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Okay, great, thank you very much. Um So hello everyone. Um My name Sean Creche. She, I am a palliative medicine physician here in Scotland in the UK. Um And I am speaking to you today about principles of symptom management in palliative and end of life care. Um I think I'm down to be speaking to you for um uh an hour and a half today, but it's not going to be as long as that, especially because it's such a small group. Um I am hoping I do have a few questions for you as we go along and I'm hoping that there will be um, a bit of participation and you'll be contributing either by coming on Mike or by um putting your messages in the chat so that we can all get as much out of today's session as possible. So to summarize what we're going to be talking about today, first, we're going to start off by what is it? I actually mean by palliative care and I'll be interested to hear what you think it means. Firstly, then we're going to be talking about management of specific symptoms which are very common in palliative care touching today on pain, breathlessness, nausea, agitation, and then some general approach is to end of life care. Um And I'm going to point you towards some resources for further study because today we're covering very much just the principles and an overview of palliative care. Um It's not possible today to go into a lot of detail, but if you can come away from this session, having uh an idea of the principles and what kind of things you would be thinking about when you approach a patient with life limiting illness or terminal illness. Um then that would be a success. Uh So firstly, I have a question for you and I know that we will only have a small group. I do hope that you will feel uh confident to participate and say what you think. I want to start off. Firstly, just by asking what palliative care is, what do you think it is? And it, it would be great because someone who's willing to speak up. Uh If I say uh we have exhausted all the elements of care to prolong somebody's life with the disease they've got and we are going towards um uh you know, no, no medical options available for them to um treat. Uh okay. So you think so there's a few things you said there. Um So um you said, I think that you've exhausted all, all the options and there's nothing left for you to treat is that Right. Correct. Ok. So that's, that's interesting. There's some good ideas there. Um I think Assad has his hand up as well. Uh uh I was going to say that in a approach to improve the quality of life of a patient as well as the around, around them, just family or friends, not in a manner that because when a person is affected with the disease or let's just an old age, they are not in a way they could help themselves, but they can support themselves sometimes friends and family needs help as well. So in a manner helping them and the people sound surrounding excellent. So there were some very good ideas there. So, um I think you said it's about trying to enhance quality of life and doing what you can to help someone including um thinking about having friends and family around them. So all very good things to be thinking about with palliative care. Um And was she, do you have your hand up as well? Uh It's the same what the colleagues have said, like it's the care that is being provided just before the end of the time and uh just to provide the quality time to the patient. Uh so the nds can be uh spending a better way you can see, right? That's very good as well. So, um it sounds like you all uh no, at least a little bit about palliative care if not having um you know, very good. Um, I'm just looking to chat as well as someone said, end of life care, aim to improve quality of life. Yeah. So all very good ideas. So I, I liked everything that you said that. All, all three of you said. Then there was just something that Christie said that made me think. Well, I think she said that there's nothing left for you to treat. And I think what we have to think about is what the patient has an underlying disease. The disease is progressing and it's progressing so um far and so it's become so progressive in advance that the patient is actually going to die. So there may come a time where the patient, um there's nothing left that you can do to treat the underlying disease. Um So we might not be able to stop the progression of cancer, for example, in a patient with cancer. But I think what we all have to remember is that there is always something that we can do to help patients'. Um even if it is looking at those other things that we've mentioned, like, um what can we do to make sure that they feel supported with their friends and family? And there's things that we can do as doctors as well to try to help treat, even if we're not treating the disease that to treat the symptoms that they have and try to give them symptomatic relief so that they can have um as best quality of life as possible. So how do we some that up in a definition because it's all, it's all very vague as quite difficult to get, to get your head around how we, how we sum up what, what palliative care actually means. And that is a difficulty that's not just being faced by us at the moment, but actually nationally and internationally, there's not a great deal of agreement in terms of exactly what palliative care means. So this is a definition that comes from the World Health Organization, which is quite wordy as you can see. But is that palliative care is an approach that improves the quality of life of patient's adults and Children and their families who facing problems associated with life threatening illness. It prevents and relieve suffering through the early identification, correct assessment and treatment of pain and other problems, whether physical psychosocial or spiritual. So I think that's quite a long winded definition, but it captures a lot of the ideas that we've already spoken about about really emphasizing um the prevention of suffering and thinking about other things as well as the, as well as the physical. We're not just thinking about the physical side. We're trying to think about how is the patient affected in terms of their psychosocial well being and the spiritual well being. One thing I will say about this definition is that, I mean, certainly in terms of the UK and what we do here, what specialist palliative care we do here. Um This definition is still a bit too broad in my opinion because if you see it says facing problems associated with life threatening illness, um uh in the UK and certainly for the purposes of the rest of this presentation, I'll try to think about not just life threatening illness but patient's in who we know have a life limiting or terminal illness. So we already know that the pro the prognosis of the illnesses that is going to advance to the stage that they're going to die of their illness. So those are the kind of patient's that we're thinking about today. And actually, um I think a much simpler and easier to understand as a doctor, but also for patient's to understand a much simpler definition of palliative care is to simply think about adding life, today's not days to life. So we're not necessarily trying to extend patient's lives in palliative care. But what we are trying to do is make sure that in the time that they have left, they have as best quality of life as possible. So hopefully, as we progress through this presentation, you understand some of the ways that we can go about doing that. So as we said, the domains of palliative care is not just the physical. And I think as doctors that we often feel most comfortable um in the domain of the physical. Um but remembering that a patient's experience of the illness is going to take on such social, psychological and spiritual elements as well and things that can be done to help them fall into these categories as well. So, like we've mentioned, you know, making sure that they've got, they've got the family support, the social support in place that they need. And if there are particular elements of spiritual distress that they have the spiritual support that they need. The other thing that I um what wanted to draw your attention to is the fact that I think it's very easy to think about palliative care is only being relevant, you know, when someone's very close to the end of their life, when they're immediately at the end of their life. So for example, if someone's in the last days, hours, maybe minutes of their life and thinking okay, now that now the care that I'm going to be providing for a patient is palliative care. And yes, that is an important aspect of palliative care, but that is not the entirety of palliative care by any means. I think that actually palliative care is an approach which is helpful to patient's all the way through