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Hello, good evening and welcome to uh this uh sex education update. And thank you to everyone who's come along today to listen to our colleagues from palliative care, come along on this rainy Thursday evening to educate us. And I know that many of you will already be six members, but just very briefly. And for anyone that isn't sex as an organization which aims to improve the care delivered to critically ill patients throughout Scotland. And the focus really is on three main areas, education, research and audit. We have a number of membership categories that come with benefits including a reduced delegate rate at our yearly ESM meetings. For those of you who do inter hospital transfers. You also get comprehensive travel insurance and there's access to various travel and education bursaries as well. So if you're interested in membership, have a look at the website and you'll be glad to know that the 6 a.m. is back for next year and booking is open with early bird rates on the six website. Um So just to introduce our speaker for this evening, and we're delighted to be joined by doctor Abby Walton. So, Abby is a palliative care consultant, the Royal in Edinburgh. And she's the clinical director for acute palliative care Services for NHS Lothian. And we also have a Dr Becky Evans that joins as well, who's also I'm a palliative care consultant at the Royal of Ed. And they have both really been key players in building the relationship between our units, our palliative care teams and they've proven critical for the collaborative management of very several very complex patients with NHS will in the past couple of years. And then Abby recently gave her time extensively and input her clinical expertise into our new palliative care guidelines. And so we thought it was a really important topic and there was a good appetite for people to hear about it. So, thank you so much for coming along and I'll hand over to you. Thank you very much and uh thank you to six for inviting us to speak tonight. Um I'll be doing the presentation but as I said before, Doctor Becky Evans is also around and is happy to join in chat later on II, think what we decided um as a team was that if you have questions, as you go along, please do put them in the chat box. Um I will try to look at the questions and maybe answer as I go along. I presume everyone can see the chat box, but if not, I'll also read out the question as we go. Um Now I know this is designed as an education session. What I'm probably very keen to put across is that it isn't me educating you. Um It's me talking about our experience, how we found the sort of increasing collaborative work between our services, maybe talking about what we can bring to things, but also raising some questions going forward. Hopefully you can see the slides as they go along, please uh comment in the chat box if you can't. Um So thinking through the aims and objectives of the oversight, um I suppose it is trying to work out where we can collaborate and where we can enhance patient care. And as part of that, I wanted to give a little bit of an oversight of how palliative care is changing. Um and how it's changed in the last decade or so, especially within the acute hospital setting. Um I'd like to show that although we feel like we might be very different ends of the spectrum intensive care and palliative care. Actually, there's may be more similarities than you might think in terms of how we approach patients, what we do for patients, all of that sort of thing. There's also similarities and also differences with medicines we use. Um And I suppose that's where some of the questions um that I raise, um maybe we approach things slightly differently with certain medications. Um and really for us and for the intensive care team at the Royal Infirmary and the wider Lothian area. It's made us think about things on both sides. So I think it's been a really useful two way learning process. So I just wanted to talk about historically for uh specialist palliative care services. Where were we and where, where are we now? So II think that, you know, there's a certain um resilience that comes with being a palliative medicine physician. And part of that is you're the one team, no one wants to see. Um, no one wants to be referred to you, they see you coming down the corridor and people actually say comments like, oh, not right now, we don't need you. Um And it's actually, I don't think any other team in the hospital sort of has that to deal with. And II suspect we Becky and I are quite thick skinned now for that reason. But actually that is because we were always tied into the old biases around palliative care equals dying. That's what we're here for the doctor, death and we deal with all the death in the hospital. But actually, things are really changing. Um, what we used to do was wait for the palliative care need to be recognized. So we'd always sit there waiting for referrals. But what we've learned over time is people don't recognize what we can bring to a situation and if they don't know what we can bring, they're probably not going to ring and refer to us on an early sort of basis. So really there is a changing face of palliative care towards more of a supportive and palliative care um environment. And this is partly based through um the more sort of um modernistic approach to seeing a palliative care is more of a bow tie model. And that sort of is a way of representing that patient care often starts early and has different interactions over the course of the of the patient journey. There's definitely more recently, however, been some even clearer evidence that early intervention of palliative care, sort of how we assess patients symptom support things like that has really improved patient care and improved working relationships between teams and probably the biggest area of that within the Royal Infirmary of Edinburgh is looking at how we support the front door. So the A&E the ED department and the AU Department with patients who are high under scheduled care users and what we can bring to see them early to be able to consider early turnaround and discharge planning especially is a specific cohort within the lung cancer group who are high users of, of unscheduled care. And actually, we've been doing a lot of respiratory