but it seems like Claire has has come to the stage. Where can you hear me? Yes, I can hear you twice. I don't know. I don't know either, but we'll roll with it. Would be able to just post in the chat. Please let us know if you can hear me. And Claire, let me just get the slides open. If anyone is out there, could you just post in the capital as Kenneth? Thank you so much. That's fantastic. All right. Wonderful news. So, as I said, my name is Beth. I'm one of the palliative care leads. I'm an f Y. Two working in northern Devery. I'm really excited that Claire is joining us this evening. She is, and I m t three currently working at Whips Cross in London on a general medro tha, um, as part of I m t. She did a six month job at Saint Joseph's hospice in Hackney. She has an interest in palliative care and living palliative care in a variety of settings, and she recently wrote a piece for the Association of Palliative Medicine Juniors blog. Looking at palliative care in prisons. Tonight, Claire is going to be talking to us about management of pain, shortness of breath and agitation. What we'll be doing is clear. We'll be doing a PowerPoint presentation throughout that, um, they'll be an opportunity to write on the chat, but I think we'll leave questions to the end. Um, and people can have a free for all if there's anything else that they want to ask Claire if you're ready, um, feel free to to share your screen and take it away. I'm just going to ask how I share the screen. Um, in the bottom columns. The bottom area. There's an option that is present now. Yeah, if you click that and then click entire screen, uh, question of share slide, show your screen share entire screen and then and then go from there. Entire screen. Great. So does that Look, um, can you see a presentation? Yes, we can see it. Thanks. They're perfect. Okay, so and this is just a quick, um, breathe through a few of the sort of common, um, problems that we encounter in palliative care and some of the kind of big symptoms. Um, that is a little case that goes with each, um each thing that we're going to talk about and they are, Well, two of them are very much based on quite complex cases I encountered in the hospice. And one is more of an amalgamation of things that you see all the time on the general medical, Um, job. I'm not going to enforce participation because it's always quite awful on over like video calls. But when I asked the questions that do you try and think what you would do, what you do in your role is, you know, junior doctor or a more senior doctor, um, maybe in a hospital setting or in a hospital setting or ngp land. And then I will say what we did. One of the lovely things about palliative care is that that aren't huge amount of very hard and fast guidelines. So I'm not going to say that what we did was necessarily correct each time. And there's a lot of escape for discussion, and and so we'll allow a bit of time at the end and say that you can raise anything that you'd like to talk about. Um, yeah. So let's start with a bit of a chat about pain and so lots of things to consider when someone is complaining of pain. And so it could be related from the underlying disease. Whether that's a cancerous process or something. No malignant ascites and chronic liver disease can cause a lot of stretching type pain of the abdomen. Uh, liver capsule pain, which is quite specific. Um, from that can be really uncomfortable. Pain, pain, fracture, pain. You already have the Oh, sorry. Bear with me. Two seconds. I don't know. Okay. Okay. Sorry, gang. I'm using a cream. Um, carrying on to lots of, um, consideration as to why people are in pain. Some things that are specific to being unwell, being miserable, being in hospital and saw your mouth not brushing your teeth. Urinary retention, pressure sores. Stiff feeling is not being able to get out of bed. Always were thinking of the neuropathic type pain or a visceral pain and the pain that you get from shingles, for example, is really quite specifically neuropathic pain that we are sort of aware that you manage differently to the pain that you get from a broken leg. And then the other thing to consider is are we good at recognizing pain and other barriers to someone asking for breakthrough? Um, or, you know, things like that. Maybe it's maybe it's linked to here. Yeah, And then it goes there. Maybe I should have sorted out after, you know, I don't It doesn't disturb me, but I wonder why you're doing that. It was okay. All right. Hopefully will be. Will be good now. And so a non pharmacological management really important, um, to be working both things alongside, say, non pharmacological pharmacologic management together. So hot water pill tools week packs tens machine, which is using sort of stimulation. Um, little electrical stimulus is to usually like hands, fingers or muscles. Um, simple things, like repositioning complicated things like radiotherapy if someone's got bony pain, um, distraction. So if someone just concentrating on how much terrible pain there in, um, there's actually some evidence about using virtual reality headsets in patients with intractable palliative pain. Um, to do really good quality distraction, um, complimentary therapies. Uh, And then there's some interventions that can be accessed to a sort of specialist pain service in nerve blocks, which is where you inject some long acting or heavy local anesthetic, which can relief give you relief for