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Yeah. Okay. All over to you Go to Okay, thank you very much. And hello, everybody. It is great to be doing this. I I'm going to speak for certainly not more than 40 minutes and try and leave plenty of time for questions. I wish we were doing this in person. It's always much better. But please, if you have any questions at any point, just make a note of them and we'll try and cover us as many as possible at the end. I am a hospital palliative care doctor s O in the UK We have essentially three different types off palliative care, clinical settings. So we have the hospital and anywhere in the hospital can have a palliative patients. We have the community so patients in their own homes or maybe in care homes and we have hospice is Onda. Britain was the first country to set up the hospice model of palliative care on, but we have got a huge number of hospice is, although only a tiny proportion off palatis care patients are ever lucky enough to receive their end of life care and hospice setting. Then we'd ups that you love that be more beds on, and I have worked in in a lot of those settings. But I really, really love hospital palette of medicine in a way, because I think it's it's the most challenging kind of in the UK The NHS is always overwhelmed. They're never enough doctors, never enough nurses that the demand always outstrips supply of staff. And that means everybody gets very over pressured on day. Perhaps things happen to patients, essentially that that the kinds off end of life experiences that patients sometimes experience, or so, so, so much worse than they needed to be. If only everything had been resource to properly and to some extent when conditions are are really bad. And they were worst of all in our two big waves during the pandemic. Although they're pretty bad now, To be honest, it can almost feel a little bit like field medicine, your fire fighting the whole time. You can't do anything like ideal palette of medicine. You just have to do the best you can on. I thought it might be useful. Teo teacher to part session with a lot of use of this today is part one, and we'll do part to next week, which is really a kind of palliative medicine. 101. What are the absolute essentials? You need to know when you guys start as very junior doctors on hospital wards, you will absolutely be meeting patients with terminal illnesses. He were very close to the end of their life. Will who are maybe actively dying. And I hope with these two sessions I will give you a kind of tall kicked for how to deal with with death and dying on the ward's when you start. Because if you're anything like me, you may be finding that a slightly daunting prospect. Certainly in the UK, death and dying is just not part of the medical court school curriculum in any meaningful sense, you you don't tend to see patients who are dying. You don't tend to talk about how to diagnose dying on. Maybe you get very little nothing in the way of experience of practice about how you have those difficult end of life conversations. How do you sit down with the patient and break the news to them in their family that they have a terminal condition? How do you tell them that cancer has Rickard, and they're not going to survive, etcetera, etcetera. And if these two initial sessions are helpful and you would like me to, I am more than happy to do a few more where we can go on to look at some of those really quite challenging aspects of palliative care. It's sometimes you'll you'll hear doctors say, for example, having a resuscitation conversation with a patient discussing whether or not Teo put Do not attempt CPR order on a patient's medical records. Sometimes doctors will say those concessions very easy that take five minutes. They're really straightforward. It's my experience is someone who has those kinds of conversations literally every day at work that although they can be very easy more often, they're actually quite skillful, and you conduce quickly if you do them badly. But to do them well, say that the patient and crucially, you to come away from that conversation thinking, Yeah, I feel like I did a good job of that. I I had a patient centered conversation. I really feel a so the patient understood the issues. We we reached the shared decision that doesn't always happen on, but sometimes in very worrying ways. So if if that would be helpful more than happy to do some more sessions around some of these other aspects. But But today and next week, I'm going to focus on the kind of absolute nuts and bolts. Imagine you're a new doctor and you are starting life on the ward's of your hospital. You're going to be in counseling patients who are Frojdfeldt of their life. How do you manage their symptoms on How do you even perhaps diagnose the fact that they're dying? Sometimes you may be the only person who notices that. So with no further ado, I will try and make my sides go. There we go. Sorry. So these hold on one second. Yeah. So this side gives the essence off the types of symptoms you're most commonly likely to experience in patients who are end of life or approaching the end of life on dive deliberately left pain, which is the one everybody thinks Well, first of all, I have left pain to next week so that we can do a whole session on pain because the management of pain in whatever setting hospital or community is so, so, so incredibly important not just for parents of patients that surgical patients, um, A and D patients accident in emergency patients, all patients getting pain management right is absolutely crucial. And therefore, I thought it would be valuable to devote the whole session. Teo Pain management. So today I'm going to focus on one to force it. So these are the other common groups of symptoms you may see in palliative patients. So risperidone every symptoms, neurological symptoms that that constellation of delirium, anxiety, agitation, G I symptoms and I have subdivided G I symptoms into nausea and vomiting and constipation on this is going to be a little bit of a whistle stop tour. I haven't done very, very detailed slides because I want this to be, um, the kind of nuts and bolts. But as I say, if you want more detail teaching on on any aspect of this, we could we could do more sessions before we get into the specific symptoms, though I want to focus for a moment on framework for how, as a doctor you should approach symptom management in any aspect of medicine, I would strongly recommend, rather than diving into the details Europe approach You try to have its Let me take a step back here. Let me think about this particular situation for a moment and let me try and apply a general framework to the particulars of this situation, this patient, and use my general framework to help structure and order my thinking. That's always the approach I take because I think if you can learn to do that, take a step back. What's my general framework? You are far less likely to miss things. You're like it to be