based work for early intervention in palliative care for respiratory patients, a large proportion of whom have palliative care needs. Um but we're also involved in prehab work and I'll talk about that a little bit more in a minute. Probably one of the papers that's made a big difference. Um to thinking about early palliative care intervention is this is this paper and it really sets out that actually, um patients who were seen by palliative care earlier. Um as more routine uh review with a small non small cell lung cancer, they not only had a better quality of life, but there were some indications that they may have a more prolonged uh life expectancy. And actually, I think I always tell uh medical students who rotate through our our department this because I think they're often quite surprised cos again, their old adages, palliative care is uh end of life care. So actually, to think through, why is that? II think really it focuses on getting the small bits right? So that the patient can focus on the big bits and that might be managing their symptoms, better reducing their morbidity from poor symptom control, but also morbidity from being on the wrong medications and focusing on what's important to them. So we have an increasing sort of evidence base of what's going on in our hospitals as well. And I did say when I was doing this project, sorry, this presentation right at the beginning that I am focusing on the acute hospital more because that's where the majority of my current experience lies. So we've got a bit of data. There was a um a paper published in a few years ago now that actually looked at Scottish hospitals in one day of the year and they actually identified that there was a huge proportion of patients who were in hospital who were, they went on to watch what happened to these patients. Um And really, there was a massive sort of cohort who were going to die in during their current stay. Um but also a large cohort who were going to have deteriorated and died within the year. So about a third of patients naturally for the elderly is about a half of patients. So a huge cohort who was sitting in our hospitals who were probably within the last year of life. And as soon as we were in the last year of life for our patients, we need to start thinking about how we help manage those patients get the most out of that time that they want in a way that they want to be cared for. And when they looked at this paper and talked about it, they then referenced another paper and I've put this in because II thought it was a really good way of of putting it out. So um it highlights the mismatch between current best practice recommendations and the observed clinical reality. And it talks about the internal momentum of the hospital towards cure and this inhibiting clinicians from standing back and thinking about the overall goals that it should inform patient care. We also sort of have to think about what the guidance is. And actually, if we think someone's likely to die within 12 months. There is a strong emphasis that should be placed on patient choice rather than our medical paternalism, however benignly intended. So I think, you know, these are things to think about. And actually we have a growing cohort who are sitting in this category in our acute hospitals in Scotland. We know that a good 50% if not more of patients actually die in the acute hospital. That is the place where they die. And we know recent studies, fairly recent studies that in the acute setting, um cancer deaths are over 50% as well. And that's in cancer where generally we're able to prognosticate a bit better certainly than more so than in the non malignant cohort. So even in cancer, a large proportion are are dying in our acute hospitals for us. Locally, there's also been a reduction in our community palliative care beds and our numbers have reduced post COVID. And as everyone is experiencing, there is variable access to social care to support end of life care at home. And a little bit of a lottery in terms of where you live as to what you can access services. So generally, palliative care in the acute setting is changing and we're getting more focused on symptom control and moving away from just end of life care. We're seeing more patients with uncertain trajectories. These patients who carry a lot of morbidity come into the hospital may die may survive. Um but actually possibly don't have a prolonged, um, prognosis. Anyway, there's a high morbidity of poor symptom control and inappropriate medications and Becky and I deal with this day in day out in the hospital. So getting that right is, is, is providing us with a lot of work. Um, we have more, more multimorbid patients living with long term often incurable conditions, which may also be quite markedly life limiting. And then we have the sort of focus where we should be um putting sort of patient centered care and realistic medicine into place and what is acceptable to you. And I think the other thing that we're really focused on as a team in the acute is starting to think through how we avoid pro protocolization of care and make it more person centered and um personalized care. And that's one of our big focus focuses as a team, just a quick note about the prehab work. So this is where we're seeing patients with advanced cancer, lung cancer, but we're seeing them after a respiratory physician sees them and before an oncologist sees them and we see them, they see me as long alongside a dietician, a physio and access to psychological support and we see them before they access treatment. And again, it's all about optimizing wellbeing, focusing on the little bits to get the bigger bit better if they are suitable for active anticancer treatment. But what we're seeing already in the preliminary pilot phase is that there's probably a big reduction in hospital admissions for this cohort if they get seen by the prehab team, which includes symptom control, which is quite a novel approach. So another way that palliative care is changing in terms of, of what the old gadget is and what we're doing now. Um OK, I've talked a little bit already about the front door services, so especially as palliative care in IC. Well, um increasingly, we've been working more and more collaboratively between the two teams and we're starting to gain a bit of sort of experience of what