the illness from the point of diagnosis. And it can, although palliative care is not life prolonging care, it can exist at the same time and co coincide with other care, which is life prolonging. So an example of this might be a patient who has been diagnosed with um an extensive cancer and they are going to have chemotherapy from an oncology colleague and the, the chemotherapy maybe life prolonging um and help them to live a longer life. But at the same time as then receiving that, that, that chemotherapy, they could also receive palliative care input to help them to control their symptoms um and to live as good a quality of life as possible with the time they have left. So I know this is all quite a lot to get your head round, especially if this is your your first time having a teaching session on palliative care. But um it's just important to recognize that palliative care is needed for a great many people. And it's not only when someone's immediately dying, it's from the point of their diagnosis with a life limiting or terminal illness. So, yes, why, why is there such a big need for palliative care? Well, palliative care improves quality of life and reduces symptom bird. And then there's lots of evidence for that. And certainly, I mean, here in the UK and in other developed countries, people are living longer with chronic disease, multiple conditions, complex needs and there's an ever increasing need for palliative care. So for example, um in England and Wales by 2040 the demand for palliative care will have increased by 25%. But even now, even before we even look to the future, um there are still people who die without receiving the palliative care they need in the UK, it's estimated about 100,000 people um that could benefit from palliative care, just die without receiving it each year. And that's before we even start to think about other countries. So that is, you know, a relative. We're talking about a relatively rich and well resourced country in the United Kingdom. But we think about globally, there's a huge amount of serious health related suffering that could be alleviated with access to palliative care. But unfortunately, palliative care is very limited or nonexistent in most parts of the world. And you know, something as simple as access to morphine, which is very staple drug when it comes to uh symptomatic relief and the kind of symptoms that we're talking about here today. Well, 50% of the world's poorest population, living countries that receive only 1% of the total opioid analgesics or, you know, total morphine that's distributed worth worldwide. So across all settings, especially, you know, countries other than the UK, where I live, there's a significant void in adequate pain and symptomatic relief. So it's not, there's lots of challenges, there's lots of obstacles, but we all need to be aware that this is an important area of medicine that it needs to be advanced and that we need to do what we can, what we each can do to address to try to address this serious health related suffering. So with that in mind, I just wanted to be clear about what we're not covering today before we go any further. So I can't today give, tell you everything that you need to know about how to care pharmacology and management for a number of reasons. Firstly, because there's too much to cover in one session. Um, but also because, you know, I, you know, I believe there's people here from all over, potentially all over the world. I don't know what access, there is two different drugs um in the country that you're in or where you'll be practicing. So it could be very different from the UK, where we're relatively privileged in terms of the access to palliative care drugs that we have. Um So what I'm hoping to do today is very much install, install the principles of what you can do. And I have tried to gear this towards um relatively uh resource constrained settings, but it's very difficult to gauge because I can't, I can't say definitively what you might have access to and what you don't have access to. The other thing that we're not covering today is Children and pediatric palliative care. And I'm very sorry, pediatric palliative care is very important, symptomatic relief and patrick air is very important. However, in the U K, um which is not the case in, in other countries necessarily, but in the UK, pediatric medicine is separate specialty from adult medicine. Um And I am uh in nowhere specialist in symptomatic management or prescribing in pediatric cases. So please, I'm going to give you principles today to apply to adult medicine. But please don't think that these can necessarily apply to pediatric medicine who need a pediatrician to tell you more about what would be appropriate in pediatric cases. Um And the other thing that we're not covering today is acute illness or any patient who doesn't have a life limiting or terminal illness. So when we think about pain today, for example, and the approach that we were taking palliative care that is very different from the approach that you might take um to a patient presenting to accident and emergency with um you know, a severe pain caused by acute heart attack or by a hip fracture. Your approach, in that case would be an acute medicine approach or an acute surgery approach. It would not be the palliative care approach that we're talking about today. So today, we're talking about adult palliative care and patient's who have a diagnosis already of a life limiting or, or terminal notice. So with all that said, we move on to discussing our first symptom, which is pain, very common symptom in palliative care. So we're going to our next question, which is um actually, I think a surprisingly hard question. Um and I'm going to ask you what is pain, what do you think pain is? So it's a discomfort, it's a discomfort liberty. That's to say it's this, this kind of do it. So, as sad as sad was that you speaking, you seen discomfort? Yes, sir. So, as I said, discomfort and, yeah, in a physical way, it's in a physical needs, discomfort and physical needs, uh, in a physical way. I mean, it can be emotional or emotional or spiritual or physical is, um, so it's a discomfort on the short term. Yeah. Yeah, that's very good. You're thinking about the emotional and spiritual aspects of palliative care. Have you uh sad. Have you had teaching on palliative care before or? You've been reading about it? Uh No, sir. This is like a glass. Has my university hasn't started this glasses? No. Okay. Well, I, I only ask because your, your answers are very good and very comprehensive. So well done. Um Was she, what did, what were you going to contribute? Yeah. It's like a feeling of discomfort. You can say, yeah, I think I'm just comfort. Okay. I would say pain is what patient say it is. You know, it might be different to one person, to the other person. You can't exactly say what is pain by just with one measure, isn't it? So, um that's excellent. Yeah. Very good. Very good thought. And are there anyone else have any, anything they want to add? I think what Christie said was, I don't know who should be said. I think it was pristine. She, she is right. Reserved. Something can be others for something else such as uh physical pain is not as same as it's enjoyed by a masochist. Yeah, she's the right gene is completely road. Yeah. So, um, yeah, pain is, is unpleasant, isn't it? So, yeah, but I mean, it sounds like you already have some very good ideas and very holistic approach is to um, a patient who complains of pain. So that's very impressive. Um So I think, well, I'll show you one formal definition of pain, which I think captures a lot of what we said, um which this comes from the International Association for the study of pain. The pain is an unpleasant, sensory and emotional experience associated with actual or potential tissue damage or described in such terms, something that, that covers, you know, everything that that's been said already, it's unpleasant is not just physical, it's emotional as well, it's an experience. Um and it can happen with actual tissue damage or there might not necessarily be any tissue damage or any tissue damage, which is still going on, but the patient still experiences it. So this was going to be my next my next question. But based on what you've said so far, I think you'll find this a piece of cake. But my question was going to be if you imagine that you, you have to patient's. So just say that maybe you're maybe you're doing a ward round and you go to see two different patient's on the same ward and the first patient is lying a bed rolling around in agony. Maybe they're crying out in pain because they're so distressed by the pain there, grabbing, they're grabbing the site that sore. Um, and they're telling you, please, doctor, please give me something for this pain. Um I just