more systematic on D the frameworks and protocols that guide our practice we use for a reason. It's because my a large they tend to work. They tend to cover most scenarios. They'll never be everything. But these are good principles for a reason. Eso with symptom management This is how I approach symptoms in every patient I meet as an experience palliative care doctor. So so two first and foremost before I even go to the bedside, I I want to get a sense of my patient. Why have they come into hospital? How long have they been in hospital? What is their underlying diagnosis? If, for instance, they have lung cancer Where are they act in the trajectory of that illness is there is the aim of their treatment. Curative. Do we know that that cancer is metastatic on? Do they are? Sorry, I'm just keeping an eye on messages as we go, but so far I think it's everybody saying whether from but do post messages if you want to. Um so where were they act in their illness trajectory? Is there anything in their past medical history that's really important to know? For example, have they got important underlying comorbidity ease? Or do they have another mental health? Um, medical history as well as their physical condition? And the other thing that I always always like to know? Not just with part of patients that every patient I'm asked, review and hospital is where have they come from? Have they come from home? Have they come from a care home? A nursing home on what is their social set up? I'm not worried about detail. I just want to know. Is this someone who's married with kids? Do they live home alone? Do they have care? Is in place already supporting them, So I very quickly will take a minute to glance at the notes and find out what the essence of this patient is, why they're here and what the key features of their background are. And I really recommend doing that for every single patient. It saves so much time. And also you will enormously impress your seniors when you're a junior doctor and it. And indeed, while you're still a medical stream, if you do that because you'll often be the only person who bothers, it's also incredibly helpful. Toe have that very, very brief background when you're thinking about management, because that background is often really, really key. So that's the first thing on then. Secondly, and this, again is a approach for all medicine, not just palliative medicine with any symptom for a patient. The first question is, what is the cause? So what is my differential diagnosis for what may be causing this symptom? So, for example, if they have pain in the context off bony metastases from Prostate comes to say, it's very easy to assume that the cause of the pain is the bony metastases. But it might not be. They might be experiencing pain because off on old, longstanding chronic I don't know back condition. They might have had a full. It's it's so important to just mentally go through what could be causing the symptom on then. Second question or any of those cause is reversible because they may be. And then there's something you can do to easily fixed. Um, um, if nothing is obviously reversible and you need to think about how you are going to, um, palliate the symptom on the words palliate comes from the Latin word palley air on a a pallium in in Latin waas a cloak so palliative means to cloak a symptom. How do we hide on mask the symptoms, for example, with analgesia. So general principle, when you're trying to cloak palliate a symptom knees only a just one thing at a time, the logical be systematic. So start one painkiller don't start to pain killers. And the reason for that is obviously because if you do more than one thing simultaneously, it's quite hard to know what works on Sometimes, if if paying, for instance is really is really difficult to manage. If you aren't systematic, you can get yourself into a until model, cause you just you're not sure what's actually helping, um, and then other crucial general principle, a free, um, every technique for managing a symptom that you try. We will always have a constellation of side effects. And so you will always be thinking about balancing the risks and the benefits off off that form of treatment. So strong opioids, amazingly effective pain killers, but also cause a great many side effects. What one of which that many patients hate is sleeping us eso always have in the back of your mind one. Is this helping? And two, Are there any negative effects going hand in hand with the way in, which is helping because that if there are, you just need to discuss with the patient from the balance off those risks and benefits? Because at the end of the day, always what the patient wants matters. So that's in a nutshell. Is a general approach to symptomatic joints or Aleve a Schintzius? Not just not just palliative once so I have bear with me he ping. I own time. We started you started five minutes late, but I will try to just talk the 35 minutes so breathlessness now breathlessness is on incredibly common symptom as patients are approaching the end of life. So, uh, in in in lung cancer in a like cancers that can metastasize to the lungs are hugely can be a hugely problematic symptoms. But also, of course, breathlessness can be a feature off many non malignant diseases. So, for example, heart disease, other non malignant lung disease is COPD etcetera. Um, but whatever the underlying cause, the principals tend to be quite similar. And this side is in a nutshell, your your options. So, um, sorry. I just realized because I'm screen sharing, Can you'll see the chaps on my screen? And does that matter? No, no, we can't see your chap. But don't worry. I'm looking at the chat. Any base. If there's I think I was I came to you. All right, well, I'll turn off the track anyway. But that's fine. Thank you. Sorry. Um yeah. Breathless less, uh, is a symptom where people tends to dive in quite low down on this list. Off options, they tends to go for opioid. It's you have probably learned already that strong opioids, as well as being fantastic pain killers, can be fantastically effective in addressing the sensation of breathlessness, which is many patients will say the absolute worst symptom to experience. There is something I think uniquely distressing about feeling as though you're suffocating you. You can't get enough oxygen in. It provokes a sense of really kind of visible fear in patients that they feel a So they're they're fighting for their life, struggling to breathe on. There's something about breathlessness, I think, that you don't necessarily have with other symptoms like pain or nausea, pain or nausea, although on President Horrible, do not feel as though they are killing you. But breathlessness feels as though it's killing you too many patients on. It's really important to remember that, because from the perspective of your patients, if you're trying to empathize with them, not managing to get enough oxygen into your lungs is a horrible, horrible sensation on it can provoke a