works well. What, what, how could we improve things which patients are we more likely to see? Um where can we sort of join together and enhance patient care? So, the sort of examples we've been uh seeing are where there's an uncertain trajectory, post extubation. Uh there might be a need or a high likelihood that they need symptom support around extubation more excessively than maybe what would have been in a normal extubation. But also there might be an ongoing need for that symptom control. Um And the other point of that is if they are then being considered for transition away from ICU to a ward where we're helping in that sort of facilitating a transition. Um We are looking specifically at a focus on discharge planning and we've got some examples of where we've done discharge planning for end of life care, but also for ongoing care with family, with sort of care plans, really detailed care plans to try and avoid recurrent hospital admissions. Um We found that being there and supporting the team and supporting the patients and the family has improved continuity of care. Um Certainly, if we're visible in ICU and we're visible on the ward, we can often be that continuity and that's what IC obviously do when they transition people off who are well. So it works that we almost do the same as an ICU team would do where they get post ICU visits when they're improving on the ward. In a way, we're just turning that on its head and we're reviewing when they're on the ICU and we are the continuity for that family when they move off the ward, the other bit where we, we, we are working together especially is, is where seizures are part of an end of life situation or where seizures are very complex to manage. And IV lines um and IV infusions aren't necessarily feasible for uh ongoing seizure management. And we have quite a lot of expertise in more palliative management of seizures as, as we talked about before, as Doctor Fleming said, we've worked quite collaboratively to and fro on the end of life care guidance for ICU and really, really had a two way learning process in all of this. I've learned a lot. I know Becky and I feel we've learned a lot from the whole processing Um and, and hopefully we're bringing something to that as well for the ICU team. We're also looking at just trying to gather a bit more data as we go along. And one of the IC registrars anesthetic registrars who did a bit of time with our team has been starting to collect the Lothian data around our referral patterns. Um What are the patients we're seeing? What are their outcomes? How long do they live? What are medications are they getting? What does their I CCU in patient journey look like? I think he's trying to sort of look is, is there a way we could have sort of thought about um earlier sort of discussions about, should they have gone to itu? And, and that isn't the purpose of our involvement isn't to say, well, his patients should never have gone to itu because that's for you guys to decide. But I think he was particularly interested in that element of it. So we're going to start looking at that and, and trawling through the data a bit as well and try and understand it a bit more to help us going forward. Now, I can't see any questions yet, which is good. But do remember if you want to ask questions as you go along, please? Uh just pop it through and II will try and uh talk as we go along. Um OK, so the other thing is II don't think we're as far apart as you would feel. Um, and we, we sort of tried to think through what are our commonalities. Um, and one is, I suppose we both deal with really, really sick patients. Um, now obviously you guys try to improve their care and I suppose ours is slightly different where we sit with that. So I'll go through that in a minute. We both manage high dose strong opioids and we both are familiar with, uh, complex drugs of other varieties. So we're familiar with complex prescribing and understanding medications and the other bit where we feel that we have similarities as teams. The ICU and specialist patient care are that we both are quite familiar and comfortable. I would say with leading complex communication with patients for us more so maybe than you guys because often the patient may be less well and unable to engage but certainly families and this holding of a uncertainty that we have around future planning and obviously the holding of uncertainty is a very uncomfortable thing for us all and relaying uncertainty is even more uncomfortable for us all. But I think his teams were probably the most familiar at doing with that, doing that. So I suppose the bits where we vary are that I said before you guys take someone to ICU but with the hope that things will improve. Um And I and I would argue maybe that for um for ICU when it fails, it, it feels bigger. Um I suppose, you know, for us, whenever we meet a patient, we already know the reality. We know that the reality is one that we've clarified, they're not going to improve and they are truly palliative and that's maybe where that slight dichotomy sits. So we both manage these big drugs. But I would argue in a little bit that we, we use slightly different drugs and we do use them in different ways and we're learning how you guys use them. And I think certainly in the royal, they're learning how we use and we're sort of finding a middle ground where, where we use them in different ways for different people. But we're also learning from each other as teams about what, how you use the drug have benefit where the benefits lie with the drugs. And we similarly sort of um put our information in as well. So, um one I would say is, is that maybe IC is much more protocol driven because you have protocols around intubation and things like that and, and protocols of which drugs use for infusions. Um And I suppose in palliative care, we're completely the opposite to that. Um And we probably um vary what we use very significantly between each individual and for different reasons because we are not sort of going through the protocol of intubation. Um So we talked about this holding uncertainty with the patients and families, but it's whether maybe the palliation comes as a bigger sense of failure. And I put that in inverted commas because it really isn't failure. But it's how does the team cope with that? And if we can support that