Computer generated transcript

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

Hi, everyone. Welcome to me all primary care. My name's Jing Jing. I'm part of the med A support team. Joining us today is Doctor Jane mcauley, a consultant in palliative medicine with S HSC T, who specializes in comprehensive palliative care with extensive experience in managing complex cases. She is dedicated to improving patient outcomes through evidence based practices and multidisciplinary collaboration. Doctor mcauley is a respected educator and advocate for palliative care advancements. And today, Doctor mcauley will be teaching us about end of life care. We have around 45 minutes for the presentation and there will be some time for questions. So do put your questions in the chat. As we go along at the end of the event, there will be a feedback form emailed to you and once completed your attendance certificate will be on your Meadow account. That's all from me. I'll let Doctor mcauley take it away. Good evening, as I say, my name is Doctor Jane mcauley and I'm just gonna try and get these slides up and we'll get started. So this evening, I'm just going to be discussing uh some issues around end of life care. So in particular, we want to look at the evidence based practice uh that I would use in my, in my work. And it would be the nice guidelines would be the main guideline even though it is getting quite old. Um, it's December 2015, it would be the out of this guideline that we would use in the UK. I'm sure in, in your own area of practice, you will have something relatively similar. Nice guidings that you're aware are evidence based guidelines. In this particular case, it's for adults. So patients over 18 years of age and it's in the last days of life, the last 2 to 3 days, it's very much written on for nonspecialists in primary care and in nursing homes and other clinical settings. But also as the baseline care for those specialist settings, uh specialist hospices or specialist palliative care units. So it was meant to be uh for the specialists as well. The aim of the document is to try and improve end of life care and focusing on that respectful communication involving patients and families in the care and all respectful decision making and maintaining dignity and comfort. So all very sensible things. There were six recommendations in the guideline. First one was that we should be really striving to recognize the last days of life. And for those of you with experienced this, it's not always as simple as it looks then really focusing on excellent communication, be that with the patients be that with the families and between ourselves as the multidisciplinary team with and also with other disciplines and then a focus on the shared decision making so that we were really involving the patient as a key partner in all of the decisions that were being made as they were able. And it was not trying to support them with the decision making is obviously key in those last days of life, focus on hydration. Uh And then the areas that I'm going to be focusing on in the rest of the presentation very much the pharmacological interventions and the anticipated prescribing. So it's not that I'm saying that the first four are less important, but just for the interest of time when we're really having the the 40 45 minutes, I wanted to focus on those on the two last recommendations that number five and six. And as you say was the first recommendation and that is something that can be difficult to actually predict when death will considering things like the likely disease trajectory. So if you know the histology, you know, the most recent scans, you know, where people are and their treatment choices, you begin to understand what the prognosis might be. There can be other biochemical markers such as albumin. Um Also looking to see how they've been responding to treatment. So if you are able to look at their records or discuss their care with uh their oncologist or with if it's a non malignant condition with the relevant uh consultant and get an idea of where they feel they are in the journey. So, seeking that expertise and then looking at that rate of change, something that we would always say to the patient or the family. Are you noticing a change month to month? Are you noticing a change, week to week or actually you seeing a change day to day and that sort of day to day change will certainly be more likely associated with getting into the last days of life. Quite often. If the patients are asking, we would always ask, well, why are they asking? What do they feel themselves? It's quite often their own perception of how things are can actually be a key part of this conversation and they can quite often be right? And they talk about the surprise question uh that was used in the Gold Standards framework uh that the mcmillan organization had used in the UK. And that surprise question was, would you be surprised if this person died uh in the next uh with the gold standards? It was within the next six months. But uh in this situation, you could extrapolate that to be, would you as a team be surprised if that person, this patient died in the next few weeks or in the next few days? And it is, it is an issue trying to identify those last few days, key things that we would look and again, these things need to be taken in context. So you can find patients that can be not eating or drinking much and find it weak. But they may not actually be in that last stage of their illness. There could be something else going on like a sepsis or uh something else that, that is reversible. But if we are feeling that somebody is uh in the context, in their last potentially in the last days of life, clues that might help support that is if they're really, really weak, really tired, just can't lift their head off the pillow, they don't even have the energy to maintain a conversation with their loved ones. Aren't even able to suck a straw even uh uh to get the food and fluids in that difficulty in swallowing the medication, reviewing the card and realizing they weren't able to take their medication last night, not able to take their medication this morning. And that drowsiness, uh even with an element of delirium are all things that, that can be associated with the last days of life. So, moving on to the second recommendation, which is not good communication and that has propped up in all of the studies, looking at what makes a good death, what can we do to do the best end of life care communication was always one of the key components of that. And it is not having a true patient centered approach. So it's not a one size fits all. It's actually for this patient, what do they need to know? What do they want to know? What are their concerns? What are the family's concerns? What choices and priorities are, what are their choices? What are their priorities because we can make assumptions, but actually having those conversations and having them early when the patient is as fit for