huge amount of fear on any patient who has experienced significant difficulty. Significant difficulties with breathing is likely to be very, very frightened off the dying process. If they know that those reading difficulties are likely to continue, they may fear that they are destined to have a horrible, horrible end of life experience on day. For that reason, very often with patients will have a very open conversation with them, where I will ask them at a very simple but very powerful question, which is this? It is. What are you most afraid off? What? What worries you most of all on? But it's amazing how many people say it's no, the idea of being dead. It's not being dead per se. It's the process of dying. That's what I'm frightened off. And once somebody admits that to their doctor, it gives you an opportunity. Teo, follow up that question by saying something like that doesn't surprise me. A great many patients say the same on one thing that patients often find helpful is to have a conversation about that. Would you like me to have a chat with you about what that process might be like? Because I think I may be able to reassure you about that, and nine times out of 10, a patient will say yes, I would like that conversation, and suddenly, as their doctor, you are having a conversation that might have felt far too risky to ever broach with the patient, which is what is it going to feel like for you when you actually die? What is that experience going to be like that? Actually, if somebody's end of life is, well palliated, there is no reason why there should be any breathlessness, any pain, any unpleasant symptoms at all, because there are always drugs and other treatments to help. Always, there's no upper limit on any drug that we prescribe if it's needed to to address symptoms, and you can have a reassuring conversation before you get to opioids. These first three non pharmacological measures can all be really, really helpful. So fans are not just a kind of nice, lovely wolfed of cool air across your face. There's a physiological reason why fans can be helpful in in patients with breakfast cysts on it's, it's essentially part of the diving reflex. So if you plunge into a freezing cold lake, for instance, the effect off that sudden cold on your body but particularly face particular, your nasal able falls here is to increase your heart rate and slow your breathing rate. So if you use a fan in any patient with breathlessness, the cooler blowing on their nose, a local so full, so you need to You need to aim. The fan here has Thea effect of slightly lowering their respiratory rate and that can feel beneficial for the patient. So fans are fantastic. Oxygen off obviously could be a treatment. Physio can be incredibly important as well. There are lots of lots of breathing techniques leaving exercises. You can teach patients who are struggling with breathlessness, which we don't have time to go into you. Just that. But you could google those on day to help enormously, not least because they give patients a sense that they are actually in control of this very, very frightening symptom. If none of those measures work, opioids are can be fantastic on D opioids s O. So there are four different kinds of opioid receptors. The most important is the new receptor, and you find new receptors in in most parts of the body. So throughout the central nervous system, the peripheral nervous system also all through the gut, which is why I hope you would call it cause a lot of GI eye symptoms. And, um, there are new receptors in the breathing centers in the brain stem and the effect off opioids in the brain stem is to dampen down thie brain stones sensitivity to carbon dioxide level's. So it's carbon dioxide more than oxygen that drives are aspiratory system that dictates our respiratory rate rise and carbon dioxide levels on. That's why oh oh, to retention is so important in COPD because if you are so two retainer term, then you, uh, effectively have, in a sense, done the same thing as having a dose off opioid. You have turned down the sensitivity of the brain stem to carbon dioxide levels on. You are therefore less aware off the the urge, the sensation of needing to breathe. So for patients suffering for chronic breathlessness, that could be a very powerful effect. Small doses off morphine can help enormously with patients who are suffering from irreversible breathlessness from, for instance, and stage heart failure or cancer. Maybe, UM, use tend to start with low doses, maybe 2.5 mg of a lot morphine four times a day on day. If those doses of beneficial you'll start the patient on a modified release form of morphine, perhaps 10 mg twice a day on, we'll just go up as as the breathlessness requires it benzodiazepine. So we'd usually use lorazepam as a as an aural treatment on dmard as alarm. As a subcutaneous treatment, Benzo's a useful because off what I've already mentioned that restlessness is a very, very frightening symptom, and sometimes people who are breathless that their breakfast this will trigger panic attacks. They'll be very distressed. And so the benzodiazepine just helps helps calm down the fear that sometimes the companies refuse nous. And then the other aspect of breakfast. Miss, that, um, you've probably heard about is Theo issue of Upper Airway secretions. So you may have heard that the phrase death rattle it's It's a horrible phrase. Lots of patients. Lots of families have heard that phrase death Rapolas well, on d they associate it with with horrible dying. Um, we chondroit out secretions by giving various an anti muscarinic medications that act on the autonomic parasympathetic nervous system. Onda common one is higher seen. You can use atropine, glycoprotein e um, but all of these drugs, like higher seen they work essentially, by drying out the patient a little bit, they reduce the amount of secretions and they can help with the Rackley noise. I'll mention something very, very important in passing the so called death rattle, which content if I have family members, especially really distressed them. It's horrible to hear your loved one. Making a noise like that is actually physiologically not caused by what patients and family members tend to assume. It's a nasty, loud, wet noise, and the public tends to seal. It comes from lots and lots of fluid within the lungs, so they assume it's a sign that the patient, their their loved ones, lungs are filled up with horrible fluid. Maybe they're drowning at the end of life. Actually, that's not the cause of the wrap it all The rattle is simply caused by the fact that when someone is very, very weak or their conscious level is very reduced on either or both of those states can occur towards the end of life. They are no longer able to swallow the very, very small amount of saliva that we are always thinking all of the time on swallowing without realizing. So you and I are doing that now, Um, if you can't swallow that slither in six here in your throat, it just sits right there