weeks and months. A nerve license, which is a rather more extreme. And, uh, I mean, very effective. But it works by injecting things like alcohol so that it destroys the myelin around the nerve and you lose the motor function to the nerve in addition to the sensation. But for patients that are in really terrible pain, that's quite a good option. Um, and then pharmacological management. Um, so we're all probably very familiar with the W H O pain scale, which advises that you work the way up through a non opiate, a weak opioid and a strong opioid. Often if someone is a really significant pain, and we miss out in the middle steps to the weak opioid, Um, and it might just be worth going straight into a strong stuff, but always worth considering. Your non opioid paracetamol is good for most people and can be very good at managing pain and in terms of how we might introduce an opioid pain killer. It's worth trying the patient for 24 hours of just prn to get an idea of how much they need over 24 hours. And then you can convert this days to a maintenance days and the breakthrough days that you prescribed alongside that maintenance needs to be 16 of the total overall requirement in 24 hours, Um, and and we'll talk in the next side about how you convert between different types of AP oId. But be aware that if someone comes in on a really massive fentanyl patch like 100 microgram patch, then prescribing 2.5 mg of more and more as and when they need isn't going to be a significant enough break through. It needs to be in proportion to what the overall, uh, requirement is, and lots of different ways that you can deliver. Um, painkillers. And particularly, I'm talking about a P. It's hearsay oral sub cup and syringe drivers. So CSC I is a continuous subcut infusion patches, which are things like fentanyl and Butrans patch PCA, which is patient controlled analgesia and So this is something that you could only really have on certain wards but is very good if someone's, you know, POSTOP pain or even sickle cell crisis. This is something that we consider quite early, uh, sublingual. So there are lozenges and melts that you can give people if you want really rapid acting pain relief. For example, if someone's in severe pain when they have a dressing change or when they roll in bed, that can be an option and then topical there as well. More to think about other things that you can do Topical opiates, for example. Someone's got really bad pressure sores, and but you have to make it up, especially with the pharmacy. So it's not a readily available option. Um, and then we've got some of your neuropathic agents, so I'm a trickling, gabapentin pregabalin, which hopefully you're all reasonably familiar with. So they're good to pains that related to nerves so burning, shooting, tingling, electric shock type pains and then a few other drugs that we use in palliative care for pain control. So steroids have a particular place. If you think there's an element of something pushing or stretching or expanding like with liver capsule pain often see someone on 4 mg of dexamethasone to help that pain. Benzos. A little bit of lorazepam midazolam can help with muscle spasms that are causing pain. Um, similarly baclofen works for spasm type pain. Uh, ketamine is used for pain relief, and the way it's used in palliative care is in a syringe driver. You get a 24 hours from this driver with ketamine, and then it resets your pain receptors somehow, and you get sort of significant improvement for weeks after methadone can be used. And it's got a mix of opiate and neuropathic pain, uh, pain killing properties. So it's a really good choice. Um, palliative care lidocaine either, is, um, you know, like instill a gel on something that saw, um, or you can do like I was talking about earlier sort of blocks with the anesthetic and just a reminder to anticipate that someone may have side effects with a P. It's particularly so it's always worth co prescribing some form of anti rheumatic, some form of laxative. And if you think someone is a little bit opioids toxic, um, slightly differently to how you manage it in a in A If someone came in with a big a peek over days, you rarely want to completely reverse the AP. It's that someone's on in palliative care because you leave them in a pain crisis so worth going with small like a. It's like 50 to 100 micrograms of naloxone at a time just to gradually reverse the little bit extra that's making them, uh, toxic without reversing the whole lot. Um, this is something that I won't talk through too much, but it's worth you taking a photo or a screen shot or something if you think it's helpful. And it's how I convert between different opioids. And so, for example, if someone was on would be a useful thing. Someone was on codeine and they were on 30 mg four times a day. And I thought, actually, codeine is not working very well for them. I want to put them on oral morphine. You would convert three uh, so if you see codeine down the bottom, you divide by 10 to get the oral morphine equivalent. Um, so if it was 34 times a day, you've got 120 by by 10 12 mg of oral morphine. So you put someone on 5 mg BD of ST That would be a rough equivalent. And then you work out your breakthrough as well. And so that I can say is, um just a little thing I have and use regularly to convert between a P. It's and I run everything through oral morphine in the middle. So if you wanted to convert from codeine to