them. So, ideally, you're having these conversations in the last weeks rather than the last hours to, to, to days of life when the patient is able to engage with them, and while they still have um some choices, because there's time for planning, uh there's time for getting things in place, having that confidence to have an open and honest discussion. Sometimes that can be about the uncertainties that are there. Um But having that hearing that the person's asking and responding in an open and honest way, picking up any cues, but managing conversations in a very sensitive way, avoiding any euphemisms jargon. So it not, you know, if it's a cancer talking about the cancer, not talking about shadows or warts or all the things that, that we've heard over the years used that sometimes if it doesn't mean the same to the patient, they may not realize. Um And then it means they can't, if they're not hearing, understanding where they are, they can't be truly involved in the key conversations about what they're actually wanting and what the priorities are one of the quotes I like to use when I'm teaching with the junior staff is that when they have quite often lacking in the confidence in these conversations, they can be all of their minds, energy can be spending uh thinking, what am I gonna say? What am I going to say? And they're not actually using any energy to listen and listening is not the same thing as waiting for an opportunity to speak. So actually hearing what the person is saying, picking up any of the cues and then actually genuinely having that connection to answer the what's being as. So as you can see, there's really an individualized care plan that you're wanting and that's what the nice guidance was very much about. Not about a pathway, not about a standardized documentation or, or plan, but an individualized one. So looking at the nutrition and hydration needs, thinking about the regular medications and how those are going to be altered when the patient is not able to swallow and thinking about prescribing for those symptoms that commonly occur at the end of life, thinking of the holistic needs of the patient. So yes, it's not all about just physical pain or sickness, thinking about the psychological, the social and spiritual. And for those of you that have had some experience with palliative care, you'll realize that those remember those are core domains of, of the care when someone's in the last phase of their life key discussions also obviously need to be part of that plan and resuscitation is one of the core decisions that needs to be made that will remain the responsibility in the UK for the most senior doctor looking after the patient. But that they can only make that decision after a conversation with the patient and with the family. So it's, it's making the patient and the family aren't making the decision, but they're being brought along with the decision making process. But the legal responsibility will remain with the senior clinician thinking about the things like prefer a place of care, prefer a place of death that these conversations are difficult, but it's important to have them so that we can really truly meet the, the needs and, and priorities of the patient and then reviewing, it's never a one size fits all in, in even with an individualized care plan, the patient has always the opportunity to change their mind. And you say actually, I was thinking about home, but I'm now worried about how we would cope or I said I would stay here. But actually now I want to go home so they can always change and we need to adapt our plan with that. So as I said, I was going to really want to focus uh majority of the time on the actual uh medication side of things, thinking about the pharmacological prescribing and the P RN prescribing. And I want you to look at three typical clinical scenarios that I would face on a day to day basis. The first scenario is the straight swab where the patient is on oral medication quite well, symptom controlled. And now just due to the fact that they're deteriorating and things are changing, they're not able to swallow their medication. So who's thankfully a less common situation where you have a distress dying patient with uncontrolled symptoms being that pain, that nausea and vomiting, shortness of breath and secretions. So we're having to make changes to the medication to try and get on top of uncontrolled symptoms. And the third scenario is that uh common enough a referral to our service in the hospital where I would work where if somebody is usually quite elderly, quite frail hasn't been on a lot of medication up to this point for any symptoms does not come in. Uh and is not for comfort care, end of life care, usually on the basis of maybe a chest infection or a fracture and hasn't responded to standard care after that has been given for a number of days. And now it's recognized that they're in the last days of life and they want a little bit of something in the sur driver to make sure that they're comfortable. So, test one, as they saying was a stress swab. As a 78 year old gentleman with advanced lung cancer, he had brain metastases and a history of seizure secondary to that he was no longer able to take his own medication and he was actively dying. So the team were very clear that this gentleman was in his last days of life and there was no reversibility. Um Everything had been tried, he appeared comfortable uh but his mouth was dry and his eyes were slightly open. So he was sleeping most of the time, the eyes were just slightly open. So what do we need to be thinking to prescribe, to ensure that this gentleman has a comfortable and dignified death when we're thinking about uh medication, most of our patients, if they've had elements of pain before will be on regular long acting uh opioids, majority will be on, on oral opioids. The commonest in our practice would still be first line would be uh sustained release. Morphine. MST would be the, the brand that we would have. And if we're changing, if some one of our patients majority of which would be on a dose of MST for any pain that they have, you're taking that total daily dose of the MST and you're dividing that by two to go to the parenteral. So say, for example, MST 60 mg BDA 120 mgs in the 24 hours, dividing that by two, you're going to have a syringe driver pump, uh morphine sulfate 60 mgs over the 24 hours long tre is probably the second commonest opioid that we would see in my practice and again, the total daily dose orally divided by two would give you the uh parenteral dose that would go on Strange Driver. So again, something like long tec 20 mgs BD oxyCODONE. That's the long tag is the, the name that we would have for the sustained release oxyCODONE dividing that by two, you would get oxyCODONE in the syringe driver pump, uh 20 mgs over the 24 hours. And always it's really key. If someone's not been able to swallow their oral medication and we needing to move to a syringe driver pump, you need to remember to change the P RM opioid to a