on a tiny little bit of fluid can generate a very loud noise, as are your air passages backwards and forwards through that little bit of pool saliva. It makes the rattle. The thing that can really help to reassure patients and families is explaining that it is. Patient is not bothered by that noise. If they're not coughing and spluttering, we know for certain that they're not aware of it. They don't know that a little bit of saliva was there in a normal person in your me. If we had a little bit of fluid there, we would cough like crazy. Our cough reflex would kick in instantly because it's a nasty, unpleasant sensation. If the patient's not coughing, they're not aware of it on. But I tends to around the side of not treating secretions the death rattle unless they are actually bothering the patient. If the patient, in other words, is coughing and distressed by the cough, and the reason for that is if you dry up secretions, you make them stickier, and sometimes you can create a problem. You make them stickier, and it's actually harder for the patient to then remove or cough up the secretions and so they actually feel worse, even though the noise is, is is quieter, that keep an eye on time. Okay, warrants that. So that is a whistle stop tour off breathlessness. Now, this constellation of symptoms that that the kind of neurological symptoms are sometimes encapsulated in the phrase terminal agitation. I'm not sure if you've heard that phrase or not, but terminal agitation. He's a phrase that lots of palliative care doctors don't like. It suggests that somehow the act of approaching the end of life generates a special, kind off agitation that is uniquely present in dying on D. Somehow is, ah, kind of acceptable or necessary or inavoidable part of the dying process. There isn't really any such thing as a terminal agitation. Some patients become agitated towards the end of life for various reasons. Some don't on off the ones that do become agitated. Actually, they become agitated for the same reasons that other non palliative patients become agitated. So I hesitate at using the phrase terminal agitation. I think it's it can be risky to use this friends, because if someone is labeled terminally agitated, what that label could do is just turn off our four processes instead of going back to the overarching framework that I suggested at the start of this talk should inform all of our decision making Is doctors instead of doing that? The phrase terminal agitation just means the doctor stops there and says, Okay, this patient is wildly agitated because they're dying. So what I need to do is sedate thumb without thinking. Could there be other reasons why this patient is profoundly agitated on? Are these reversible? Can I fix them on their four help? The patient s so it's really, really important, particularly these neurological symptoms to think what's causing them, what's underlying them. Because if you can figure that out, it can be incredibly easy to stop thumb. Um, just before we come on T pharmacology, Um, to give you two examples or three examples of very common cause is off agitation in end of life patients, uh, the most important thing not to miss, because if you if you think about this is fix it, you transform the patient's quality of life. In an instant is urinary retention. It's incredibly common for patients to go into urinary retention towards the end of life. There are lots of drugs like opioids that contribute urinary retention S O. If you have a patients, any patients in the hospital who's agitated, make sure you palpate their bladder. Make sure you find out if they're passing urine. If in doubt catheterize thumb and you may find they have, ah, residual volume of, you know, a liter of urine. And suddenly the act of catheterizing them transforms thumb and they go from crawling the walls, agitated, being blissfully relaxed. And there you go, you're a genius. You have you have just given that patient the most precious improvement in their quality of life in their final days or hours. So a very good example of a cause of agitation that's easy as pie to fix constipation. Also incredibly common in end of life in Paris, it patients very, very easy to fix accidents, suppositories, animals and the other cause of agitation that so so important not to miss is, of course, pain. So often, Palatis patients are very, very vulnerable because their nonverbal they're no longer able to verbalize on game A. Not be able to express to you the fact that they're in pain and the number of times I've been asked to see a patient for their agitation. And actually, maybe by communicating with them and asking them to nodules shake their head different pain rather than expected them to be able to use words Eventually, I've managed to figure out what they really need is analgesia. And get in there. Paying controls is the thing that makes there agitation just just melts away. So think about all of those things. I'm just checking, Okay? There is a question, but I'm actually going to just close the questions again and carry on. Hold on. All right. I'm only going, We're doing okay. And we want to get one question, so I think we could Okay. All right. So, having thought about reversible causes, these are the two most common neurological symptoms at the end of life. So anxiety, agitation. The mainstay of treatment for these symptoms is benzodiazepine on. If a patient is frightened, fearful, anxious, distressed, a low dose off any off, these drugs can be enormously beneficial. Diazepam is the longest acting off these three s, so you need to just be careful about it accumulating. But if someone has a chronic anxiety, it could be very, very helpful. I tend to use the lorazepam instead because it's first of all, was shorter acting on D. Also, um, you can get it in a sub lingual form so it could just sit under the tongue and dissolve under the tongue, whereas diazepam is is tablet form, so a lot of our patients can't easily swallow on then midazolam. You can give intravenously, but we tend to give our injectable meds subcutaneously imperative carrots kind or it's nicer. It's just a tiny butterfly under the skin, and you keep reusing it on a lot of those drugs in incredibly beneficial, even at very low doses. Um, DeLaria. And sometimes it is hard to figure out if a patient is agitated, anxious or delirious, or both. Um, we would treat slightly differently, since it'll area, is it a huge confusional state that the fact of the confusion often triggers agitation on top of the delirium. But technically, delirium is. It is an acute confusion ulcerate, and there's a very big underlying differential diagnosis for the causes off delirium, which I've have summarized they're a huge range of drugs can cause delirium. Pain can cause delirium infection every everyone I'm sure knows about the metabolic causes things that hide the Cassini a cause, acute confusion, delirium, ondas a whole raft of other things, and you want to think about what of? Those could be reversible