can't go on like this. I need something for the pain and they're, they're clearly very distressed and everyone can see that. So, and then you ask the patient how severe the pain is and they say, oh, 10 out of 10, 10 out of 10. And then you imagine that you go to see another patient on the same words and this patient is very low. They're being very quiet and they're just staring at the floor or they're staring out the window or they don't really want to engage with anyone and you go and speak to them and ask them what's wrong and they just have quite a quiet voice and they just softly say I'm in so much pain and you ask them how severe the pain is and they say, oh, it's, it's the worst pain ever. It's 10 out of 10. So my question for you, then you have got two different patient's with pain and both are presenting themselves in very different ways. So which patient remembering that they both said it was 10 out of 10 pain. Which patient do you think is in most pain compared to, compared to each other? Which one is in the most pain. Uh There are two separate cattle reviews. You can see motor equal somehow happen if it would be an emergency. Uh, if it wouldn't be an emergency, such as uh for a patient in the patient age, you could just give some painkillers if it's a physical pain. But if the patient being seem slow in a moon, you might have suicidal thoughts. That would be in an emergency as well. Yeah, that is true. But just to just to clarify, sorry if I didn't make this clear, but just to clarify, patient B is in physical pain. So the pain that patient b is talking about is physical pain. Also, it's not like a psychological pain. I think it would be patient age because uh it's unbearable for them whether shouting or and this you can see on the face come back to patient D Yeah, like they're not faking. Uh That's the problem is that some, some people can fake it. But uh just by looks likely patient, they might be more in a need compared to be interesting. Okay. Yeah, good. Thanks for, thanks for contributing. Um Does anyone else have any thoughts on this? Yeah. Okay. Well, this was a bit of a trick question which was unfair of me. Um So I do take a sad point that um clearly patient a is much more demonstrative. It's much easier for you as a doctor. But really anyone who can see the patient but to see that they're in pain, um, whereas patient be, it's less, that's less obvious. Um, but really remembering what Christie says, pain is what the patient says it is. And it is not our job as doctors to, um, try to, you know, discern whether or not the patient's telling the, really telling the truth about their pain or, um, to think of someone's pain, someone says they're in 10, out of 10 pain, but I don't really believe them. You know, these are not things that we should be thinking about as doctors. It's not our job. Our job is to try to help people. Um And remembering that people do behave in very different ways. Um And, you know, patient be in this scenario, maybe they've had that pain that's very severe, but they've had it for weeks or months. So they don't, they don't roll around in agony anymore. They just sit there quietly but trying to cope with the pain. So the answer and what I would like to you to take away from this really is that pain is what the patient says it is. Um And that's the approach that we should be taking when we're assessing every patient as an individual. So to start off thinking about the type of pain presentations that we see in palliative care where you would have to think about symptom management. So, so these are some kind of just snapshots of ideas of the kind of things we might see, we might see a patient with lung cancer experiencing left sided chest wall pain. We might see patient's with metastatic cancer like prostate cancer, which is causing spinal metastases, which and then having weakness and burning pain in the leg. We might see patients with liver metastases like metastatic colorectal cancer experiencing throbbing, right upper quadrant pain. So we will look at these examples in a bit more detail in a few minutes. But this is just to give you a bit of a flavor of the kind of presentations that we need to be able to manage. Okay. So the first thing we do when a patient presents to us with a symptom is an assessment. Um And so the key things for assessing a symptom and palliative care very similar to other types of medicine, we want to do what we can to establish the history um and gather information about the patient background. Uh And we want to do a physical examination and assessment as appropriate. So when we're taking a pain history, what are some of the things that we ask? What's very important to ask a patient with pain? We went to your phone assessment. So produce my produce, please. Yeah, good. So you spotted my obvious uh hint where I put uh photo of a statue of Socrates on the screen to prompt at all. So um does someone want to go ahead then? And, and tell us what Socrates stands for. Thing is the site. Yeah. Good start. So s is for sites and? Oh. Mhm. Remember, it's sorry, I'm sorry. Right. Does anyone else remember the rest of Socrates? Is it the cage? Yeah. Okay. So Jeb has put in the chat site, onset character radiation and associations. Time. Yeah. Good. So, we're getting there, we're nearly at the end of Socrates. So I think we have the last E N S. Remember the two, your hypothetical patient's that we spoke about a patient a and patient being and they spoke about this. They gave a number to describe some aspect of their pain severity. Yeah, good. So thank, thank you to Jeb who's put that in the chat. So I'll just put it up on the screen as well. So we can all see. So I think this is a good framework as a student for you to utilize whenever you're assessing a patient who complains of pain because it helps you to remember all the aspects that are important to include. Um It's not necessarily the order in which you would or should ask these questions. For example, severity is at the end, whereas that's probably naturally something that you ask quite early on. Um But yet we need to know all these aspects of the pain to try to help us to understand what's causing the pain and what we can do about it in terms of exacerbating and alleviating factors. It's also very helpful to know. Um, if they've already tried analgesia and what effect this has had. Um, so for example, if a patient has been taking loads of morphine and it's not touching the pain, it's not making a difference whatsoever. Um, then we would think actually this pain is maybe not opioid responsive pain. And so we'd have to think about another type of pain killer, like a neuropathic pain killer. If it's, if it's possibly nerve pain, the other thing to bear in mind is that, you know, a patient could have set, could have multiple pains and they might be different. Um So if the patient's complaining of pain in more than one site, we should repeat the pain assessment for um every site of pain. Um and we try to remember the other aspects of palliative care also when we're doing this assessment of the patient. So not just the physical side, but how is it affecting the patient socially? Are they able to um go to work, for example, are they able to spend time with their family or is it how is it affecting the quality of life? I know always remember as well when you're taking a history from a patient to ask about allergies and adverse drug reactions. So really, I mean, this isn't specific to palliative care, but really for medicine in general, the vast majority of helpful information that you're going to get to inform your management plan comes from the patient history. That is the most important aspect. I'm really trying to get the patient to express and whittle down water is that they are experiencing to give you a clue about what's causing the pain. Um because, and that will help you know how to manage it. So, is this um maybe organ distention or pressure on surrounding structures like the patient with um lung cancer, for example, who's getting pain in their thorax is this bone pain caused by um a worsening on which causes a worsening of pressure or stressing of the bone or weight bearing. Could this be nerve pain which causes the burning tingling shooting? Is it in the distribution of a dermatome like shingles? Do they have hepatomegaly or right upper quadrant tenderness which would suggest liver pain, maybe they've got liver metastases or are they having a headache that's worse on lying down or first thing in the morning? Which might make you think actually, does this patient have raised intracranial pressure? Do they have cerebral metastases? Are they having colicky cramping pain which could be caused in their abdomens, which could be caused by a bowel obstruction. Um So the pain history very, very important and very