subcut one because they're not going to be able to swallow their breakthrough. So we need to make sure they have a subcutaneous version, other important regular medication at this stage. When you're looking at the cardi uh few sort of key points that I always like to remind uh for when I'm teaching, if we're thinking of moving uh oral medication into the syringe driver, if they're on oxyCODONE or alfentanyl for a any reason in the syringe driver, I wouldn't put cyclizine in as the antiemetic because at higher doses, it will crystallize. Now you might get away with it at lower doses, but certainly at higher doses, it can crystallize. And I would have concerns for your antiemetics, your syringe driver doses are by and large the same as the oral doses. So if you're aware of the, the regular oral dose that frequently will be your syringe driver dose. And le with promazine would be one of the antiemetics we would use probably most commonly in the end of life setting. Obviously, earlier in the disease, we might use something like metoclopramide or cyclo. But in this setting because it has slightly sedating purpose and these patients might well be a little bit agitated a little bit 24 hours or 10 mg would be typically what we would use again if anxiolytics are needed medication like Midazolam can be used in the syringe driver, particularly pertinent for this uh patient. I would have said maybe 1015 years ago, we just weren't able to put, we didn't have the knowledge but these uh antiepileptics in syringe drivers. But now we are aware that we can use things like levetiracetam or so they inva in syringe drivers in normal saline always going by themselves. So the levetiracetam or sort of inva uh it needs to be in its own driver, not mixed with other medications, but these are much more useful um anti epileptics to be able to use in this end of life setting than previously, sort of 10 years ago. We might have been just using a high dose of Midazolam, which was obviously less, less satisfactory. Also, if a patient is on steroids, you want to pick that up early if they're not able to take it orally and consider how necessary it is. Are they at risk of adrenal crisis. So we're continuing it for that reason or actually, was it controlling a very important symptom? Maybe a patient like this might have had raised intracranial pressure, headache and sickness. And if we abruptly stop the steroids, they may get those symptoms back again. So in the scenario where the dexamethasone was controlling a significant symptom, we would be looking at a way looking for a way of getting that medication continued either as a subcut injection, if we can get it under two mil, two mils, which would be the maximum we would volume, we would usually do in a subcut injection or if it's a very high dose, we might put that in a syringe driver as well, thinking about P RN medications that we would give subcutaneously. And this is really important because patients at the end of life can have pain, they can have nausea, they can have restlessness, agitation secondary to delirium. They can be short of breath or they can have those upper airway secretions that frequently happen at the end of life. So it's very key. And part of the nice guidelines was to make sure that we were prescribing uh medication for symptoms that might occur. So, as you would expect with P RN subcutaneous uh medications, if the patient didn't develop the symptom, they never received these medications. But it means that if they do develop the symptom, they can be administered in a very timely way. Uh And the patient's Smptom can be controlled much more quickly than if we're then trying to get a doctor in the middle of the night, uh to prescribe things. Um So it's much better to have this done early at the time that we're identifying the person as end of life. It's the common symptoms that uh we would recommend prescribing for would be pain. And again, if the person's on a strong opioid in a syringe driver, we would be going with usually about 1/6 of the 24 hour dose written up four hourly P RM, subcutaneously, the majority of cases that should be the same analgesic as is in the syringe driver. The main exception for that would be if we've had to use a fentaNYL in the syringe driver, which usually we're only usually when we're using that if someone has had a significant grave renal impairment and EGFR under 20 under 15. Uh In that scenario, we might have a fentaNYL, but that's a very short acting opioid. Uh So it wouldn't be useful as APR N uh subcutaneously for pain. So, in that scenario, we would use oxyCODONE uh as the slightly better uh strong opioid. In, in this scenario, again, if we're very concerned about renal function, in that scenario, we might increase the range that it's allowed to be given relatively 4 to 6 hours. Um If we have concerns another symptom that we need to make sure is covered with period medication would be nausea. And as I've mentioned already, even pros is a common one we would use in this scenario. It's broad spectrum. So it covers the sort of multifactorial uh nausea that commonly occurs at this stage. And it also has that element of angiolytic sedation effect as well. Delirium is probably one of the commonest um symptoms that can occur at this stage. A lot of symptoms are systems are failing somebody's very hypoxic. There may be a degree of renal failure, liver failure, maybe a even degree of dehydration at this stage. They're not. Well, and the delirium would be quite a, a common thing. A lot of most of our patients are terrified of pain, uncontrolled pain. That's not the commonest symptom at this stage of someone's life. It usually is that delirium, uh that is difficult to control and using something like either midazolam 2 to 5 mgs, four hour P RN or even the promazine 5 to 10 mgs four hourly. And then if those medications are being needed and are working, you can add those to the syringe driver for, for regular uh use as well. Dyspnea, someone's maybe uh lung primary uh cancer or has secondaries in the lung or something like even lymphangitis, carcinomatosis conditions like that may well be dyne at the end of life. And medications such as low dose opioids or midazolam at low doses can be used to uh to try and alleviate those symptoms. Final symptom we're talking about from P RN. Use would be uh the upper airway secretions that moistness. If you remember the erum is lined with uh goblet cells producing a lot of mucus, we clear our throat all the time. This patient is too frail to clear their throat. Uh So this moistness can gather at the back and as they breathe, you hear that sort of oscillating sound uh of the upper air secretions. So, Glycopro or hyzine hydrobromide or hyzine, butylbromide or all medications that can be prescribed P RN at this stage to try and control the symptoms. None of those agents will reduce the noise. If it's coming from a genuine chest infection, they won't do anything for the green Praulent sputum, but they do help with drying up the mucus that