on investigators and see if there's anything you can reverse to to help patients symptoms. For many patients, particularly if you're elderly or frail, just the act of coming into the hospital and being in a very alien distressing environments contributor on a on A Q delirium in patients on gets very hard to to fix, because hospitals and noisy they mean C has disrupted that unfeminine er on. A lot of that is just a kind of horribly toxic environment in which a very, very vulnerable patient finds themselves for delirium. You'll tend to use antipsychotic medications rather than the ancillary takes. The benzodiazepine is, and haloperidol is a is a fantastically effective drug. For many patients with delirium, there is a whole issue around Oh, medicalizing Andi over. I'm a prescription of these drugs in delirium on blots of doctors will argue you should avoid drugs like haloperidol and mad as Lamictal costs in hospital patients because they can make the problem. Worse, they have a whole set of side effects. I must admit, in palliative care, we tend to be sightly more liberal. Um, particularly of our patients have a very short prognosis because somebody may go from having the unbelievably distressing hallucinations, for instance, is part of their delirium. They may have a full paranoid or ms almost psychotic state and giving Had a parrot all can just the wonders in in helping that melt away and help in that patient have a a calm, relaxed and dignified and life experience. So So? So I think parents of care is a very pragmatic um um, specialty. We have to be pragmatic because time is short and we're just we have to work with what's best for the patient. Um, I think that I'm gonna pause there, not having covered the whole panoply of symptoms. And we'll take some questions. And if there is time, we can carry on with the eye symptoms or we can pick up with those next week. So thank you very much. Great. Thank you were very informative. Lecture on a lot to think about, so thank you. We did have a couple of questions the first one was Suppose you get an hourly patient who's skinny looks weak, not drinking, eating properly on suddenly presents with and high acute tachycardia. Would you say out of the patients can potentially die from an acute attack due to weakness, I'd say, Well, it's that question when I could work out how to stop screen sharing. So I know I want to see you guys let me do that. I could give you just Can you turbuhaler? Yes. Okay. Great. Well, I just stopped you to do something. Um, I'll stop. I said yes. Hold on a sec. Yes. Okay. Brilliant on. Yeah. So I've got this question up here is Well, so Okay, so it's it's it's a good question. So So So this is a scenario that you will very commonly encounter in hospital. Imagine you have a patient who is elderly, frail week. They have stopped eating and drinking, and they suddenly present with, um, que tachycardia. Could could put that patient die from a from weakness. And I I think the person asking the question It is Belisa, isn't it? I think you're asking camp a shins be so frail. Simply the act of stopping eating and drinking, becoming dehydrated. Could that be enough to end their life? But I think that's the question on. But I suppose the answer is any patient, no matter how Rebus to if they stop drinking in particular for long enough, will die from that. It doesn't take very long for dehydration to become a a terminal state. So so your eyes someone who's healthy if we don't have any fluids for three days were at high risk of dying from that. Now, interestingly, elderly patients often end up in some ways, I think, better able to tolerate severe dehydration than perhaps someone who is young and healthy because they tend to run it a chronically dehydrated state. So it's incredible how little fluid a frail, elderly person comes subsist on some two cups of tea a day. And you know, tea is a diuretic, so they're technically likely to be excreting more fluid than they're actually bringing in. And I've certainly seen patients who have been entirely nil by mouth. For instance. They've had an esophageal Jima's. They cannot seem anything or really, they've made the decision not to have any fluids of any kind. No IV fluids sub cut LeWitt's and they have carried on living for sometimes weeks rather than days, confounding all our expectations about how long someone's able to live without fluids. But in general, yes, quickly, a frailty person can become life threatening. Lee unwell through dehydration. On they will run a tachycardia, they'll become hypotensive, and that absolutely can result in a cardiac arrest. And that's no necessarily something you would want to try and avoid eso. So in this country, in our care, home nursing home cohort of patients in particular, we will often have patients where a treatment escalation plan has been written. Part of that plan is is not to give this patient any life prolonging treatments, including IV fluids on if they do stop. If they do stop eating and drinking, that will end up claiming their life on. But it's it's their natural dying process, and we wouldn't intervene on that. So it really depends on um, either The patient's wishes are what the patients, which is were when they were able to express a ring. I'm so sorry. My phone just started talking to me. Um, yeah. So, um, that can happen. It depends Ideally, as a doctor, you want to be trying to encourage patients and their families to think in advance about what the patient's wishes would be if they deteriorated so that you can make a plan in advance for how to handle that situation. The worst thing is, for this to happen all of a sudden, and it be an emergency situation unknown in the family knows what the patient would have wanted so that the key message is advanced care planning half these chaps in advance. But ah, hope that out of the question. Yes, thank you. Okay. Sure. Should we carry on whizzing through these? Yes, sure. Metformin on a sec. Ah, unless you want me to read them out. No problem. That's okay. So So we've got a few now, So you are. I'll just read about. So? So the next question is from Jessica. Should we avoid medications that disturb the G I track? So the floor other microbiome in the G I trapped in elderly patients, but because they're weak are, um and to some extent, I would say the answer to that is yes. Onto given example of why this is important. I imagine this happens in Ukraine. Justice. This happens in the UK, depressing the often so every every year we will end up with an outbreak off C D. F C difficile in our patients in hospital, because lots of the patients are on IV broad spectrum antibiotics that severely disrupts the gut flora on the US expose our patients to infection with C diff on, of course, in an elderly, frail patient that could be fatal on do every year we have patients who will die from C diff infection that they would not have caught if they haven't have ended up in hospital having these boards spectrum antibiotics. So it undoubtedly is a