useful. And the other thing that we would do in the information gathering is to look at what's already known about the condition. What's known about the extent of the disease? Have they had any recent scans? For example, which has shown that they had, um they, they've got metastases somewhere. Um you know, has a patient. Um It should say hypothetically a patient with known vert metastases in their vertebrae, skeletal metastases in their vertebrae has now developed acute onset back pain. That should and you can look, you can look back on the scans and see that there was vertebral metastases prevailing previously noted. So now you think actually, uh I have a high index of suspicion that this patient now has had a pathological fracture in their spine, possibly causing spinal cord compression. Um And you can also do further investigations at this point. If, if appropriate, depending on the case, then we want to um examine the patient also. So you, you know, the patient might be like patient a they might be more like patient be, they might be like someone else entirely. But you are looking for non verbal and nonverbal cues for pain, maybe their heart rate is raised or the respiratory rate is up because they're in so much pain. And you also just what you want to examine the area of pain and there might be something that you can identify that's causing the pain. Um And you would do, you would do investigations depending on, on the specific um circumstances, the specific patient. But in patients with palliative care needs, there is often a risk of hypercalcemia which I'm not going to talk in detail about today. Um I will in my next lecture in this series, which is about emergencies and palliative care where I'll talk more about hypercalcemia. But please don't forget to check calcium levels in patient's, especially with metastatic cancer who complain of pain. So, hey, we'll move on now to what you're going to do about it. The patient complaining of pain and they've come to see you, you process them, but you need a plan. So we'll start out with the pharmacological management. So, does anyone have any thoughts about this or does anyone, I mean, do you think you need to do something at all or do you think you would just send the peace in that way? Pain killers? Yeah. Good. But for a while because uh some patient's who come to clinic, like not for the value to get, might get addicted to opioid uh energy essex. So, um there's concerns about opioid addiction. Yeah. Oh, and Jeb has put in the chat using the W H O analgetic bladder, which is very good. We're getting ahead of ourselves here. That's going to be a couple of slides along. So that's, yeah, that's a very good contribution. Um So in terms of what Assad said, yeah, in some patient's, you would be concerned about opioid addiction. We have to remember with, you know, the topic today that we're speaking specifically about patient's who have life threatening disease. Um And then actually if we think about what we spoke about at the start of the presentation, this absolute void of adequate pain relief that exists in the world. Most, the biggest, the biggest problem is patient's not getting enough opioid. That is a much bigger problem than patient's taking too much opioid. Um, and I, I do agree that we have to be conservative and we have to, um, be a, probably be more reserved. Yeah, when we're dealing with patients who have pain and they don't have a life limiting diagnosis. However, when we've got patient's that we're dealing with in palliative care. So we already know that they're going to die in the next, you know, weeks, months, maybe short number of years and they're in pain. Now, these patient's really do need an analgesia and it's not uh is not a concern that we need to think about really with this patient group is about opioids dependency. Although that can be something that patient's are worried about and that can make patient's less likely to take to try opioids despite being in severe pain. But as doctors, we need to try to reassure them that actually, um this is the right thing for you to do is you shouldn't be in pain if it can be avoided. And um we need to do something about this. And sorry, Christie, I think you did, you put your hand up and then put it down again. I was, I was actually going to say that because if someone is uh you know, in the end of life are nearing the end of life. We can give them anything to, uh, you know, alleviate the pain. A small amount of addiction is acceptable. I supposed to get the, uh, symptoms under control rather than making them worry about addiction itself. Yeah. Exactly. And you will, you will have patient's who are worried about addiction. Um, but we have to remember that it's very different, it's a very different situation from say a young person who was 30 years old and they have a normal life expectancy. Um and they have just for example, neck pain, but there's nothing, there's nothing sinister causing the neck pain. They just unfortunately have chronic pain, but they, you've got no reason to think that they're not going to live till their like 78 years old and you in a patient like that you would not want to set them down the road of um you being on pink are being on medication lifelong unless you can't avoid it, but you would try to avoid it in a patient like that in the patient population that we're talking about today. It's a very different because these are patient's who uh I mean, to be quite um plain about it, to be quite abrupt about it. These are patients who are going to die soon. Um And the priority is their quality of life. Um And long term opioids, dependency is not um an appropriate concern. Okay. So good Um So what we have to remember though is that pain relief is a human, right? So I'm glad that, uh you know, from what we've said already, it does sound like we are all on, on the page with this and we want to do something about it. We want to do something to help our patient's who have pain. So a couple of questions to try and bring home the principles of pharmacological management of pain. So first question, what route should we use when we can to treat pain? What, what route should we be giving drugs by whenever possible? It might depend upon the thing. So, um sorry, Assad, I think he spoke, but I couldn't make up what he said. Uh He wrote the route of uh might depend upon the pain as well. What kind of pain it was? So, are you talking, are you talking about the roots? Yes. The route might depend upon the type of physical when it's a shouting or doesn't bend? Why? Why does it depend on that? I just thought of that it could be pinned. So, just intravenously. Yeah, a constant pain might be different from a recurring police. Okay. So that, yeah, those are interesting uh thoughts. Um Does anyone else have any ideas about what route we might use? What someone's written in the chart? Jabs written relatively immediate relief. IV we prefer for the overload and for the emergencies we might prefer like IV Okay. Yeah. And Christie, were you going to say something? I was going to say how quickly you want to get their pain under control, how intensity it is and how long they've been having a simple type of pain, uh, how well they respond to certain medications and how they are used to it and it's okay. Okay. So I'm glad that you're all thinking about it and you're thinking quite laterally. Um, it sounds like you want to take an individualized approach to every patient, which is really good. Um So I'm going to just give you the answer here, which um is the oral route. Um But you are, I've said use the oral route whenever possible, but you're right, there are other circumstances where that might not be the appropriate thing to do. But I think what we need to remember is that the mainstay is giving analgesia by the oral route and we, in other circumstances, we may have to do something different, but most of the time we should be aiming to use the oral route. Okay. So, um I think with Jeff who mentioned the uh World Health Organization Pain Ladder. So that is the next concept um that we need to understand when it comes to pharmacological management of pain. And so we're using the oral route and now we need to choose what drug or what drugs to give. So, um it sounds like you've already heard or at least one of these already heard of the World Health Organization Pain Ladder. I wonder if someone who's heard of it or is read about it would like to tell the rest of us what the different steps are of the ladder. Well, the first step is a mild pain. You use, uh, something like paracetamol is the tablets. You wanted to listen it. Paracetamol. Yeah. So, step one, we think about paracetamol. So, basically, step one from mild pain. We're thinking about non opioid analgesia, aren't we? So paracetamol is really that, you know, the principal