buprenorphine patch, I would go to the oral morphine equivalent, which is 12. And then I would divide by 2.3, uh, to get a five microgram patch, for example. And so here's a nice, juicy case. Um, and I said, this is based on someone, and I met at the hospice and looked after quite a while. Um, I've not changed the name very much, so there is a small chance that I could say a different name, But just forget that if it happens, so it's a 37 year old man who's got a very nasty, quite aggressive, advanced right upper lung cancer that's invaded right through the clavicle, up the neck and into the brachial plexus. Got a background of hepatitis C in the next IBD the currents maker. So use your history. So he's a sculptor, artist and a DJ. Before he came to the hospice, he was living in the hospital, Uh, and he was primarily Spanish speaker. Um, when he got admitted, he was on gabapentin 300 mg TDs, a small dose of amitriptyline at night, and then 45 mg methadone be day, which is, um, which was on for substance Missy's. He was using PCR and morphine up to eight times a day. Um and particularly he was using it overnight for a pain in his arm he was describing Is burning and shooting. So what would you do with these medications to try and get on top of this pain? And what are the non pharmacological options that might help? Um, So as I said, you don't have to interact. Uh, and I'll just explain what we did. And you can see if that's roughly what you might have done this sort of. And so we up titrated his gabapentin, and you can actually go up to, uh, 1200 mg TDs. So we gradually went in a sort of step boys way right up to the big dose of gabapentin, we all say stopped trying to give it our drug around time. So we wanted to do 82 and 10. Actually, he was a bit of a night owl. He wanted his last days before he went to bed, which is usually around midnight, and he wanted his first day is a little bit later in the morning because he could usually sleep in a little bit later and we increased the amitriptyline because as well as having a neuropathic roll, it's quite helpful for sleep. And it would help him stay asleep over night. And we went up to 25 mg of that, and we also increase his methadone. Um, I think we went up just to like 50 mg b d. But that does have a significant benefit for his pain. So we were using that in in a dual way. Um, he engaged well with physios. He got, um, using a tens machine. So he found that helpful for stimulating the nerve distal to where he was getting the the intrusion from the tumor. And he also enjoyed hand massage massage elsewhere, including his feet for just general relaxation. We also got him listening to audio books in Spanish as a really helpful distraction technique so that he was feeling his time and slightly more, uh, engaged way than when he was just flipping out for a cigarette all the time and worrying about the pain and the and the tumor. Um, we worked with an anesthetist at the hospital who offers complex pain management procedures. Um, what do you think we asked him for when we were thinking about Oliver? Um, and interestingly, what did he get? Which is something slightly different. But he offered Oliver either a brachial plexus block so high the arm, uh, infiltration with the anesthetic, um, or nerve license. Which would mean that he lost the use of his right arm. Now he was right handed, and he found a lot of pleasure still in sculpture and art, and he was not keen for that at all. In the end, we settled on a medium nerve block, which is, you know, when you think about your median nerve, it's bit lower down the arm, and it really only affects, like, your carpal tunnel fingers. So he didn't get a huge amount of relief from that, which is a bit of a shame, as it could have been really good. If you've gone through the higher up block, um, and then I've just thrown in at the end, Uh, the masses growing rapidly and starting to press on his neck and esophagus. What would your plan B if he can no longer swallow Just to make you think about the fact that a lot of the neuropathic agents, uh, only really come as tablets? Um, so pregabalin is a capsule that you can occasionally get as a liquid. Uh, gabapentin is just tablets. Um, So what we did was that we had a syringe driver that you put the methadone in. Um, and you can also add a small amount of clonazepam, which works very well. Um, as a neuropathic agent, if someone can't swallow it, and it also helps someone not be too distressed by the pain. Um, yeah, that's a with three pain, and we'll be all right to go straight onto breathlessness. Take silence is yes, because I can't see the chat and I'll come back to all questions and everything at the end, and so we'll go first. in the same way. And so the shortness of breath in patients that are dying and it could be a reversible condition. And I put reversible in, um, quite marks because obviously not all of these actually are reverse. Well, we've seen lots of people die from chest infections, but potentially reversible, uh, also think about whether they have decompensated, uh, underlying lung disease. They did. They have well controlled CAPD, but they're now short breath for other reasons, and they can't manage their inhaler anymore. Um, is it a complication of treatment so pneumonitis can be caused by immunotherapy? Chemotherapy? Radiotherapy, um, is a non respiratory courses something neuromuscular like MND or an anemia that would make them breathless