problem on. But I think the way to think about this problem is exactly the same as I would encourage you to think about any other particular medical scenario with this patient. This particular patient in front of me, based on their wishes on their particular hopes, desires aspirations for the future. What are the pros and cons off treatment? X Now, ideally, you'll have that conversation with the patient if you can't have it with the family. But dont necessarily be that doctor who kind of rushes into giving a very, very strong, broad spectrum antibiotic because we always need to think about the risks, and it just may not be what the patient wants on. But you can't go wrong if that's your approach with every treatment. I okay, how do we manage these medications if they have to take them? Okay, so sorry, that's part two of Jessica's question. Um, I think I'm won't answer that now, just because, um, it's it's a very long answer because it depends on the particular kinds off, all the different possible medications got. Perhaps you could email and say, if for any of these things you want to pick up because we can cooperate them in future teaching sessions, I hope that's okay. Pool has asked how early in the chronic disease process should you involve part of care? So I love this question on, but the answer is as early as you possibly can please. Now, palliative care is one of those works that puts the fear of God into patients, lots of people where the patients or family members know a bit about palliative care, and they know that it is the death bit off medicine palaces, care doctors of the death doctors. They think that we only get involved when someone is dying, and so they're very, very frightened off the P word because they think it's some on, um, a slip back and dying. So when I say pull in, answer to your question as early as possible, I don't mean that globally. If you are sitting in a room with a patient, for instance, and you're telling them that they have a diagnosis off cancer, and it's it's cancer that has spread. So it's incurable cancer. It is cancer that is going to play in their life. You could argue that that is the worst possible time to mention palliative care, because already that patient is having to cope with a devastating diagnosis. Won't make it worse if we involve palliative care. And this is how I would answer that question. Palliative care doctors, nurses on teams are not just the death people, so we are very involved in the end of life care, the care of people who are dying. But we're also very involved in patients who have difficult, complex symptoms off any kind to manage, irrespective of where they're not. They're dying. So I will often be asked to review patients in the hospital who, for example, may have liver disease on do. They may have a liver condition that is likely to kill them in 2345 years time, but they're not dying at the moment. But they have got really difficult symptoms to manage on. The team needs help. So I try to be very honest and open about that with patients and say, When I introduced myself, Um, I just would like to explain what we do. People often think the palaces carotene work only with patients who are dying. That's absolutely not true. One of our most important jobs is to work with patients. You have symptoms that are difficult to control. We've got lots of expertise and helping patients pain, breathlessness, things that other teams aren't sure about. That's why I'm here. I'm here toe help you with any of these difficult symptoms you may have so that you could be getting on with living your life as fully on, but um richly as you possibly can, so that's a positive on. It's a really important role of palliative care teams and we will often try and introduce ourselves to patients in a way that stress is okay, you've got a terminal diagnosis. But that's not why I'm here. And my job is to help you live. However much time remains of your life as fully as you possibly can, and on terms that matter to you on different political and that sense, patients confined that really comforting because that's about living. It's not about dying. Um, how do you count sort of power to care a question from Lisa. I think. I imagine you're getting out. How do you broach the idea with a patient that parts of care maybe suitable on board? I think I've just alluded Teo, the answer to that question. What I just said, does it. There's a difficulty with palliative care if a patient believes it's only about the dying process, because they may feel a so there is still a space between where they are at currently on that frightening dying process to come. Um, and the last thing they want is a doctor kind of collapsing that space and suggesting that they're closer to dying. Then they want to be s. So I would suggest introducing the idea of palliative care by saying, by framing it in terms of symptoms and figuring out how best we can help a patient get back to doing what they want to do. Most of all on. That's to get the experts in at dealing with symptoms. So if someone is desperately short of breath, maybe they can transfer from their beds to their wheelchair, and that means they can't get out of the house, maybe of palliative care. Get involved. We can help the fats and therefore get the mobilize and get them out again. So it's a frame it in that sense on Do also, it could be really helpful to you talk to the experts about your worries around after dying, because we are the team that very often can. Elaine. Lots of those worries. We can help them. We can make them go away. Eso you confirm it in that sense to, um, okay, shall I carry on? I'm conscious of the fact that it's three o'clock Asti. I remember ways through your clock. We don't have another session, so if you're happy to continue and you got the time, we'll be, yeah, no problem. I won't be offended if you'll go. That's what I could see. A few of you over there I could see the numbers are falling asleep. Talk. Okay, Uh, we will wait three quickly. So his saying has said you mentioned not prescribing an anti muscarinic for secretions if it's not bothering the patient. But what of? It's really disturbing family members or a care plan put in place prior to the situation. Very, very good question. Um, those loud secretions do often bother families on D. If you imagine for a moment what it's like from the families point of you sitting in a little room with the person you laugh, watching them die on. Hearing that noise can be incredibly painful for a family. Occasionally we will give the anti muscarinic the drugs, like higher seen because the degree of family distress is so great and will be quite pragmatic. Perhaps the patient is unconscious, so we know it's not actually going to do any harm for the patients. But it may really help the family. Actually, often, though, if you just have the conversation I mentioned, where you explain what's causing the secretions, and that it's just a little bit of saliva sitting there on the air, going backwards