non opioid analgesic that we we would use. Um So yeah, that's good. That's probably the most important thing for step one. But what about step two for moderate pain? That's not controlled and paracetamol alone, what would we do? They can add insight and uh yeah, the answer is, yeah. And weak opioids. Yeah. So end sides, we can also use a step one. Um So, but that's good. That's good thought. Um And then week opioids were adding that into step two. So what do you do you know any week opioids or do you know what we mean by weak opioids? Coding the head goading? Yeah. Good thought. Yeah. Um So and jabs right in the chat step one and say it's non opioid step to mild opioid step three, strong opioids, a step for nerve blocks. Okay. Good. We're not talking about step for today because we're sticking to um kind of more rudimentary principles. But that yeah, that's good. So step to Christy, you said you're thinking about from mild opioids, codeine dihydrocodeine. Um The other thing that we can use is just a lower dose of morphine because we think about um codeine. Um I mean, I'm not gonna go into too much detail about doses today, but codeine has a ceiling and dihydrocodein as well. So as a ceiling for how high a dose you can give. So 60 mg in one dose, which is roughly equivalent to 6 mg of morphine. So the alternative to giving a week, week opioid like uh codeine at step two would be to give uh morphine in a low dose that's in that range kind of below 10 mg of morphine. Okay. But then step three, we're thinking about strong opioids. Uh huh. So you would not give the strong opioid at the same time as the week opioid. So you would, if you're moving from step to to step three, you would stop codeine if the patient was encoding. Okay. So I just give you the details there. So as we've said, step one, mild pain, a non opioid analgesic plus a medicine adjuvant. Then for moderate pain, it step to, we keep going with the non opioid analogies like plus or minus and abdomen. But we add in a week opioid analgesic and then step three for severe pain, we keep going with the non opioid analgesia plus or minus the adjuvant and we are adding a strong opioid analgesic. Okay. Does anyone have any thoughts about the word adjuvant? Um, in this context? So, an adjournment analgesic, do you know what that means? The two medications combined together have a synergistic effect? Yeah, that's a good thought. Um, so that is true. Um, yeah, in this specific circumstance, the main thing you can give an opiate and a paracetamol, which works better. Yeah. so that's, that's true. But you can also give an adjuvant alongside it. So step two or step three, the patient could actually be on three, potentially three analgesics. So they could be on something like paracetamol, they could be on morphine. Um but they could also be on the adjuvant analgesic. So in this context, when we're thinking about analgesia, an adjuvant drug is really, do you think about something that is normally used for another purpose? But um when it comes to analgesic, it can also be used for that as a secondary purpose. So the examples I would give the main ones to remember our um anticonvulsant antidepressants and steroids. So all those categories of drugs, they're normally designed to be used for other things. So obviously, anticonvulsants are normally for seizures. Antidepressants are normally for depression and steroids, what they have multiple users, but they're normally immuno suppressant, but we also use them in palliative care for in special circumstances as painkillers. So, um can anyone know what type of pain in particular, we might think about giving a patient an antidepressant like amitriptyline as a pain killer. What kind of pain would we use that form? Noodle for the pain? Yeah, excellent. That's good. So just thinking that we can, we do have other tools um in our armament that we can bring to the fore when we need to manage pain. Um And again, thinking about if a patient has paying this neuropathic and it's not necessarily responding two different doses of morphine, we want to add in. Um think about adding in something else, which could be something like I'm a trip to them. Okay. Good. So the next thing I wanted to you to think about just I was timing, okay. So I won't ask you so much about this just um because it's maybe a bit tricky if you not prescribed too many painkillers or been around people prescribing many painkillers. But if you think about you try and understand this basic version of a graph, which is that along the Y axis, we think about the dose and concentration of an opioid like morphine. And then along the X axis, we've got time and there's a, then there's potentially a window when we get to sufficient concentration or dose of morphine where the patient doesn't experience pain anymore. So then we give the patient some morphine and that's good because we managed to give them a sufficient dose so that they become pain free. Um and so that will probably kick in within about an hour of taking um oral morphine and maybe last for a couple of hours. And the patient thinks, hey, this is great. My pain is under control. But then a couple of virus later, the dose and concentration have decreased. So the concentration of morphine in the patient's bloodstream has gone down again and the pain has come back. So this is not satisfactory pain control. So we might think, oh, what we're going to do about this, let's give the patient an even bigger dose of morphine. Let's just give them, you know, a large dose too tight them over. But actually what can happen then is you end up having such a high concentration of morphine that you've exceeded um the optimal dose and then they start to run into symptoms of opioid toxicity. So, what we're actually seeking is uh to get that fine balance where the pain is under control because we've maintained a steady state concentration of morphine in their system. Okay. And the way that we do this um is through well through careful Tetrick initiation and titration of morphine. But um probably in, in normally in, you know, in most places in the world, you would use a regime of regular morphine. So, you know, there might be times where someone it's appropriate to just say to someone or here's some morphine, have it in your, having your cupboard. And then if you have an ache or a pain every now and then just take it as required. Uh So that is only a suitable regime in palliative care for a patient for whom pain is not a serious symptom is not a significant symptom. Any patient who has significant pain as a symptom should be taking regular analgesia, not only that required analgesia, regular analgesia. Sorry. Um So we're aiming to maintain that steady state of analgesia in the patient's system and the main stay of of treatment for for patients with palliative care needs and palliative um sorry, pain is morphine. And the way that we're going to do this using immediate release, morphine is to tell the patient to take the morphine four hourly by mouth. Remembering were want to use the oral route and we can start if the patient has never taken morphine before. They're not already on regular morphine. We start at a relatively low dose. We can monitor what their reaction is and we they can start to titrate it up. Okay. Be a bit cautious for any patient who has renal failure or her hepatic failure, especially cautious in those patients'. Okay. I'm not going to talk about it in detail, but in the United Kingdom, we do have other because of our access to different forms of drugs. We do have other ways of um giving, maintaining a steady state of an uh patient. So we wouldn't this regime about taking morphine for hourly we wouldn't use that in the United Kingdom. We would use a modified release formulation of morphine. Um So, which can be taken twice a day, which does the same thing, it stays in the patient's system for 12 hours or we could give it by infusion for 24 hours. However, like I said, I'm not going to say any more about that. Um But for most places in the world, um what you're going to have, if you have access to morphine, it's going to be immediate release morphine. Um And as we said, that that is what we give regularly for early. So, like we said, a patient on know pre established opioid regime, we're starting off with aura morphine, immediate release 3 mg to 5 mg as a starting dose and we're giving that four hourly. So that's our ideal to use morphine overly. If for some reason, we can't use the oral routes. Um for example, the patient's vomiting or maybe they're unconscious or maybe you don't have oral morphine available. You only have morphine by injection. You can use um the subcutaneous route instead. But note that the giving morphine or giving diamorphine, which is an injection, giving either morphine injection or diamorphine injection is