the goblet cells would produce with in the mucous membrane. So getting back to the se the first case, this patient was on MST. So, uh long acting slow release, morphine, they were using morphine, sulfate oral solution for breakthrough. They were on cyclizine regularly for sickness, dexamethasone, uh had been on a higher dose, but now had been reduced down to 4 mg to control headache and sickness relating to the brain metastases. And they were on levetiracetam for seizures. So, what are we going to do to make sure that these medications that he wasn't able to swallow that day are if are continued? So we continue to keep him comfortable. So a syringe driver with morphine sulfate is on 60 mg orally dividing that by two to give you 30 we can add cyclizine 100 and 50 mg because it's cyclen in the driver. It's probably one of the few drivers that I would use in water for injection. The majority of syringe drivers I would use the dilutant. Uh not percent, not uh your normal saline, not 0.9% sodium chloride. But in this situation that you, it was called cyclizine is in the driver. We need to use water for injection. Otherwise it would crystallize a second driver with Levetiracetam or Keppra and that's 1 to 1 so that he's on uh 1000 mg over 24 hours orally. And that's the dose we put in the syringe driver in normal saline. You're limited with how much of the Levostin you can put in a syringe driver just by volume to 2000 mg. Uh If in that situation, you're needing more and it's the best drug to use, you can, you would, you would have to use a, a third, a third syringe driver. The dexamethasone was quite easily changed over to a subcut injection. Uh The subcu injection equivalent is 3.3 mg. Uh It depends uh it varies uh on which preparation. So just know which preparation you have uh in your, in your workplace. And if you remember he had quite a dry mouth and eyes were slightly open. So it's this time, it's really important to consider protecting and, and uh looking after dry mouth and dry eyes. So biotene gel and Hyla Fort drops just to make sure that all of the comfort is thought about. And then as you remember, we talked about having the P RN medication there. So if breakthrough pain, breakthrough, sickness, agitation happen, the nurses have something that they can administer in a timely way without having to wait for, for um really quite hard pressed medical staff. So if you, if you look, you see you've got 30 mgs in Syringe driver, dividing that by six, give you five mgs for your four hour P RN dose. So only given if required Levo promazine, five mg is the antiemetic again, only if required. And the Dazla two mgs uh in case there's any agitation four hourly if required. And the Glycopro 200 mcg again, only if required II move on to the second case and we can take any questions uh at the end if that's OK. Second case is the more difficult one. It's the one that I'm getting would be more involved in the p the specialist palliative care role where the patient is still has uncontrolled symptoms despite all the best efforts uh with from the general staff. So this was a 66 year old lady with advanced breast cancer. She had lung liver and bone metastases. She was now actively dying. The family were fully aware and were present. Uh, they were staying with her around the clock. She was, um, uh, a Syringe driver and had the P RN medications prescribed. So she hadn't been able to swallow oral medication. We had moved everything over to the Syringe driver. She was at home at this time but very distressed, very agitated. She'd had a lot of, uh, of the P RN medication that been prescribed the out of hours services, the district nurse team, they had been out a lot to the house to try and give all these medications, settle things down, but things were not well controlled. So what do we need to prescribe to ensure that this lady has a comfortable and dignified death? The majority of these patients, you were looking to see what is that? Are they initially symptomatic, uh because they haven't had their medication transferred to the strange driver. If there's been a delay in the syringe driver starting, that wasn't the case in this first, in this, in this current uh history. But that's something that can be the case where people like the staff haven't picked up that they haven't swallowed their medication and there's maybe a day has gone by and they're actually just missing the routine medication. So checking that out and making sure that they get what they were needed uh regularly, then making sure that the subcut hearings are prescribed and available so that you can cover any uncontrolled symptoms and then the meat of this case, which is really, then titr the medication, the analgesia in particular as needed. And generally, what we would say is you're needing to assess the patient as an individual. So you're trying to get an idea of the medications working. Um, is it, is, you know, when you give the medication, do they actually settle, do they seem comfortable or is there an element of toxicity? Is they, are they getting toxic? Uh too much medication? Kidney function not good. And they're actually becoming more agitated and more distressed because of the medication or are they uh not responding to medication because it's not actually working? It's something else that is going on. Maybe they fractured something, maybe they're in urinary retention, maybe they're very, very constipated and fecally impacted. So it's always having that element of, of inquiry, you know, what is going on, what is working, what's not working, what can I do to improve this? It's not always about increasing the medication, but quite often it is usually when I'm teaching the, the junior staff, I would say if you're feeling that the medication is helping, but we're just too low. I would usually go up each day by a third. You can be guided by the P RN use. And if you feel you need to uh particularly after discussion with maybe specialist teams, you might go higher than that, be aware of the state of renal and liver function could be worsening in the background. And that's something that you might need to take into account, particularly as evidence of toxicity, myoclonic jerks, hallucinations. You might need to be thinking about changing the medication to one that maybe is better suited to the clinical picture. The pr medication should always be prescribe someone. The patient should always have something to take while we're trying to working to get uh the background continuous medication, right. And as you can see, it's exactly the same as in the first case, your breakthrough pain analgesia should be 16 to 24 hour dose, something like leamp promazine should be prescribed for nausea. Midazolam again, very similar doses, 2 to 5 promazine, 5 to 10 for agitation, low dose, midazolam and opioids for dyspnea and your secretions, the Glycopro. So coming back to the second case at that stage, she was on morphine sulfate 30 mg and midazolam five in the, the first syringe driver. All in normal