if it isn't the airway? Because occasionally short of breath and wheeze actually mean stride or an impending airway compromise. And And I've been caught up with this one fairly recently where I thought it was just a bit wheezy, and actually it was upper airway noise and signaled impending airway compromise. Um, and then consider there's a big psychological overlap with panic and anxiety and panic attack. If you think about someone who's having a panic attack is typically someone very short breath struggling to catch her breath and they feed into each other. Really is a vicious circle. Um, so non pharmacological management, uh, breathing techniques. And this is something that, uh, it sounds quite obvious, but just trying to combat the anxiety and the up regulation of the shallow, panicky breathing and by getting someone to breathe around the square. So if you take your inhale as you look at the top edge of the square or a rectangle and then hold as you look down and then exhale if you go back across the bottom and hold if you get up. And that just helps people breathe a little bit more slowly and consciously fun therapy literally means putting a fan on so that people can feel the oxygen or air just blowing across their face. Um, and that helps people feel significantly better, Um, positioning. So often, patients position themselves best for their breathlessness. They're sitting up leaning forward. A tripod position even lying on one side, can be helpful. The worst possible position is often what patients are in in the hospital in bed, whether slumped down. They've got three pillows behind the head and they can't really get their head back on the next street to take a deep breath in. It's always worth trying to set them up and get them a little bit more. Um, well positioned long term oxygen therapy, uh, and drains like a pleurisy strain. If someone's got recurrent infusions, um, and then moving on to pharmacological management, Uh, a few bits to talk about here. Well, these nebulizers, which works the same way as an asthma or COPD so just relaxing the is treating bronchospasm can be very helpful if someone should be on inhalers but can't manage them anymore. Um, the mainstay of breathlessness management, where it's just breathlessness alone, is, uh, opioids. And they recommend a small dose of an oral opioid, uh, every four hours. So, like a little bit of our, um, off, um, can be given as a modified release or syringe driver as well, and it tends to give it as, uh, like small doses regularly, uh, for breathlessness. Benzodiazepines. Particularly helpful if there's an element of anxiety, and the one that you'll see is most of them. For this is sublingual lorazepam, very rapid onset. You get them to just pop it under the tongue and it will dissolve and it's half a tablet to one tablet. And then I just thrown in about secretion management as well, because secretions are worse than breathlessness. Um um, and the stress and your treatment options there are, like upper any, um, or highest in beautiful gray mind, which is best. Japan and different trusts have a different first line secretion agent. It's worth just looking to see what your local guideline is. And so this is the case. It's a sort of a combination of a number of people that I saw on my water cover a couple of weekends ago. Um, so you're covering a respiratory award? You can ask to see an 88 year old lady called Ana. She was admitted with pneumonia five days ago. I got rapidly increasing oxygen requirements. Overnight she got started on CPAP. She's on pretty high pressures maximum f i o t. Someone's done in a BG, and it just shows Type one respiratory failure with the P 02 of let's say seven. Um, the daytime have thought about her treatment escalation, and she's, you know, quite frail. She's got pulmonary fibrosis bronchiectasis CKD Um, she's not got a very good functional baseline, they said. More based on IV is the ceiling of Cat. She's on broad spectrum antibiotics, and they've been escalated 72 hours ago. But despite that, her infection markers are getting worse. The CRP is 3 20. She's got a good going acre. I, um you're going to have a look at her. She's in bed, She's drowsy. She's very tack up. Nick. His SATs aren't very good. She's not sinking with the n. I. V keeps reaching to try and pull the mask off. Looks very dry, very sweaty. And she's feberal. And so you feel that she's not going to recover from this pneumonia. On the background of these, you know, to quite significant lung disease is and that she's probably reached the ceiling of her treatment. Um, so I've been sort of two questions, Um, and I think neither of them have a clear answer. But what would you do regarding the oxygen therapy, and then what? Medical management would you start? Um, so my thought here and what I what we'll end up doing is I mean, it happened in IV can be a real barrier to people who are breathless, dying comfortably. It's a tight fitting mask. It stops them talking to your friends, family loved ones and saying things that are important to say before you die. And so I would often suggest either moving to humidified face mask or too high flow nasal oxygen where the oxygen just goes up the nose so that someone's able to talk. Have mouthcare, um, eat and drink a little bit more alert, um, unable to have those important conversations with people. And it's not as noisy or as aggressive or as uncomfortable as leaving someone on an