more potent than giving oral morphine. So the starting doses for injection or lower about 50% of what you reduce in oral morphine. So, uh here's an example of the prescription that you would give for a patient with ongoing at pain in palliative care. So you think about the fact that we want to maintain that steady state of analgesia in their system. So every four hours giving them by mouth, 3 mg of oral morphine. So in total, for this patient is a starting dose to getting 18 mg per 24 hours, which is still um you know, a relatively conservative dose. Okay. But if, as you notice in this um prescription, this involves the patient taking a dose at three AM in the morning, which is not very pragmatic. So uh in reality, what you would probably do is give them a double dose at night at bedtime and then not give them a dose at three AM. Okay. If the patient that you're, you're assessing and managing has already been on an opioid regime, then you want to be guided by what they're on already and be be guided by the response to opioids that they're already experiencing. So let's just say that you have your patient and they are established on this opioid regime that we've prescribed and things are mostly okay. You're keeping them in this window of being pain free throughout the day. However, there are a couple of incidents where things are not so good, they have episodes of pain which is not controlled or is suboptimally controlled and it's not all the time, but it's just happening every now and then. So we would talk, think about this as being breakthrough pain and what we would do for in this instances. And actually, I mean, really, we anticipate this in, in all cases, we would anticipate that this would be a problem. So you want to get them as well as the regular morphine we spoken about. In addition, you want to give them as required morphine that they can take in addition to the regular morphine and the dose of A P R N or break through a dose of morphine would be about 1/6 of their total 24 hour regular opioid dose. So again, we go back to this prescription, we're still continuing that regular morphine um to make sure that they're getting their steady state of morphine. And in addition to that on the add required part of the prescription, they can also have additional morphine. And what you would do is, I mean, there's no, um there's no hard and fast rules about how you titrate morphine in a patient. But you want to look at how, what's their state? How is the pain controlled? How many um additional breakthrough medication are they needing in a day? So if I look at a patient's drug prescription and they are not really needing any breakthrough medication or there may be using one a day, I might think, oh, I don't need to really change this prescription. I can keep it as it is and continue to monitor the patient. In contrast, if I see a prescription and actually the patient is requiring several doses of breakthrough morphine throughout the day. That makes me think this patient is not on enough regular morphine. So their their pain is so sub optimally controlled. I need to think about increasing the dose of regular morphine that they get in order to try and keep the pain under better control. Right. So I know that that was a kind of a quick overview to initiating a patient of morphine. But does that, does that make sense so far? Yeah, I said I had to get his time up. So. Right. I'm just going to move on. But you can let me know if there's anything that's unclear. Okay. So what here's a question for you. What should we always remember to prescribe alongside an opioid? Our our patient's any idea not uh home? Okay. So Christie is written in this chat still softener and anti emetic. And someone I think said naloxone, is that right? Yes. Yeah. What makes you think that because of overdose? Yeah, respiratory depression? Okay. Good thought. Okay. So I'm going to tell you know that in our patient population, which we're talking about right now, which is palliative care patient's, you have significant pain. Um You do not need to be very worried about respiratory depression, okay. Um So I'm never say never obviously because you know, things can go wrong. But in the vast majority of cases, respiratory depression is not something that you need to be worried about what you need to, especially if you use the regime or the kind of approach to morphine, which I have told you about, which is starting low, seeing how the patient is and then uptitrating it in response to their pain. Um So yes, if you rush in and give a patient whose opioid naive a whole bunch of morphine at high doses, then that would be something to worry about and think, oh, we need to get the naloxone out. But thinking about the regime that I've spoken to you about um respiratory depression is very, very rarely going to be a problem in uh palliative care. Patient's who have significant pain. Okay. So um Christie has said stool softener and anti emetic, okay. So the main yeah, anti emetic can be relevant, especially when you initiate a patient on morphine. Um it might take them a while to adjust and it might feel quite nauseated. Um So the, but what I'm really trying to get at is um lack stick. Okay. So let this be a reminder that when you're giving a patient morphine, um there constipation will occur. So you can have a patient who's in this nice range of being pain free. They're not in the range of being toxic but they still will get constipation. Um and that will bring with it. It's a whole range of problems and remembering that these patients have enough problems to be getting on with without introducing constipation as well, which they won't thank you for. Um So do remember to prescribe a laxative along with morphine. Okay. So I will briefly just mention opioid neurotoxicity. So the main clinical signs that we would think of if we were ever, if we were to get into that range where the patient is developing toxic symptoms of morphine, we'd be looking out for myoclonic jerks, um hallucinations, hyperalgesia and Aloo genia. Okay. And I I won't ask you if you know the difference between hyperalgesia and allodynia just because of time. But just to explain hyperalgesia is when a stimulus which is already uh slightly painful is experienced as being severely painful and allodynia is when a stimulus which is not normally painful is experienced as being painful. So, um these are patient's whose nervous system has become very excitable. So they have neuro excitability and you know, these might be patient's who are lying in bed and just um like a simple sheet lying on top of their legs can start to feel painful to them because the nervous system has this toxicity. So what you would do in this case would be, first of all, you have to think why has this happened? Have they had a sudden dose increase of their medication or do they have an inter current illness? Like have they developed sepsis? Have their, have their organ function gone downhill, their, like their hepatic and their renal function. Um So try to think about why it's happened, but it is important to try to do something about it. Um So I'd be thinking about probably giving the patient some hydration, some fluids. Um You know, you certainly would want to reduce the opioids. I mean, it can be very difficult if the patient is in pain to say that you're going to stop the opioid, but you definitely want to reduce it at least and probably withhold at least a few doses until the condition improves. Um But you don't want them to be in pain either. So we need to make a measure decision, okay. And you might want to try to get some haloperidol to um try to get on top of the hallucinations, okay. And remembering as well that um palliative care is not just pharmacological, it is holistic. So we want to assess for spiritual distress, want to avoid any activities which trigger pain. And we want to think about what can we do, you know, in terms of patient spirituality, their psychology, um their social life that might help them reduce or manage the pain. And you know, you may think, oh well, we're doctors, we need to, we need to give patient drugs to make them better. And that is true. Um But there is evidence that um you know, other interventions like making sure that a patient feels spiritually looked after, feel social, looked after is in a calming place, a calming state of mind maybe has, you know, calming music being played, maybe has, uh, the religious needs met. Um, there is evidence that patient's in that situation. Well, let have all those other elements, calming them down and making them less distressed, the experience less pain. Um, and I think that we can kind of think about this ourselves as, um, you know, even without having seen the studies, we can kind of think ourselves that does actually make sense if you think about it. So, you