saline. She had been on parox uh with benefit. That was a cox two and hit her, a nonsteroidal and non uh antiinflammatory drug for bone pain. Uh and that was also a normal saline. She was written up for the P RP medication, morphine sulfate Levo Midazolam and Glycopro and she was on biotene gel and she was also on home oxygen. So we increased the syringe driver by a third. So a third of 30 would be 10. So we went up from 30 to 40 the Midazolam, we went up from 5 to 10 and we added a small amount of le bromazine to see if we could get on control of the agitation and the, the anxiety, the pain medication also was increased. It's always important to titrate it up as well. So if you a six of 40 you're getting closer to 67. So that was increased to 7 mg. four hour, the lamp promazine dose was increased giving a range of 5 to 10 mg. So if she was very agitated, she could get an extra dose. And the midazolam was kept pretty much at the same, the same level also checked with the last bloods. The last bloods have been done relatively recently and there had been no sign of uh renal failure or liver failure. And it was felt at this time that she was, there was no evidence of toxicity. Respiratory rate was good. There was no myotonic jerking and she didn't seem to have hallucinations. She wasn't reaching out or plucking something that you sometimes see with toxicity at this time of of of the illness, she was reviewed the next day. Uh And the review is always crucial to that. If someone's very uh symptoms are not controlled, we need to find a way of making sure that, that, that we titrate and review and uh and increase things as as needed. She was felt to be more settled. But it was felt it was more bony aches and actually still some anxiety. So at that stage, we put the parocoxib up to 60 mg, starting dose is usually 40 goes up to 60 then 80 would be the maximum that I would usually use felt that we would, would leave the morphine sulfate at the 40 mg. But the midazolam went up from 10 to 15 and the leroma went up as well to try just to control that anxiety to make them as mentally comfortable as possible. There was a planned review for the next day, but she actually died very comfortably overnight. So I'll move on to the third case and then we'll have time hopefully for questions. The third case is one that I would say probably because I'm in hospital practice uh relatively frequently and it's just a wee bit of something to ensure the person's comfortable tends to be some uh more typically non malignant cases with very elderly patients that are extremely frail with a lot of multiple comorbidities. And you're having to take all of that into account when you're prescribing to make sure you're prescribing safely. But that you've also got a very large focus on making sure that person's comfortable. Uh It tends to be when they've come into the hospital setting and they've had all of the acute care that is appropriate and they haven't responded. So, acute measures have been tried, they've tried to reverse things and after a period of days, it's felt that actually the body is so frail that it's just not responding to the, to standard care and that they're felt to be in their last days of life. And it's having that discussion with family and the rest of the MDT and making sure that everyone is obviously in agreement with that. This would be a typical case for case three, a 96 year old gentleman admitted with a history of dementia, history of a stroke and he was in C QD stage three, history of COPD and he was in a nursing home care home and he had been admitted with aspiration pneumonia. He had had antibiotics for several days and the team looking after him and the family really felt that he wasn't responding, the antibiotics hadn't changed anything. He was deteriorating day on day and IV access was becoming more and more difficult. He was very bruised and just very restless. They feeling that comfort care was the really should be the goal of care. So what do I need to prescribe to ensure this gentleman has a comfortable and dignified death? So I was saying that the majority of these patients were asked to see them non malignant elderly frail. Usually, the key thing is that we usually previously haven't had very severe symptoms. So they're usually not on a lot of medications. They're naive, usually for um opioids and um, sometimes they'll have a little bit of benzodiazepines and maybe some, uh, medication to control agitation, maybe some phenothiazines or something like that. But again, you're, you're wanting to look at the cardi and make sure that we're, um, making sure that they have all the medications that they, they do require that we should be continuing, I suppose in this situation I'm thinking about somebody maybe who's, maybe, has been Parkinsonian and is suddenly not able to take their ma apart and you're needing to think about medications to, uh, for that, uh, either as, uh, or a patch that, that replaces that or something like that. But in general, um, you're not looking at a lot of high dose medications. So in general, what we may even just do is make sure they're written up for the P RN medications. So small doses of, for pain, for nausea, agitation, dyspnea, secretions, uh, the standard, the standard medications. Again, you're usually using even lower doses than we might be described because you're looking at somebody who's very elderly, very frail, a lot of comorbidities, kidney function may be not the best, maybe very light of themselves. So not a lot of body weight. So you're going to go very light. If you feel that they do need a syringe driver that they're needing something back around, you're usually going with something very, very low. So something like morphine sulfate, five mg midas five M GS all over 24 hours. So you imagine that's over 24 hours. The r dose that they're getting is, is really, really quite tiny. If there's a degree of kidney impairment, you might go with something like oxyCODONE, 5 mg and midazolam 5 mg over the 24 hours. And you may add an anti secretory agent. Um if needed if that's something that if, if you're listening to this and you can hear that, that bubbs, that chestiness. So this case, the patient was on carbocysteine simvastatin, aspirin, digoxin, memantine, these were still all written up um but they have not been able to take them for about three days. Obviously, the carbocysteine wasn't something we could replace the simvastatin. The cholesterol is not relevant at this stage. Aspirin. Again, one that they're not able to take and not replace digoxin. Again, you can't easily replace it. Um but you might want to keep an index of suspicion. If there's any of the symptoms are coming from a rapid heart rate, you may want to, to check that and be aware of that. So, in this situation in the UK, we would have early warning scores that the nurses will be routinely checking uh to try and trigger more active treatment in this end of life setting. We would usually be requesting for those to stop because we're