and forwards. Once families understands that simple physiology, it completely changes their view of discretions. And they don't find them distressing in the same way, particularly if you can explain why you know it's not bothering their loved one. Um, so you may prescribe the antimuscarinic six, but I think a conversation first can often be really helpful. And then this point about Well, what if a care plan was put in place prior to to this situation we're in right now? The answer. There is a general on sir. Care plans are never, ever something that starts set in stone, even a DNA CPR form that's not set in stone. They are changed. Some signs someone will be not pheresis, and that decision may change and they may become very source and vice versa. Um, so any cat, even if it's there in the nose, it always needs to be reassessed, reappraised in the lights of conditions that have changed. So it doesn't matter that there's a plan there. You may change it at any point because that's clinically indicated on you. Always in that flexibility okay from a Jessica, um about Pallister treatment. Vitamins being increased. Imperative care? No, um, in palliative care. Tablet burden is often a really problem for patients as you become so so. If you have a metastatic cancer, for instance, you tends. Typically, the trajectory is you're gradually become weaker and weaker, weaker, and then they'll become a point where that process sort of speeds up, escalates and suddenly starts to write more quickly. And you're very old, old or frail or overwhelmed with the disease. I can't, sir. You often start wanting to eat and drink at all. The first thing that goes is your appetite at people struggle with taking anything, let alone tablets on. But they also if they're very frail, physically on a longer able to swallow. So we will always try and D prescribes much as possible. We'll try, um, cross off the drug chart any drug that isn't actively helping the patient now. So, for example, statins on anti hypertensive medications cross them off. There's no point in a patient who's in their last weeks of life taking a statin. It's not going to affect their lives, so we'll do the opposite. We'll get rid of everything apart from the drugs that we know are definitely helping the patients on about includes vitamins. Um, a question. Important question from Sabina about end stage renal patients Are the medications for neuron? Wasn't um still considered? So would you still give antipsychotic drugs like haloperidol or anti must anti a benzodiazepine like lorazepam? In a patient who has severely impaired renal function? The answer is yes, but with caution. Those drugs are renally excreted, and you need to think very carefully about dose, and you may get much lower doses than usual and you'll try and give the most short acting drug you can because they're likely to accumulate and renal failure. So I wouldn't give diazepam, for instance, because it's long acting. I could feel much more confident about giving midazolam Azzam, uh, shorter acting drug. But you'll always give in Paris of care the drugs that are necessary to control the symptoms, that the only thing that matters is how the patient feels all right. Now, the question from her saying, What is the actual cause of death in Paris of patients? Is it the terminal condition or an acute cause? And how would a junior doctor. Document this and the death certificate. Very good question. So, um, it a profound sense. The cause of death for nearly a lot of patients on or maybe you dark it all patients is exactly the same. It is the the cessation off the heart beat. So until the 19 fifties, death waas defined as the heart stopping, beating the lungs, stopping respire in respiration. In the 19 fifties, the definition of death changed and became more complicated with the invention essentially of intensive care s O in the 19 fifties, intensive. This realized that you could use the ventilators that until then had only being used briefly to ventilate operative patients in a surgery. They realize they could use them longer term to keep a patient alive in intensive care until their respiratory system recovered sufficiently to to breathe independently, spontaneously on that change the definition of death. It complicated it because suddenly you have the concept of the brain dead patients whose heart was still beating lungs, still inflating, but their brain was dead. They were being artificially ventilated. Um, so, in a profound sense, everybody dies the same way. The final thing that happens is the heart stops beating on that. That is when the patient is dead on it doesn't matter what the illnesses Cancer, heart disease, liver disease. Still, the point of death in most patients is the heart stopping beating. That doesn't mean the underlying cause of death is anything other than, for example, the lung cancer. Um, you know to this question from his saying, I would say, Um very often we will only as a cause of death. Me will only puts the underlying condition on the death stiff. That's a four example. A patient has lung cancer. They become frail cachectic, and they end up stopping, eating and drinking and then dying. I would just put their lung cancer on the death certificate. What if the scenario is a little bit different and they come in to hospital with the lung cancer? But they pick up in acute infection and pneumonia on top off their lung? Cancel. Then I would probably put us the cause of death. So one a on the deaths difficult by would put pneumonia and is one B on the death certificate. I would put the long camp so whatever type of lung cancer it waas on. That is because the pneumonia has been caused by the lung cancer they are. They probably would not have caught the pneumonia if their lungs were not already severely impaired either. Pneumonia. You'll often right to death certificate where you have a one a and one be on be The underlying cause of death is the chronic condition with cancer, the heart disease on you might have an acute event is one A which could be a P and pneumonia. Often it might be covitz. So for the last two years, I've written a lot of death certificates where one a has been povid it and one B has bean, for example, a malignancy because we think the patient called Cove it when already perhaps in hospital, very, very unwell with their cancer. Um, this is quite tricky and probably needs more of a session. And if you did want to have a session about how to complete death, stiff curse on what counts is a cause of death will not, as a course of definitely we could actually do that. But that that's the essence. Um, listen, my home have pronounced that correctly, whereas you draw the line between empathy and sympathy in an elderly, dying patient that needs your care. Um, so, um, so empathy. Trying to understand what it may be like to be that patient in that condition and sympathy suffering with that patient feeling what the patient is feeling, This is a really interesting question. Arguably, if you are