IV to die. Um, you could also, if the patient's not happy with any of those things, just try normal nasal cannula, Oxygen World leaders and the aim of the oxygen is just to help them feel not so breathless. Um, it's not to correct the hypoxia in, and and the medical management is really the the stuff that I talked about on the previous slide, Um, I would personally be reaching for little days of oral or subq oxycodeine and giving oxycodeine because of her correct in in her HFR rather than morphine. In this case, um if you think she is going to get rapidly downhill, you could start a syringe driver at this point as well with oxycodone and maybe a small amount of medication to help with anxiety and distress, which leads us very nicely on to our last, uh, topic, which is agitation. Um, so I think of all the symptoms, agitation is probably the one that, uh, we may be. Don't do quite as well. Um, so thankful. Think about why it might be happening. Is there something that's manageable or reversible? Like constipation? Your your attention big overlap with pain and particularly being able to express pain for some reason. Um, undertreated pain hypoxia like we talked about before. Um, electrolytes particularly think about hypocalcaemia. If someone's got bony Mets, they can be quite agitated. Quite muddled. Um, think about drugs and that drug's that left on. And also drugs and alcohol withdrawal. And is it brain mass? Is it steroids that their own for brain math? Um, are they simple things too hot to cold, and then a huge topic, which is just psychological distress? Have they not accepted that they're dying? Is there something that they feel that they should accomplish before they dye that they feel that they're not able to, um, the non pharmacological management. A lot of it is quite familiar, probably with sort of delirium type management. So offer reorientation. Keep a little diary of who's been in to see them, uh, clocks. Familiar faces? Um, introduce yourself each time if someone forgets them. Other things that can help, if particularly someone's very hot and or uncomfortable fans and ice chips to suck can be really helpful and then psychological, which kind of encompasses spiritual and religious needs as well. Um, often people don't feel able to discuss death or don't want to discuss it in front of the family in front of the Children, but also worrying about how it would affect the family. Um, offering support financially for funerals, support for Children to have time off school. Do they need social work to get involved? Can we make people feel more at home if they can't get home? For some reason, if they got their own clothes, blankets, pillows, pets, visiting can be really helpful for agitation. Um, and then I put in again complimentary therapy and and there's actually quite good evidence that just, uh, non specialist hand massage. So just like rubbing someone's hand can be helpful for agitation. Um, so it doesn't need to be a trained Marcy's Just like holding some one time and rubbing it can be helpful for calming down. Um, And then, uh, pharmacological management. Uh, there's two main drugs that I think you should be aware of. Uh, which are Benzes and the majority of the benzos that we're talking about here in Jerusalem, Uh, so small days prn every hour. And if you're starting a syringe driver, stop somewhere between 10 to 20 mg over 24 hours, uh, and then leaving the promethazine, which is a old school antipsychotic that also has quite good anti emetic properties but will make people very sleepy. And again you give a fairly small dose is like 6.25 sub cut P R N. And start a driver at 25 to 50 and I've put on phenobarbital pain and not because anyone should ever be initiating that by themselves. But that's kind of the third line I've got self forgotten, the exact status that you give, but it's, uh, it's very effective and it was what we ended up using. When Oliver that we spoke about in the pain case, Um, he was very, very terminal agitated at the end. Um, because of his substance issues in the past, he didn't really respond to the first two things. He seemed quite sort of immune. And we gave him phenobarb getting the thing to know is that the first day you give i n before you got the driver? So it's not particularly pleasant. Um did work really well for him, and he became much more settled after he started that driver. But it's very much a specialist palliative care thing. You don't need to be starting it of your own plan. And and then a little bit of a chapter about God, A a case of someone who really stuck in my mind as someone who we have lots of issues with managing her agitation. And so this is also the hospice. It was a 41 year old who were going to call Cathy now she had a endometrial carcinoma, and when she was first in the Hospice for Pain Control, the plan was that this was potentially operable. Um, she had previously been very overweight, and she had a gastric band in that would lead to some malabsorption. So she only has to be MRI of sort of 15. 