not escalating to more acute care or moving to comfort care. But this might be a scenario where you might say, well, actually, if you're concerned, you can obviously check a pulse, uh, if you're concerned that, that, that they're being made symptomatic by something. So, again, it's that individualization that tailoring of the care to the patient, just like you might not be checking their observations routinely. But if they look like they're having a temperature and you might want to give them paracetamol for it, you can take a temperature to check that, um, and guide your care with that. So again, it's the individualization, it's the common sense approach to care. So, this gentleman uh because he had uh uh some kidney impairment, we went with the oxyCODONE five and the Midazolam five all in normal saline over 24 hours biotene gel. Again, it's a a gel designed uh really for those uh dry connective tissue disorders that have dry mouth comes like in a toothpaste tube, er clear and you can use a finger uh sponge and just rub it around the mouth. It just keeps it moist. Uh the highly ford eye drops just they're, they're quite a good long acting eye drop. Um So it keeps the eyes moist and then the P RN medication, as you can see, this is a lower dose. You, you're using oxyCODONE one mg. You might even do midazolam 1 to 2 mg, Lepine 2.5 to 5. Again, lower doses uh can be used if, since that person is very, very frail and Glycopro and these pr in. So if they're never used the if they're never needed, they're, they're not used. So again, I always find it's very important teaching to signpost uh people to the resources because you don't expect people to remember everything. Uh We say so the nice guidance is there. Uh We locally have uh an app that we have our regional guidance on. And I would suggest that for yourselves, you will have something relatively similar depending on what part of the world you're in. And it's worth checking that out. Speaking to your palliative care team and saying, what do you have guidelines? What guidelines do you use? Where do you find them? Because in this electronic world it'll be an app somewhere that has your relevant guideline be if you uh whatever part of the world you're from, there will be access to, to the guidelines um or ones that are, that are relevant. Um because it's very important that you have guidelines that support what you have available to you to prescribe. Uh That's always the key thing that what, what you have available and what your local region will use. But these are the ones that we would use uh in Northern Ireland. Again, uh very specific to, to my region. And the guidelines do um again, paper copy because I am a certain age, but I find that most of our juniors will use uh calculators, electronic calculators on the phone and those apps are, are very good and very important. Also, I would say it doesn't, it's always very good to actually have two people do it or ask your pharmacist to check if you're doing your conversions. I'm not completely sure. Get a colleague or get the pharmacist uh to, to, to run that over it. There's always, it's always good and I'm just going um if you are interested in that a LS app, that's one that you can access that or again, uh micro gu is another one that we have. Uh and it has this guideline on it and it's a very useful guideline from the point of view of. Um it gives you the the steps to a nice flow chart. And I always think that that's very useful, particularly for our junior staff. You know, they can look at the person. Well, actually they're on a weak opioid or actually they're on a fentaNYL patch and it talks them through uh if they're in pain or not in pain, uh they can walk through that, that flow chart. Um I'm more than happy for the slides to be shared. Uh If that's something that, that uh you want to contact uh the mo people and, and, and use this as a resource even just to, to, to access the, the app, OK. Particularly it will talk you through guidelines uh around the nausea and vomiting again, a very useful flow chart. Um Give you guidance on what to use, particularly helpful. Uh The Sweet Table giving you the choice of antiemetics and the situations where you might use that. So leave them as it says, a broad spectrum anti emetic, which is quite useful. Um If you're looking for a little bit of sedation, uh metoclopramide, maybe one you would use and when you're wanting something prokinetic, so again, just a very useful little table but you what you'll, you will find if um each region will have their own version um of, of the guidelines. And it's important to access those from the point of view of um knowing that those drugs are available in your area delirium, as I said, was one of the commonest symptoms. And this is a very useful little flow chart that's in our guideline. Um And it guide you through Midazolam for being the first line choice. Uh and then moving to Haloperidol or promazine. If that's, if that's not working again in the setting you're working in, if you can reach out to the specialist team, when you 1st 1st measure hasn't worked, that's usually what um ideal. So you try something like it doesn't work and then you're reaching out to your specialist support and saying we need, we need a wee bit of guidance. You wouldn't mind seeing this person and our region went with like Caproni. But you're, you may be more familiar with hyzine, hydrobromide or hyzine butylbromide uh just depending on what's available and what is preferred in your own region. So the key principles. Just finally, just to wrap, wrap things up is really looking at the key principles would be involved with the patient and those close to them. And I think that's the big take home message from the nice guideline. Uh It's very much that individualization. And the only way we can individualize things properly is if the patient is taking the lead on the care, collaborative approach uh with the healthcare professionals, again, listening to your nursing staff, they will know in general when things are changing uh and have and giving them that respect to, to listen to what they're saying, using appropriate medication and tailoring them uh to prevent the symptoms and having that regular assessment and having the P medication and having that access to specialist support for when things uh get tough. So that's the end of my presentation. So I'm happy to take any questions fab Thank you very much, Doctor mcauley. Um I've just started the Q and A and the first question is, isn't DNA CPR now replaced with respect form. I'm in northern Ireland. Nothing's replaced with anything until we've let 20 years lapse. Uh and Wales do it and we managed to get round to it about 15 years later. Um So it's being talked about it's with the department. Uh But we're still sitting with red forms um that we're completing. So, yes, if you have the, no, we'll catch up eventually. I'm not sure where I suppose there will be a lot of folk coming from different parts of the world as well. Uh Maybe not