team in recognizing there are still things we can do and and palliative care is always focused on what, what can we do, not, what can't we do? So hopefully it's a way of supporting the team alongside the patient and family to say, OK, we haven't been able to achieve this bit. But what can we do to make this next bit feel more comfortable or feel like we've added something in um to help autonomy or help patient wishes or anything within, within that arena. So where our practice may differ, um We've sort of talked about opioids, the use of different opioids, the choice, the dosing. Um We use very different dosing and I'll, I'll, I'll move into that in a little bit. Um at the end bit later in the talk, I suppose the other is, is where we use drugs for agitation. Um And for example, in ICU, I think you use a much higher ceiling dose of haloperidol than, than we would use in specialist palliative care. My comfort zone is probably 3 to 5 mgs in 24 hours of haloperidol and I suspect for most intensive care positions it's a good double or travel that um and that might be different in different departments around the country. And again, we're trying to learn that a little bit but we probably use the broad spectrum antipsychotics, um the phenothiazines more. Um and actually, um one of the things of developing the guidelines together is trying to find those middle grounds and use some advice around how we would use these drugs. But they're quite unfamiliar, often drugs like Levo premazine in the intensive care setting, that's not gonna move. OK. Right. So one of the things is looking at the literature around um the involvement of palliative care integration into the intensive care unit. And there's actually quite a bit when you look around for it. The first we pulled out a couple um probably a little bit biased to pulling out things that we felt highlighted things that we wanted to speak about. There's probably um also evidence that sits with things that sort of challenge some of what we're trying to think about. But I'm, I'm going on the slightly biased um approach here. So this was a Singaporean tertiary teaching hospital um that had a H 51 ICU beds. Um And it had um it basically set up a study where they looked at focus groups with healthcare professionals and um how, how they integrated palliative care into the unit. Um Now, the reason we highlighted this one was trying to sort of work through what, what the clinicians felt that palliative care integration did. Um And there were three areas where they highlighted the benefit. Um And one was that it helped bridge care, which we talked about as being a benefit that we'd experienced. It was a cultural shift and change in attitude towards maybe thinking through palliative care approaches. And that um having the palliative care team involved helped in power and advocate and to a degree enhanced job satisfaction for them. Um There was more mutual understanding, more shared decision making, more alignment to care goals and a bit that we found really helpful. Although you've got to be careful how you phrase this because if you say active process of death, it turns it into active process. Got to be careful of what we mean by that. But, but really seeing not just the withdrawal of care and that's it. And then the patient dies, but actually trying to actively manage the end of life care and manage that in a way that provides people benefit both in front of them, the patient, but also how they feel about what they've done for a situation. And there was a real feel that they felt empowered to advocate for patients and they felt a better sense of job fulfillment. And I'd certainly say our interactions on the ICU ward is, is certainly for the nursing staff, especially who are in charge of that patient. Obviously, it's such an intense relationship when we have managed to get someone home for end of life care. The nurses on the ward have been hugely involved and very intensely involved. And if they've really sort of really seen that sense of job fulfillment of achieving something, especially in a situation where they may not have felt it would have been achievable. And we'll give an example of that later. Um So the other one and as I say, slightly biased, um but this one was a cost analysis that we pulled out. Um So it was in Texas. Um And they compared length of stay in hospital costs between two treatment groups where patients got P care in the ICU versus usual care in the ICU. Um Now it did talk about mean length of stay and then it did say that it was slightly increased, I think in the control group. But what they found was that the overall the hospital costs reduced in the treatment group versus the control group. So there were probably less interventions as a result of everything. Um And that the overall the costs were reduced. Um Even if they were in hospital or out of hospital. And I, and I think that probably just reflects again that you're probably tailoring care, you're making sure that you're not doing inappropriate interventions and you're focusing on what is required for a patient and family. So I was hoping um I just check if there's any questions I haven't seen any come through. Um uh what I was going to talk about now is a few case studies and then a little bit about maybe challenging, um some questions out there that may just for us to think about going forward. Um So, um I brought five cases which hopefully, um sort of oversight just quickly. Um The types of things we've been involved with. Um, the first one was a 76 year old uh patient and this actually highlighted the uncertain response to extubation. So the patient had significant brain injury. Um They had been switched off, They were not really responsive but were biting uh at the et tube and agitated and they'd remained on, on a fentaNYL running at three mils an hour. Um They really didn't have any awareness of the surroundings and no motor response and the feeling was yes, they, they could self, they probably could self ventilate although it wasn't sure. Um But um what, what was very clear for the family is the recognition this patient would have significant brain injury and significant disability and there was an agreement that he just would not want to live like that. So the decision was made to extubate. Um But they weren't sure about how well or otherwise he