know, just a very simple example I would give you is that, you know, if you remember when you were a child, if you ever, you know, we're running or you, and then you ran and you scraped your knee and you fell over and you were crying in tears or maybe you've experienced this with a younger sibling or a child in your family, they're running and they hurt themselves and that, you know, they're so distressed. You think about all the things that you could do for that child to try to distract them, to try to get their experience, to be less distressed and their experience to be more um cam, so you might do things like you might, you might pick them up, you might try to soothe them, you might put on their favorite TV program, you might give them a bowl of ice cream. Um And actually very soon they get distracted and spacing the smile star and the, the tears stop. Um And actually the whole experience changes. Um And that's a very simplistic understanding that we have to remember that for everyone, no matter who they are, I mean, obviously they're not a child and the problem is much more significant than having scraped their knee. But for everyone, there's multiple contributing factors into what someone experiences. It's not just the physical side and we might not be able to solve everyone's problem, but we can make their experience as good as it can be okay. So to summarize pain management, um we've spoken about the pharmacological management and the non pharmacological management. And for the pharmacological management of pain, I really, we need to remember that morphine is going to be our friend. Morphine is going to be the mainstay of treatment. Um And we're remembering the principles that is by the mouth by the clock. We're thinking about our timing and duration, we use it by the ladder. So we're using the W H O analgesic ladder and it's by the individual and we've spoken quite a bit about how individualized um our approach to patient's and palliative care should be okay. So with that in mind, let's look again at these examples of pain, which we mentioned earlier on. So these three patient's which are very common presentations in palliative care. So let's go through them one by one and think about how we would manage each of these So let's say our first example, the patient with lung cancer experiencing left sided chest wall pain. The pain has a stabbing character with no radiation and he reports no other symptoms and he's been taking regular paracetamol that his pain is poorly controlled. So what are you going to do if this say this patient presents to you in clinic? What are you going to do? Use the Socrates again to assess the pain. Uh I think you already have a sites when you started seeing letter method. Oh, okay, Assad Hold your horses because Christie was right. So I was very pleased to hear what Christie said, which was remembering. Uh firstly, that we want to do our assessment before we go to management. Okay, sorry, don't, don't uh you don't need to apologize. But so remembering that the first we want to do our pain assessment and our pain assessment would consist of um our information gathering, our history taking and our examination. And someone said that, yeah, we need our, we need to do Socrates as part of our um information gathering. Uh You'd want to probably try and establish what's causing the pain. Maybe you can look at old scans, old x rays and you'd want to do a physical assessment as well. So let's just say that you, you have examined this patient and there's nothing in particular to find, there may be a bit frail, but you can't see anything externally, which is which is obviously causing the pain. But looking at the scans, you can see that where they, where the experience pain corresponds to where they're known lung masses. So you have think that that you've identified the cause of the pain and it's somatic pain, which is due to their lung cancer. So you've done that assessment. What are you going to do? Now, in terms of management, you need to find out from the treating consultants or whoever, what's the air plan regards to the, the mass itself? Are they continuing treatment or is there any other plan? Yeah. So yeah, that's a good thought. Um So I should be more specific and say you can do it. Certainly you should do that. But right now the patient is in pain today. So they, and they want you to do something about the pain. So what are you going to do? So, Jeff is written in the chart next at traMADol or codeine. Um So that is a good thought. Um So yes, I think you're right. We're moving on to think about what analgesia we can add in for this patient and it says that the patient's already taking regular paracetamol and the pain is not controlled. So at this stage, we're thinking actually thinking of the who analgesic ladder. Um This is not enough that paracetamol is not enough, we need to move up to the next step. Um So traMADol or coaching, I are opioid analgesics we can add in weak opioid analgesics that step to. What else could we do and saves as well and saves you a good thought. Okay. So I would um, I'm not good. Sorry. Someone, someone else gonna speak. I was going to say more things that we actually use a week. Opioid extremist. Yeah. Morphine, selfies. So good thoughts. So, so sorry. So yeah, we are thinking about adding in an opioid analgesic here. So I for simply it's going to depend a little bit what you have access to where you're practicing. Um So for a patient with cancer, I would always advocate patient in cancer who's experiencing pain. I would always advocate to go to morphine if you can, even if you're only thinking step to, you can give low dose morphine. The reason being that it allows you to have a smooth up transition if you want to titrate the morphine up and if the patient is going to have significant ongoing pain and you're going to have to go to step three anyway, you can up titrate the morphine whereas both codeine and traMADol have a ceiling. So you will get to a maximum dose, then you're going to have to move over to something else. You can't continue them at step three. Okay. The other thing I would say is just be a bit cautious with traMADol or be very cautious and say because it can have quite a lot of side effects that we've, we've not spoken about today. Um So if you don't have access to morphine, I would advocate codeine if possible, although you could also give traMADol and, but just be conscious of the side effects. Um So in this scenario, I thought that what we would do is yes, do an assessment, Philippine history, assessment of the social, psychological and spiritual symptoms. Um continue the regular paracetamol. I wouldn't stop that. We would initially a regular morphine dose as we spoke about giving the morphine regularly by mouth. And we want to prescribe a laxative as well. And we'd also prescribe as required morphine that they can have. In addition, we monitor the effects and we want to see how much breakthrough analgesia they're needing and how the patient reports, the pain is controlled and use that to cautiously uptitrate the morphine. We could consider an achievement and think about if there's anything non pharmacological we would do in this, in this case. Okay. So, um now let's just I made it a bit more tricky now. So let's say some time has passed and the patient has come back and this patient has um now it's maybe been about four weeks and they come back to clinic and the patient is reporting that they feel generally uncomfortable and he's with his daughter and the daughter says that she's seen, she's seen the patient twitching. Um And when you ask the patient, if there's anything troubling him, he says that he feels that there's, when he's lying in bed, there's a shadowy figure looming over the bed. So, what do you think has happened now? And what you're going to do about it? C W O P A. Toxicity? Yeah, because I think that's what I was getting at. So he's, he's uncomfortable in bed so he could have allodynia. He's twitching myoclonic jerks and he's seeing a shadowy finger looming above his bed. So he's um hallucinating as well. Visual hallucinations. Um a sad yes, I was like Kristie says she's right. Uh toxicity. We have to check for that for the twitch. I think you might also have to check for the calcium release. Yeah. Yeah. You figure shadow figure is like tender submission which is a symptom process it. Yeah. Absolutely. Yeah. So what, what's your management going to be? Now? His pain, he says his pain is now fine but he's got these other symptoms using the opioid like nothing. Uh for the twitch, we might get catching heat on it. Yeah. So let's just say you, let's just say you check the calcium and the calcium spine. Okay. So his he doesn't need calcium replacement. Um but he does need something done about the opioid toxicity. So you're