listening at the moment, but maybe listening later on and you will obviously document uh your DNA CPR decisions as it is appropriate in your, in your region, in your country. But the respect tool is a tool that has come out. I can't say when it came out in England and, but it, it documents a lot of sort of ceilings of care if I'm right. Um And one of those ceilings of care is obviously key to document would be the DNA CPR decision. The tool that is meant to stay with the patient is my understanding um which I would be interested to know how that works. Um I can't imagine you stick it to there, their pajamas, but um I presume it goes with them home and comes back into the hospital and then goes in their notes at that stage. Are there any other? There are um I think if you stop sharing your screen just for a second, I think things are getting delayed. Um When you go to any of the guidelines about what to dilute, uh the commonest things to dilute will be their water for injection and normal saline, uh There's no right or wrong from most drugs, but you will find the more unusual ones like octreotide, uh Paroxy Levitras and those should definitely go in normal saline. We tend to put most of our combinations in normal saline because it is more saline, less irritant, less site reactions. It's just a better dilutant. But in the hospices, uh in the areas that are specialist, uh they will use uh normal saline. The only one where we say not to do it is, would be cyclizine. But there's a lot of evidence that water injection for injection is fine for a majority of, of medications. It just, we just find that normal saline um, is more physiologically appropriate. Uh So there's less problems cos where I work at the moment, I've only worked for a number of years. They use a lot of water for injection. They also use a lot of dexamethasone for site reactions, which I wouldn't have been used to. So I think there's a trade off there. Um, but it's whatever you have available, there's no right or wrong. Um, just for a majority of things we would find normal saline makes better sense. Perfect. Thank you. The next question is, can you explain background pain and breakthrough, pain control, background pain with? We're talking about someone that has an advanced cancer, they are having pain all of the time. So you're needing to provide that pain relief that, that matches that. Um So you're having to have something that's 24 hours. So morning and evening medi medication or a syringe driver so that there's something that they're having all of the time, but there will be episodes of breakthrough pain. Uh be that because they've got up to move around and they've got a bone pain from a week. You know, they've got a lytic lesion in there femur and they, they're standing up and mobilizing. Uh, and, and that hurts or they're having a dressing change and that hurts or, you know, uh they have just having a, a, an exacerbation of their pain and that's what we would tend to call breakthrough pain. And that's where you're looking something short acting. Um majority of those pains, we would still use something that has uh like morphine, sulfate oral solution or oxyCODONE, uh shorter release, major release preparation. So something that takes maybe half an hour to get into their system and it's out again in about four hours, you may be aware of um more than fentaNYL preparations that might be used more specifically for very uh brief periods of breakthrough pain. Uh So something that's really just immobilizing and it's only for a couple of hours. So you may see different medications used in different situations. I hope that answers that the question. Absolutely fab. And the next question is other than myoclonic jerks and hallucinations, are there any other signs of toxicity that we should look for in an actively dying person? Those would be the main ones. Um Hallucinations are harder to pick up because if they're not able to tell you. But if they're able to say, and sometimes the family will say they were talking to. Usually that's a dead relative or something like that. Um It can be hard with hallucinations because there is an element of a delirium that, that creeps in at this stage, just given all of the other things that are, that are going on. So the myotonic jerks are probably the most specific. And if you are standing at the bedside and you're looking and they're doing that little jerk, that myotonic jerk you at least know for definite that that's uh toxicity and you might want to do something about that. I tend to not worry about pupils because the pupils tell me they've got an opioid on board. I can read the cardi, I know they've got an opioid on board. So that's not a terribly specific sign uh respiratory rate. Again, uh if you're getting seriously concerned about respiratory depression, but again, it can be a grayer area because if somebody's really actively dying and there's no opioids on board, that surgery can be going all doing all types of things as well. They can be having pauses, they can be uh change, stroke, respirations, lots of different changes in the breathing that might, might have nothing to do with the opioid. So there's things that you can look at and tie together in the clinical pic picture. Uh But my drugs are probably the most specific uh one to actually opioid toxicity. Thank you very much. We've got one question which asks, what is the right time to speak about organ donation, I think. Well, out of this territory, well, out of this territory, uh, you want to be in the last months, uh, where the person can have a very, you know, they can think about it. They have time, they can discuss things, they can uh complete any forms that they, they want to do. So I don't think I would be doing it um in the last days because nobody has the energy of the time the patient has and the family. Um obviously, if you're in a different setting where it's a traumatic incident, that's the only time you can have that conversation and you frequently will be having it. But in, in the end of life situation where somebody has been actively dying from progressive advanced disease, there has been time to think about that. And actually, there's probably very, you know, you're usually not or harvesting in our um things only, maybe cornea might be the only thing that, that may be of relevance at this stage. Um Given, if you're in, in the advanced metastatic setting. Um So again, sensitively broaching it uh when it's appropriate, I think as early as possible. Um If it, and if it's appropriate, thank you very much. We've got a question is the GP qualified to make a decision on palliation or should it be made in secondary care with the GP? Only sharing management what are you? Uh, I suppose I'm not quite understanding the question if the GP is in a, in a situation where he has all of the information in front of him and knows the patient and knows the trajectory and knows everything that, you know, that is relevant and is speaking to the family, speaking to the patient, they'd be