would self ventilate it because he obviously did seem to have some brain function even though it was, it was a low level. So at the point of extubation, the alfentanil was stopped and he commenced on morphine and midazolam infusions. Um But what happened is he, he, he then as he was extubated, he started to develop really abnormal disordered breathing. Um It, it sounded quite obstructive breathing, sorry breathing. And there were a huge amount of secretions and actually the family are in the room and became very distressed and the patient became very distressed very quickly. Um So, um we went to see him. Um and I really spent time with the clinicians and the patient and family. Um And what we, what we were wondering about was for this patient, whether actually some of the rapid reduction in our fentaNYL um had maybe caused some and then a relative reduction in his opioids that he was getting in the infusion. There was a bit of a mismatch. Um But also some of his distress was happening probably generally because of the extubation itself. So it was a mix of things going off. But what we were able to do is be there and support because the ICU was very busy. There's a lot of other things going on, the team members going in and out and actually always with palliative care. One of the things we can give us time. So we support our day in a way that if I need to spend two hours with a patient and a family, then probably I can do it. I mean, we're getting busier and that's the challenge of it, but that's where our benefit lies, we can be there, we can stay, we can be that consistent. OK. Let's let's quickly titrate this morphine and Midazolam, we gave boluses, we assessed response, we gauge benefit. Um We, we got to a better level on the infusional rates where we were comfortable with what, what he was getting. Um, it was titrated very quickly to bolus dosing. Um And by being there and staying there and supporting that, we were able to support the staff and the ward and actually you did become much more settled. Um, and we stayed until the patient died. Um, and it, and it calmed and everything calmed quite nicely for the end of life. Um So that was one example. The second, um one is where we've, um, we've talked about transition of care from IC to ward. So we do do this an awful lot. And I suppose it's just an example of, of what we focus on uh to do that. So, um this patient was actually expected to self ventilate for some time, post extubation. Um And prior to this, we talked about what might be needed and what might be required. And when we first reviewed, they still had large a fentaNYL infusions running for sedation. But there was a desire to take out all IV lines and minimize interventions. Um What's often the case is the amount of drug running through at this point is too big um, for any syringe driver or subcu line delivery. So we are left with goodness, this patient lives lovely and settled, but they're on huge doses of medicine. There's no way I can convert this into subcutaneous medicine in order to transition to a ward and be sure that we're not gonna witness a withdrawal of opioid or benzo or something like that. Um So we need to work through how we do that um to get them to manageable levels to go to the ward. So what we work through is OK, what is this patient on? What are they on it for the fentaNYL in this situation? I can't, I must admit I haven't put the diagnosis in, but actually, in a sense, the diagnosis was more irrelevant. And what we did work out though is that the patient didn't have a painful process. Um They were on it for tube tolerance. Um But there was an uncertainty about whether they'd have an underlying agitation. Um and questions about whether other drugs or medication would be used. So, what we did is we, we spent time in the ICU and did slow and steady down titration of the alfentanyl to see how the patient responded and if any agitation developed, so we could try and gauge a threshold at which we were comfortable where OK, this patient should manage that. Um And this helped us work out then the doses of the opioid alongside the sedative medications that we were gonna use and transition the patient onto and that probably took a good hour or so to get that sense. Um Then we were able to set syringe driver doses. Um And what we usually want is a good four hours of the pump being titrated. So, uh the pump being running subcutaneously. So there is good steady state. And then at that point, we usually ask for the ivs to come down, but only four hours occasionally, we've done it quicker if there's an urgency in the beds. And we've just had to say right, we'll bolus dose them at the ward if they're unsettled. Um So that worked well, we got a nice steady state uh patient and uh family were transferred to the ward. They had seen us, they knew who we were. There was a continuity of care and a comfort for hopefully for the ICU team as well. The third case um was where we've discharged home for a dying patient. Um This is a patient that we had relatively recently. Um longstanding background of c spine injury and paralysis um admitted with abdominal pain and a pseudo obstruction of the bowel and then developed respiratory decompensation probably as a result of the sort of push on his, on his chest and his and his poor ventilatory capacity in the background. Um He was transferred to ICU for high flow nasal oxygen. Um but unfortunately, he became, when he was on high flow, he became very distressed and agitated but was still able to talk and express his wishes. Um My colleague, Becky actually was the first person to see this patient. Um, and they had to work through, I think, was she correct me if I'm wrong? But I think he might have been on a PC or something at one point. Um So they had to work through, um, how they were going to manage his distress and agitation. But actually what he was able to relay was that he didn't want to live like this. Um And he'd had 20 odd years of being in quite a lot of pain and distress. And actually, this was all now proving too much and there was a feeling that he would not improve globally. Um So it was quite a difficult complex decision making process. Family were very distressed, but actually all came round and supported him in, in his decision making. Um So, Becky had been there to uh to help stabilize his symptoms prior