right. You said um reduced the opioids. So Jeff has said naloxone, okay. So I probably should have specified this in the information like I gave her the screen, but let's just say his respiratory rate is fine. His respiratory rate is 12. Um, and he's not, he's a bit drowsy but you're not worried about him becoming more abundant. So, we need to, we need to generally check if he's taking the character regime, whether he's helping himself a little bit extra, uh, dose of medications because the patient's tend to do that, isn't it? So, yeah, that's a good thought. You know, clarify what he's actually been taking. Has that been? Maybe he's not understood what dose he was supposed to take and he's taking double the dose, something like that. Yeah, good thought. Uh, so I think, sorry, go on, sorry, I was just only going to say that we can't completely take him off the opioid because it is somewhat controlling his pain. So be careful and yeah, exactly. So you don't want, you don't want his pain to come back. So it's tricky, isn't it? It's a balancing act. Um, between wanting know you need to get, you need to reduce his neurotoxicity but you don't want him to be in pain. So, um, I would say that we want to consider why has he become toxic? Is that because his dose we overshot with the dose? Did we give him to a higher dose by mistake? Has he been taking too high a dose? Has he been like he said, increasing the dose himself? Has something else happened? Like, has he developed a urinary tract infection or has he developed acute kidney injury or something else. Some other inter current illness which has precipitated this. So, or if there's an underlying cause, we want to address the cause. Um, this patient probably, well, they definitely need them more being reduced, probably okay to skip, you know, a few doses but not take him off completely. Um, probably needs a bit of hydration as well to try to flush the toxicity out. You could consider adding in haliperodol to reduce his hallucinations. Um And you know, just a thought that if he was on edgy, any adjuvant treatment, like any anticonvulsants or anti depressants, I would also reduce or stop those at the same time if a patient becomes toxic as well. Okay. So that was very good. Um So it sounds like you're getting the hang of what to do. Um So I am actually just quite conscious of time. Um I was supposed to speak to half past three. Um Sorry UK time and I know that time is getting on. Um So I wonder there is still quite a lot to cover. Um So I wonder Anna if you're there and you can hear me whether or not um I could perhaps be slaughtered in for another heim in the schedule to do the second part of the presentation, do you think? Yeah, sure. We've got a few, we've got a few empty slots. Um So I can message you later. Um And you can decide when is best. Yeah, that would be great. Um, I think, because I think there's quite a lot, there's still quite a lot to get through. Um, so I'll maybe I'll just maybe go ahead to the summary for just now. Um, and then the other symptoms that I was going to speak about, we could maybe speak about the next presentation. Um, is that, is that okay for everyone? The students are here today and we do it that way. So Jeff has said yes. All right. Okay. I know that. Um I know that I've used up quite a bit of your time, but I think it's been a really good session and we've certainly covered the principles of pain management. Well, um and there's been really good participation as well and even though it's a small group, we've, we've had quite a lot of discussion. So thank you very much for that. Um Christie saying yes, it's also thank you for that. So, what I'll do is I'll just skip ahead to just this summary section. Uh um Which is that, um we've spoken about pain, we said that we were remembering that pain is what the patient says. It is. Um Pain assessment is an essential part of our strategy toward dealing with pain in patients with palliative care needs. So, we do need to do this assessment because it's going to inform us about how we're going to manage the patient. Um because the patient is an individual. We want to do an examination and gather what information we can about the underlying positive pathology. We've spoken about pharmacological management today, which is by where we, we remember the principles of by the mouth by the clock. So we're giving regular analgesia to try to maintain that steady state concentration in the system. We're using the who analgesic ladder, the W H O analgetic ladder, and we're remembering the individual and we're also remembering non pharmacological aspects of management as well and that, you know, pain relief is a human, right? So we can always make everything better for someone um can always take the problems away, but we have to do what we can to try to help. So try to reduce the patient's suffering by doing what we can to relieve the pain or at least reducing. Okay. So, thank you very much, everyone. Um Was there any specific questions about palliative care generally or about pain that you wanted to ask just now? Or should I just let you go? Jab says, thank you. You're welcome, Gem. Hi doctor. Yes, there is actually okay. Yeah. So um regardless of the palliative or not political, just for pain in general sometimes uh is you can get to be difficult. Maybe I should say like to know which pain relief to choose from. Yeah, when you have so many options, like example as dinner doctors and it's just disseminating uh and then we'll add your ad we based, we want to give you a different kind of pain, different medications. Um, so I think your question was there's so many painkillers to choose from. So how do you, how do you know which one together? Is that what you're asking? Yes. Like what's the logic? I do? Like what, what would be reasoning for choosing that, that type of pain relief? Okay. So, um, so ultimately, I mean, there's no, there's no easy answer. Um So the answer is always just going to be, you have to give the patient the pain relief appropriate to their situation. Um Which I know it's not, it's not a uh perhaps a very useful answer. I mean, the guy, the guideline that we stick to in principle is the W H O analogy music ladder. When we think about if a patient has mild, um moderate or severe pain, a make stepwise increases in according to the ladder. But even within that, there's going to be patient for whom that's not appropriate. You know, if you have a patient with who's, you know, just broken their femur until they're lying on the ground in agony, then, you know, a paramedic who comes out to see them isn't going to mess around with, you know, step one and step two of the analogies gladder, they're going to go probably straight to I'm putting in a cannula and giving that patient intravenous morphine. Um Likewise, if you have, uh you know, a patient with um maybe it, we've not spoken about this today. We will next time. But a patient with intestinal obstruction or a degree of intestinal obstruction, they have lots of colicky pain in their abdomen. In which case, you might want to give them an anticholinergic drug like bask upon highest seem to try to reduce um those colicky effects in the abdomen. Um So it's all about um addressing what you think is, yes, the W H O analgesic bladder is there to guide you. But you have to remember the individual and as a doctor, you're trying to get down to what is the um what is the underlying pathology which is causing the patient's pain and what is the best drug or other management to address that pain? Um So I have given you hopefully some, you know, an approach to take for a patient with life limiting disease, life threatening disease, particularly patient's who have chronic cancer pain. Um But that's not necessarily going to be the approach that's appropriate for other patient's with pain. So you really just have to treat, treat patient's as an individual. Um So sorry, I know that's not a simple answer to your question, but hopefully it's given you a bit of insight. Yeah. So basically, I guess um we have to go by according to severity of the pain as well as the mechanism of that injury that, that might be happening in the body, right? Yeah. Exactly. That's a good summary. Yeah. All right, lovely, thank you. Okay. Well, thank you. Um Did anyone have anything else? Okay. That's great. Um So thank you to everyone. I do have another lecture booked in which is if I just go to the end, remind myself, I think it's the 14th of March on palliative care emergencies where we speak more about. And yeah, 14th of March 2 PM. You Kate. I will speak more about how to care emergencies like hypercalcemia at that point. But I will also book in another slots to talk about the other, the approaches to the management of the other common symptoms of palliative care. Um So, thank you very much.