16. Um, and so the plan had been admit her to a hospital setting for a period of perioperative optimization. Um, so some TPN for about a month and then go ahead with the surgery, Uh, and the the thought have been that it would potentially be either very life prolonging or even curative. And unfortunately, while she was over at the hospital being optimized, she developed neurological symptoms. So she got metastatic spinal cord compression and, uh, that actually set everything back that had to be sorted out there. She went from radiotherapy, which, unfortunately, did not work and also left her with burns to her back from the radiotherapy. And so she came back to the hospice bedbound, Um, and incontinent. Um, the social history was quite tricky. So Mom had dementia and was in a care home. Her dad came to visit her every other day, and I went to see his wife every other day. Her brother was in prison and she was a lifelong smoker, so she was on a very high dose of morphine and quite a high dose of the neuropathic agent. Um, she's also on an SSRI, And she was, uh, someone that is using pure in or, um or very frequently, um, often having sort of 8 to 10 doses in the course of 24 hours. Every time you went in to see her, she was distressed. She was crying out in pain, and the pain seemed really difficult to manage. It wasn't responding at all to P r n, and it didn't respond when we increase the doses of morphine or the neuropathic agent in the background. Now she was someone that said that, uh, when we asked about ways to cope with pain and anxiety, she said that smoking has been something that's very important to her. Um, but she was struggling to manage pain, anxiety since you become bed bound. And so we we actually negotiating with her, and this is quite tricky and in a hospital setting. But it's just an example of trying to think a little bit outside the box. Um, we would take her outside on the bed once or twice a day if you can manage it so that she could have a cigarette. And she found that that really helped with mood and her anxiety, Um, and two degree with the agitation. And next question I said, is given that we know she's got metastatic core compression. What other things like physical things that might be making her more agitated? Do you want to exclude? And And I guess what I was getting out here was sort of, uh, neurological stuff. Say, check that she is not constipated because she will lose the ability to regulate her bowels with metastatic or compression. Um, I think about urinary retention. Does she need a catheter? Would that help manage her pressure areas? And the fact that she's sort of aware that she's now newly incontinent and quite young, And it might be very hard for her to, you know, manage that psychologically, Um, how do you support her? Psychologically huge question. Um, And again, not the right answer. One thing that we did do that we felt was very important to her was we spoke to the prison, and the chaplain helped us get her brother to come and visit her and from prison. So that she was able to talk to him about the fact she was dying and see him before she died, and we tried offering some. It's almost like pre bereavement counseling to her. Um, trying to come to terms with the fact that something that she's been told was curable is certainly incurable. In fact, she's dying while she's very young. Um, and that had possibly some success. Um, we have lots of support to Dad as well. Who was going to become very isolated when Cathy died? Because his his other child was in prison and and his wife was unable to recognize what was happening at all. And yeah, it was It was very challenging to support her psychologically. And then I put in one last question just to end things on. Really? I don't know. Challenging note. Um, so one night you're on call from home and the nurse brings me and says that Cathy is deteriorating rapidly. Um, she's very agitated. They can't settle her at all. And when they've been in to check and see, you know, she constipated is your retention. They find brisk nonpulsatile vaginal bleeding. You have a think and you assume that you might have eroded into a pelvic vessel. So what management do you advise the nurses to do? Over the same? And so really, what we're talking about here is a terminal or catastrophic hemorrhage. So a life, um, it's a life threatening event, and it's also a sort of terminal complication of the cancer. Where it's, you know, it is untreatable. It's eroded into the vessel. There's very little that you can do here in terms of, you know, blood transfusions, trying to stop the bleed. It's an incurable cancer, and it's just spread to the point where, um, it's now causing someone to to bleed significantly. It can be very distressing, Um, for the patient and the kind of management that we advise, um, the nurses or the family members. If someone is having one of these kind of major hemorrhages at home is, uh, someone needs to stay with the patient, reassure them, don't leave them even to go and get medication or towels. You need someone to stay in the room at all times. Um, you put down dark color blankets, a dark green or red um, just to make it so that the appearance of the blood is a bit less frightening. And, um, do you give, uh, middle school? Um uh, to manage the symptoms of distress that someone, uh might be having And you give it I am because, uh, physiologically that person is going through a sort of, uh, sort of state that you would expect if someone's having a big bleed. So they are peripherally cold there, Hypertensive. The supply of the blood to the skin is very poor, so giving something sub cut that won't work. And it's quite rare that patients at home or in the hospital to have a cannula. So you need to give it I am. And and the advice that I gave was to give 10 mg. I am now, um, to do all the other stuff to call the