to his removal of high flow oxygen. And I think there was quite a concern that he'd come off his high flow oxygen and deteriorate very rapidly, but actually, uh sorry, he was on the potential PC. Um But it was nurses who've been delivering it. So we converted over from that to um Syringe driver with good conversion timings of oxyCODONE and Midazolam and his high flow nasal oxygen was removed. And what we often find is you manage their symptoms and actually they rally a little bit and this is exactly what this man did really, he came off the high flow medicine, the high flow, the oxygen, sorry. And then as his medication settled in his system and was titrated, he actually got a lot more comfortable and his condition started to stabilize. So I saw him the next day and actually the question was from him and his family. I want to die at home and I'd like you to facilitate this for me. Um And I think the staff came to us saying goodness, this can't be feasible. And, and the family were almost like, can't we recognize that's probably a long shot. But I saw him on that day and felt, I think it was the Thursday. And we said, well, we've probably got a window. You're as good as you're going to be. And he was pretty certain that this is what he wanted and he'd always wanted this. Um, so actually we turned around and said, yeah, we'll, we'll give it a go and we gave them a lot of uncertainty that he may not achieve that, but also a lot of reassurance that the family had the reassurance that they'd seem to his wishes, even if events took forward that he couldn't make it. And actually that was a huge psychological burden taken off them that he'd heard them say we'll do this for you and heard us say it. And if in reality it hadn't happened, we reassured them that that was important that he'd even just heard that. So for that family actually, that, that took a huge burden away from them. Um One thing that's familiar in all these cases that we do manage to get home is that they have a package of care already and this man did and actually they are so much easier to get home when they have a longstanding private package of care funded through the partnership. So, um, the care wasn't an issue and that was a big barrier removed. So we didn't require extra care. He'd actually said I'm not having a hospital bed. Uh He wanted to lie next to his partner in his own bed and be there when with her next to him, when he died. Um, he didn't need oxygen. He was actually saturating pretty well considering he was off high flow oxygen, syringe drivers were working well for his, his symptoms. So actually, this was the window, we had to get him home. So it was a rapid coordination of discharge planning. Um We had a bit of an argument about the bed because of carers and health and safety and things like that. But actually the, the sort of um compromise was we get a repos mattress. Um, and everyone was accepting of that. So that went in family, picked it up, was there and ready when he got home, uh all his A cps and we gave him enough for to, he went home on a Friday and we gave him enough to get through the weekend all counted out relate to the GP GP did community prescription charts early. So they were already everybody have out of hours contact numbers, hospital, sorry, community palliative care were informed, everyone was ready. So we had a risk about risk of going home, risk of ambulance journey agreed that he wouldn't be readmitted and he was all care at home. Talked about what if he would die en route. He um he didn't really want that level of conversation, but his family had that with us and agreed that he would go home. We asked his GP, if that was the case, would you verify the death? And he agreed, he very supportive. Um So we had a small window. We knew if we left it past the weekend or even then Saturday, we'd probably miss the opportunity because he was probably going to die pretty quickly. So enough, a CPS sent home with him, everybody involved. He was discharged successfully and he died within 24 hours of being at home. Now, I haven't heard anything back, but he certainly wasn't readmitted and I haven't been called about any major traumas that happened once home and I would have thought the amount of work up we did that we would have been informed by that. So my hope is that that all went smoothly and we sort of this man's wishes case. Four was a 30 year old gentleman with a complex background, including cerebral palsy. Um he was peg fed, he had learning disabilities. He lived in a care environment. He had lots of problems with recurrent small bowel obstruction. Um and he kept getting recurrent ili, he would vomit, he wouldn't absorb his amp epileptics. He went into stasis. He had poor IV access. Um, family had been keen for all active treatment, but actually watching him go through, this was starting to question whether he was starting to suffer too much. So they were more open to um discussions about what that might look like. Um very, very complex communications for the, for the staff, Becky, my colleague led on this one and um lots of conversations with HD U family, patient carers and ourselves. Um We were involved and helped with discharge planning and look at anticipating planning and say, well, what if this happens again? Um So it wasn't so much about palliative end of life. It was more about how can we keep this man out of hospital. He's used a lot of unscheduled care and we're not sure it's really aiding his wellbeing and it's not in a place that is good for his, his global wellbeing. And can we get him back to there where he knows people and where, where he feels safe um went through everything. It was an incredibly long process, this one and agreed that actually coming back to ICU or HD um wouldn't be a good, a good thing for him and everyone agreed and he was discharged straight from HD. Um So lots of extensive collaborative work again, palliative care, supporting ICU leading really good collaborative working. And what Becky was able to do was it was right, an extensive care plan which had many iterations going back and forth and agreed with everybody including the, the, the family and, and, and the oversight of, of what would happen. So what would have, what's happening? What are the plans for discharge? What about feeding symptom management? What have you vomit? What have