eminently qualified. Uh The GP is, are usually brilliant, uh and will probably make a better educated decision than focus somebody in Ed or the person doing the ward round uh the following day. But uh if there's any uncertainty, if there, if there's any concern um that maybe there's maybe a third or fourth line treatment, uh we're in the world now where you have 4th, 5th line treatments, there's new mabs and Nibs and things appearing every day. So if there's any uh issue or concern, it's always good practice to, to check out with oncology. If that's the cancer be cardiology, if it's a an advanced cardiac condition or the respiratory team, they are looking after, it's always good practice if there's any concerns, but usually the GP is looking at the notes and can see what the last clinic said, what the last discussions were and will probably be fully aware of the direction of travel. So if that information is there, there's, it's all very clear. The GP is usually a very highly qualified, well experienced individual to make those decisions. Thank you. But again, we all make those decisions in the, you know, you're discussing that with the family, the patients and what multidisciplinary team is there. Nobody should be making it as a single handed uh decision. But that those with primary care, you'd imagine the links are more tenuous. You're not sitting all in the one room. So it might be communication by letter, communication by phone. Um You know, it might be through family that have already had those discussions. So it may be a looser sense of discussion that's very helpful. Um Laura's asking, she's a newly qualified nurse starting out in the community. What's your best pieces of advice for caring those who are dying at home in what regard? That's a huge, a huge topic. Um I that's too big a question to answer in one. I think, you know, I I've, I've covered, you know, I think you, you look at the nice guidance and you, you follow that. I think that is the best. So I mean, I access the nice guidelines that applies to the community and that will give you all of the best uh pieces of advice that you need for the more holistic care because obviously I've just covered the medications tonight uh because with the interest of time and focusing on one part of it, um But the nice guidelines will give you a lot of the advice around the communication around the identification. So that would be a document as a new nurse that I would send you to, that, that would be the best thing to look at fab. There's a few questions about, um, treating long term conditions, including diabetes and th, um, for example, continuing thyroxine in hypothyroid patients. Um, I think it's a practical thing. If the person can swallow it safely, I would continue it. But if they can't swallow it safely, it comes down to a very pragmatic approach. Um, but, you know, if they can't swallow it, they can't take it. Um, so, you know, it's a case of you can't, rather than we're not giving it to them. Um, but hopefully if somebody's in the last days of life, the thyroxine becomes, you know, their thyroid is, is less relevant. Um, but we continue it as, as long as possible. It's probably one of the few that I don't actually put a line through and just in case they ch change, you know, I don't put a line through the first day. I see the person when they're dying. I might put a line through the next day when it's really clear, they're not gonna wake up. Um, just in case they go a wee bit longer and they, and they, it wouldn't make any difference. Um, the blood sugars, that's a whole different talk. I'll do that one for you about January. I think. I'm not sure when it's penciled in. Um, because that there's a very good guideline on that. But yes, for type one, you would be concerned about the blood sugars and you're probably gonna check that at least once a day and alter your insulin regarding that. Uh, a type two. Again, there's new answers to that. You're probably going to check less, you know, less likely to check but never say never. Um, but yes, for a type one, you would be concerned about lower high and them being symptomatic with DK DK A. So you're, you know, you're, you're going to check that and prechange the insulin, but that's a whole different talk. We will do that one at a later date. What kind of options we trialed to help with Stridor. Stridor again. Um You are really discussing that probably with the ent head and neck uh specialist that are looking after them. I would usually try steroids, high dose steroids initially. Um I know they use um Nebuliser, I'm gonna call it adrenaline, but I'm sure my age again, epinephrine uh as well. Um But again, what you're clearly wanting to know is is there anything that they would actively do so as a quick conversation, is there anything actively that the patient would want or that is possible and considering that uh and acutely, um, steroids are useful. Uh And I know they certainly used nebulized epinephrine as well sometimes if it's, there's nothing going to be done and it is pure last hours. Um You've certainly, you, it's one of the rare situations where you're using sedation, um, where the person isn't awake for the, the distressing last hours, if that's the situation you're in, but again, you're wanting to check. Are there any active options? Is there something that a specialist would do? Uh, and if not other, would steroids help, would nebulizers help. Um, I think if you go to the Southern Trust in A Os, that's where they have that one or if, if you have micro guide as one of the other apps, if you go to the Northern Trust, um that's where the palliative care are, but I'm sure in each area will have their own if you speak to your palliative care team in whatever area you are, um They'll signpost you where they will have their apps that they're teaching the juniors to go looking for. And it's quite often the app for the trust that they're working in. Uh they'll have uh put the access there. Hi, Virginia. I think that's all the questions is it? I think we have just reached the end. That was some incredible teaching. Thank you so much. Thank you so much, Doctor mcauley. Uh It was really informative. It was a really interesting talk and a very, very helpful Q and A as well. We really appreciate you taking the time to teach and thank you to everyone who joined uh to all those who joined, you'll be sent a feedback form shortly. Please fill in the form and you'll get your certificate added to your account. Do get the meal app on your phone or laptop to have easy access to certificates, catch up content and slides as well as tools like QR code to easily share patient info leaflets which are in our reference section. Please do let us know what other topics you want to learn about in the feedback form and we will try to arrange teaching sessions on those topics. We also have more free events coming up. The next one is on the fourth of November on CO PD and I'll put the link in the chat now. Thank you for joining and take care of everyone.