father and to get him to come see Kathy And to repeat the I am midazolam as frequently as needed up to 15 minutes apart until the patient was comfortable and settled, and no longer agitated or in distress. Say, And that is my whistles, Doctor, Um, of these three symptoms, um, is there I know you weren't quite quick. Answer to leave. Lots of time for questions and hopefully answers. Is there anything that anyone would like to ask based on any of that? Just type in the chat books and I can see it. How the A periods and Wednesdays wife and shortness of breath, um, say I mean, the benzo is mostly act to improve anxiety and panic associated with shortness of breath. Um, they don't really act so much on the breathlessness side of it. It's more to do with anxiety. Um, opioids have a bit of a respiratory depression effect. So if you think about someone that's had a like an opioid overdose, pinprick pupils, respirator eight. And so it's just using it a little bit like that, but in a really tiny controlled states and to just reduce the respirator, make it a bit more manageable, a bit more effective. Um, yeah, I think the answer is out. A lot of palliative care. We don't know exactly why some of it works or whether one thing is better than the other. It's all very individualized because it's a really difficult group to conduct, like, uh, randomized controlled trials, because, you know, these patients are very different to each of their There's so much going on people, you know, like a re holistic sense. So, um, you know, thinking about managing the first and the last patient, they've got completely different social backgrounds. Actually, they both had a bit of an issue with pain. Um, but you approach it very differently because, you know, it's It's so, so diverse, um, and so important to think about people holistically. Um, it's a really good question. If you anticipate a terminal catastrophic bleed, how do you prepare the family for this? And so it's really important to you talk to families about the fact that this may happen because it would be far, far worse if it happens and they weren't prepared with them. And for the patients. Um, what we tend to do is just explain why someone has a risk of a catastrophic bleed, and often it's like with them head and neck tumors. So things that are up now around near the carotids are at high risk of like a karate blowouts. I think the radiation to the Claritin people bleeding to death really fast and quite kind of horrifically. Um, so we talk to the patient if they're able to talk to the family and explain that, um, you know, this is something that may happen. You've seen it growing, you've seen. It's quite big, quite angry, and there's a chance it will grow sort of inwards direction. And there's a chance that it will affect the blood vessels. And if this happens, it will bleed very profusely. And then you go through and you talk about the sort of management plan. And if someone's at home, we tell families to ring 999. Not because the paramedics will, you know, do anything life saving. But they can come out and give you, like injectable medicine, um, for the family. And they're also going to get there quicker than my community McMillan, or like a district nest, you know, whatever time it is. Um, so every 999, they stay with the patient if they can manage it. If we discharged him from the hospice, we give them a red blanket or a green blanket to take home with them. Um, and if they feel you know, they're young, relatively involved in the person's care, until this point, we give them, um, oral gel midazolam like the Coumadin as well. Um, that they can, you know, squirt towards that person's mouth, Um, and hope that some of that gets absorbed, and then they feel like they're able to help ease the agitation. Distress a little bit, and we tell them not to press on the neck, and it may worsen things. It may be uncomfortable. It may panic the person, and ultimately, it's not going to. It's not going to stop the bleeding in any meaningful way. And so if it's a really big bleed and it's postal, particularly, we tell them, Don't touch it. Don't try and stop that. It's going to happen very quickly and you pressing on it won't won't help. And so that's sort of roughly what we talked through. We put it on, you know, when you do, um, our charts in the chart, the district nurses to administer medications at home. You put it as a one off dose on there, um, and right, this is for catastrophic hemorrhage. And and make sure that you've got enough. You know, I am needles that otherwise wouldn't be sent home with injectables. Uh, so there is my doctor alarm in the house in case they need it. Um, and, uh, when we have a patient on my diabetes ward who just happens to have a heavy neck tumor, Um, and we have this kind of plan. I've written it out and put it in the folder next to her DNA hour so that if something unexpected were to happen, hopefully we would get that folder, um, out to check about, you know, the other part of the treatment escalation plan. And they would see, you know, this is an anticipated consequence. This is part of her dying from her head and neck tumor. Um, you know, we're kind of basics of and I said, you know, it's not wrong to put out a cardiac arrest call if you feel like you need support. Um, but do not start, you know, a major hemorrhage protocol, because we we don't transfuse blood. That's not going to help the situation. Um, but, you know, it's