you had seizures? How would we manage it? And actually, what's worked really well is that, that um the plan was that when he starts going into an eye and he starts vomiting his medication for his seizures are easily transferrable into syringe driver pumps. And we've had more than one episode um since he's been home of achieving that, keeping him out of status, which is the bit that usually brings him in, waiting for the eyes to settle and then um reinitiating his tube antiepileptics. So it was all agreed um circulated huge amounts, hours and hours of work, which again is what we can provide to support that. And often what the day to day clinicians who are in charge of ward patients don't have the ability to do. Um and lots of documentation in his electronic notes which is being followed. Um So it's, it's worked really well. Actually, he was discharged, home, remained at home for a number of months. He has had these episodes, but he goes on a pump that manages medications that way and then everyone knows what they're doing. So it's actually worked really well and it's credit to all the teams that it's worked so well and kept him out of hospital last case quickly. I know I'm tighter on the time. So I'll just quickly, um, start going through this one. This is a relatively recent one. And I suppose it's just to highlight where we might have some slight changes. So this is a recent 78 year old man collapsed while holiday in Scotland from Australia. Um mix of things, multiorgan failure, COVID sepsis. He had an ischemic brain injury. He had an AK I with an EGFR of nine. He was extubated and self ventilating. So it'd already made those decisions. Um He'd been on our fental with the intubation, but at the point of extubation, they went to morphine and Midazolam for like um he was only on a low dose of morphine, but we do worry about morphine accumulation um as, as with an EGFR of nine. So we're a bit worried that the more we give him, the more we infuse it, starting accumulating and then we'll run into causing a problem with it. So our worry would be accumulation leading to toxicity, agitation and distress in a way that we might go to stress. Let's use more drugs when actually it might be the drugs we're giving him and in palliative care, we always try and reduce drugs other than add drugs, we didn't know what his trajectory would be. We thought it was probably days that was the, any of the teams. He had IV lines running, but his head was sort of pushed over to one side because his ivy lines were so big and there was a sort of hope that we could get those removed. Um But we were keen to probably switch him back to our fentaNYL for his ongoing infusions. So what we did um is actually we just switched the IV infusion to begin with. So we switched it to the equivalent which was the tiniest smidge dose of a fentaNYL in the world compared to what ICU were, were normally used to infusing. So um it was just a bit like really, so really is that all you want me to give him? I think it was 100 micrograms per hour. So my thought was, yes, that's all I want to give him. I want to ensure that he's nice and stable. We switched him over for an hour, no worsening of pain or short of breath. But I was pretty sure that if we then went with that dose over 24 hours, that we probably would avoid the accumulation that might lead to more distress and agitation. So we had a four hour overlap of starting in our fentaNYL pump with his sedative and then we removed all the IV lines, um and he became suitable for transfer. Although I think, um they didn't get a bed before he deteriorated. So I've gone through a variety of, of cases which have hopefully given you an oversight as to the myriad of things we can support with. And I suppose the time that we can provide is, is one of the benefits of our um intervention. I suppose all of these things make me sort of think through some questions going forward. Um And the one, there's a few questions we have and I am by no means making a comment on them and just maybe questioning how do we do this is this the right thing. And I've had lots of chats with colleagues on ICU about these things. And I know there's a talking to colleagues in ICU. There's a bit of an uncertainty generally within the ICU cohort of things. Like do you wean sedation or do you abruptly withdrawal? Um And um then the other big sort of thing, uh I think we've raised questions about is morbidity of high dose opioids. Um And even with our fentaNYL with something with a really short half life, I think there is a question about it and one of our big questions has been, are we risking things like um opioid induced hyperalgesia? Are we right to use opioids as sedatives? Um And are we risking maybe a patient being more agitated. Now, I'm not talking about your patients where they're well and you're improving things that is all for you guys. Um and all you know, protocol driven and that's great. This is the cohort where there's this uncertain trajectory. And actually, maybe we're not going to win in these patients and maybe we are heading to a more of an next duration palliation route. So I was informed by one of my colleagues in I ce that, that there is a bit of an uncertainty about weaning and sedation and abrupt withdrawal. And he pointed me towards the ABC study, which was very interesting. Um and a sort of sense that actually it it's probably better to abruptly wean and hold, sorry, abruptly sedate, stop the sedation and do holds and then starting at lower levels if it's distress. So I learned something there and that's been helpful for me to understand. But I suppose if you know, the extubation is a one way, should we be doing it differently if we know the outcome is that the right way to do it? Because my understanding is your your weaning uh holding a sort of mechanism is is to try and reduce the morbidity experienced. Um So our our concern would be rapid, abrupt weaning of an opioid may cause a rapid withdrawal. Um and a potential for an escalating agitation and distress. It's really hard. Like the first case I pointed out to tell what is drug withdrawal at what is distress that would have been there. Anyway, what are we trying to plug? Um, it, it's really hard in the acute, uh, moment to tease that out. Um, so I just point out as well. We have an uncertain relationship with our fentaNYL as