really sympathizing with the patient, If you're really feeling even a modicum of the distress that they're feeling, then you're probably finding it difficult to do your job because you are suffering, too. And if you're a doctor, he's suffering. That's likely to be impairing your judgment, your objectivity, whereas you can work very, very hard to empathize. And really imagine what it is like to be this patient in this condition without it necessarily affect you emotionally at that time. Um, I think that this is one of the hardest issues in medicine. The question of maintaining sufficient detachments to do your job to be a good, good practical doctor versus empathizing enough to be a caring doctor. A doctor who really, really tries to understand what it's like to patients on do is able to see things from their point of view. I think it's a challenge. It's a titrate that we'll walk. And it's not talked about anything like sufficiently. It's very, very hard to do on. But we can pick up on it. Perhaps at some stage, see that full? Uh Okay, Steve. Put full. All right, now. Syringe drivers, Opioid tasting death facing death. Just hold on a sec. I've got five minutes for I have to go and cut my Lord of School. However, um, massively important question syringe drivers and your taste and death. So I don't know what the debate is like in Ukraine, but in the UK, there is a massive debate at the moment about a sister dying and, ah, big, big move to change the laws so that her sister dying is legalized in Britain on lots of political doctors are strongly opposed to that. I I My position is a bit more nuanced, which I won't get into now, but thanks in all the question, hand lops off. People believe we should be able to hasten death in the UK on do it is an absolute scandal at the moment that we are not able to do that that legally no doctor is permitted to deliberately hasten a patient staff. Conversely, there are lots of lots of people, members of the public patients who fear the doctors do deliberately hasten patients tax. And they also fear that the syringe drive is the way in which we do that. Send. There is a lot off, um, misinformation and fear circulating among the general public about this really important issue. Um, the law is really clear. A doctor was not allowed to prescribe anything with the intention of hastening death. However, I mentioned earlier that in palliative care there are no upper limits toe any off the drug doses we can prescribe. So long as we are giving a drug with the intention off, hoping a symptom of helping address the patient's needs, they're suffering. We can give the dose of the drug that is required to do that. In most cases, the doses we give our not doses that would hasten the patient's death. Um, for example, in strong opioids, which obviously are drugs that can kill in excess patients who have very difficult pain. Where you've had to build up the dose is over a long period of time, they can be on crazy high doses of opioids, and they tolerate them beautifully on those doses. Doses that would kill someone who was a pure naive immediately they they could live with. Um, absolutely fine. Um, so there's no upper limit on doses. Sometimes we will be in a situation where the only way to control the patient's symptoms is to give doses that may hasten death. That's an uncommon sorry, but it does happen. And then in medical ethics, you invoke thecal insect off double effect. So double effect means that a doctor or somebody performs an action that has to effects the intended effect in this case, addressing pain versus the unintended effect in this case, potentially shortening life. And so long as you could be clear in your own mind and to your medical establishment that you are acting in order to help the patient address their symptoms, then you can go ahead and provide those drugs because you're not trying to hasten deck. You're trying to remove horrible, distressing symptoms even less commonly, and now I'm saying this is incredibly rare. There will be a scenario where a patient symptoms are so difficult to manage. They may be a particularly awful kind of pain or a particularly awful kind of spiritually distress that know amounts off drugs can fix thumb, and very occasionally we end up in a scenario where the patient is begging us to give them or give them. Or they would rather be unconscious than live like this. And then we can use a technique, which is called continuous terminal sedation on continuous terminal sedation is literally giving a patient such doses of sedatives that they are completely unconscious and, of course, of some list completely unconscious. Eventually they will die. They can no longer meat and drink. We only ever do that. When patients, we judge them to be very, very, very close to the end of life in their last days of life, for instance on, so we can be confident off know, knowing what is actually ended, not taking the life of patient. Is that the cancer? Is it the sedation? That's a highly unusual treatment part of care? I have been involved in it maybe once a year, twice a year, but it is a last resort for that tiny number of patients who have desperately distressing symptoms. There's no other way to Teo Managed. Um um, syringe drivers should never hasten death. They only might taste death. In this scenario, I've just described Button awful lot of patients and off lot of family members are very frightened. That will do use thumb to hasten death. And I always have a very honest and frank conversation with families and patients about that. And I will get the elephant out of the room and into the conversation, And I will say, Have you heard of a syringe driver? What have you heard about it? Some people are worried about syringe drivers. They think we might use thumb to do this. We absolutely don't. And I will just address it directly. Okay. Thank you. I know you have to go pick up your daughter, so I think we'll stop it there on. We've got a session with you anyway, next week. So any other questions people can ask next week? Thank you for the questions on the questions will. Really good. So maybe maybe in your feedback, if you can try and do the feedback. And if I haven't answered your question, put it in the feedback, because I think will I be sentenced that yes, you will be out. I'm making our make a note of the questions are aren't and you weren't able to answer. And then we can always ask me send it over because then we could make sure we address the next week. And I'm more than happy to do. Morcellation is on parents of care. If if you would like it to demand is that it's my own personal belief that all of this is not really palatis care. This is a cool part of ulna medicine. So I I am delighted to do more so I definitely think so much for your time today. Thank you. Bye bye by everyone Em We've shared the feet but form Please make a note of it on. Well, end the call in the next couple of minutes. This is the final session for today. So yes, we'll be back tomorrow. Thank you.