fine to fast bleep someone more senior or get the whole capacity in there because it can be very, very frightening for everyone if you've not seen it before. Um, so yeah, so that's, uh it is something that certain specialties will see more. Um, E N T. Max facts, oncology and palliative care and all that sort of head and neck stuff is, um uh, it tends to happen on these kind of specialties. But as I said, it can happen anywhere. If someone's just happens to have poorly controlled diabetes and a big team, uh, it's worth knowing about, Um, there's a question that just says it's because midazolam equally as effective as I am, it's absolutely not as effective because, uh, again, the supply blood supply to the guns in someone who's really shut down is poor. Um, and, uh, we don't really expect it to be as effective. It's just there's so there's something that can be done while you're waiting for someone who's able to administer and I am gets that. And if a family member doesn't feel like they can do it, you make it very clear that it's not something that they have to do. It will probably make not that much difference. It's fine for them to opt out. They can just sit there and, yeah, hold their hand or whatever. Um, so there's never any pressure in the family to feel like you need to try and do that. Any other questions? Yeah, Go. That's absolutely era of political alongside active management. Um, And like I said about Cathy in the case when we first got involved with her complex pain management, um, she was actually being lined up for curative treatment. Um, having a potentially life threatening illness. Um, particularly if it's a cancer type illness. People have palliative care needs. They need to have a space to talk about what it feels like to be living with something potentially life limiting. They might have complex symptoms related to the disease or related to, um, treatments. A chemotherapy immunotherapy. Radiotherapy can all be quite nasty. People might need, you know, a short amount of time on a syringe right there while they get that pain under control or where they get vomiting under control. Um, we also get palliative care involved for patients on intensive care. If we think that, you know, we are actively managing them. But they are approaching the ceilings of what we can do. And we want to start talking about what's important, um, where they would like to be. All these kind of things um, so definitely. And inpatient palliative care and in reach, palliative care teams can get involved. Um, as long as you have a kind of clear question about why you want them involved is the advanced care planning? Is it because you think that they're going to deteriorate and die on the submission is its symptom control. Um, is it Yeah. Advice about medication or medication? Side effect. Um, palliative care can look after people for years if they've got a life limiting condition. Um, and it may just be that what they do more intensely is towards the end of someone's life or very early on when they've got a lot of difficulty adjusting, um, or when they're in hospital struggling with treatment. So, um, escape of palliative care is quite broad. Um, I would just say if you're getting involved in patient, just be clear what your kind of question is, Um, and make sure the family or the patients are aware of why you're asking them. So patients can be really understanding of, um, you know, we're struggling with your pain. It's very complicated. It's related to the fact that you've got, uh, multi organ failure or each other. Um, so we're going to ask palliative care because they're very experienced in managing this. Um, because that is different, too. We're gonna ask palliative care because we think you're going to die from this pain or during submission. And just make sure the patient and family understand why you're doing it as often. People here hospice and think you're going to die when actually it can be the, you know, short admission while you get that sorted out. Going to your symptoms, get a new care package in place. Um, while your wife, he normally does the nighttime carries on holiday, that can be a hospital commission. Um, so just, uh, need to sort of careful about what you're asking them to be involved in. It's quite a lengthy answer for quite a straightforward question. Is there anything else in the last two minutes? Anyone wants to ask? Thank you so much, Claire. That was fantastic. And really, really, really helpful. Um, for the final couple of minutes, I think I will bring things to a close. But if anyone does have questions that they come up with in the next few days, they can post those in the Facebook page for the event. And I can forward those onto to clear. Absolutely. We also have a question in the chat about feedback for me. At the end of this, a feedback form will automatically come up. And we'd love you to fill that out. That would be helpful. Um, I'm just going to post in the chat the link to our next event next week, which is palliative care emergencies. Claire, do you have anything final that you would like to say? No, not really. Thanks for the really good questions. It's really nice to know that, um, some of it was a bit talked about going on, Um, and you know anything that you can give since the email, and better let me know and she'll All right. Thank you very much. Everyone. I hope you have a lovely rest of the evening and thank you so much. Declare. Okay,