palliative care physicians. Um, it's a very high strength opioid but it is, this as with all fentaNYL has a very short half life. Um, there's, there's an unwritten rule in palliative care that you don't trust fentaNYL past a certain amount in 24 hours. And so most people, it sits around mid teens, um that actually we don't quite trust how it's acting. We don't quite trust that there is a linear dose response curve above that and we certainly worry about conversion ratios beyond that level. Um So you guys use it in doses that we are highly uncomfortable with from our own um sort of personal perspective because in, in um sort of uh well patients as well, um that we see where they're not ventilated. We, we do have this uncertainty and nothing is written. And actually, if you look in the literature, there's nothing but you go to any palliative care unit and often that's very high off fentaNYL. Is it really working at that level? So there's a lot of sort of this thought in the background. But what we do know is that actually we do see morbidity of high dose opioids and there is definite evidence, there is morbidity of high dose opioids. Um So, um when we calculate sometimes the amount of opioid they're on, in an ICU setting, we get this, oh goodness, they're on a gram of Omine equivalent to 24 hours. And we'd have already way before that started to question the benefit risk of opioids before we got anywhere near a gram. I mean, you do see patients on that level, but you've questioned it quite significantly and we all question it and, and I suppose that is in a patient who's sort of alert and well, and all of those sort of things and it's very different in the ICU setting. So it's just something we think about as clinicians, but we think about the bowel function, the immune system, chronic longer term opioid requirements, things like that. But also this phenomenon of opioid induced hyperalgesia. And we certainly had a few chats with our ICU colleagues about it and talked about it and they, one comment was they thought that Pe's ICU are more aware of opiate induced hyperalgesia that maybe adult ICU S. But it would be interesting to hear what people think. It's a very real phenomenon that we see a day in day out. And as I say, we might see it at higher doses, sorry, lower doses than are infused through an ICU. So just a very quick note of opioid induced hyperalgesia is really complex and there's lots of uncertainty about why it's um why it happens. But there's the theory that maybe G proteins have something to do with it. And when, when your opioid receptor um is, is uh bound, the G protein coupled with that and, and you bind your receptor, opioid binds and you get conformational change of your G protein and it goes into subunits. And actually, when you get analgesia from opioids, you get inhibitory G proteins released and they have a series of outcomes. And the, the, the one is maybe actually uh opioid induced hyperalgesia somehow develops the production of stimulatory G proteins. Um And that's how you get this overstimulation of the nervous system or plus or minus, you might get then an MDA receptor channel activation. And, and we often see that actually opioid induced hyperalgesic can be compounded through ketamine, which is an NMDA receptor blocker. So, um but the other thing is you can't really predict who gets this. It's not opioid necessarily dosage. Uh It's, it's, it's quite a bit of variability in terms of genetic variability as well. So they're not necessarily things you can predict. It's just worth thinking about it. So I would just question how many times do we see agitation, pain and distress? Um How often do we miss the diagnosis of opioid induced hyperalgesia or increase the opioid to manage the pain. And we certainly are aware of that as a team. And um if we're using opioids more as a sedative. Are we missing it a bit more? So, it's a question. It's not an answer. It's just something to think about. Um But it may be more common, especially in that last patient where actually we were giving morphine, they probably couldn't process it. The opioid is going up and they're experiencing it as part of toxicity. All that. Sorry, I didn't reference but a lot of that information about G proteins. Um We get from things like our palliative care formulary, which is um the book that we use for a lot of sort of information based around palliative medicine. It is very, very helpful resource. So um into the future, I think there's a lot of benefit to be gained from collaboration between our two areas. Um We can help with transitions of care to different environments, complex symptoms, we can positively manage end of life care um and help support the team and give the time that maybe the team are unable to give because of everything else going on in the department. Um There might be an opportunity to discharge home and that's something you know, that hadn't even been thought about or wasn't even possible 24 hours before. But in a rapidly moving situation might be um but where small services and our demand are growing for all the reasons we've explained. Um But I think there is benefit to all if we can progress this relationship and that's the end of my talk and I think I can see one, 10, I, so there's a question here, Alex mcdonald. Do you think it's valuable to have certain ICU situations where a palliative care referral should be considered automatic or triggered? Um I suppose that the ones that we've looked at there might be the ones where, um, I would um I think transition to awards should be and actually we've written into our guidelines with ICU that if a patient is to be set down to a palliative care, have to review if it's for end of life. So without doubt, because we had one situation where unfortunately for nobody's fault, a patient ended up on the ward still on IV infusions and it was a bit of a, a bit of a nightmare trying to get it all sorted. So we've agreed um as I say, there was purely a bed pressure issue and it wasn't clinicians at all. But I do think that's a situation where we would and maybe we should be opening up that question. If someone's deteriorating but not imminently dying, where do they want to die? Should we be looking into it more? Then there's a question from Thomas pride. Thank you for the talk. Your support in the ICU has been hugely beneficial. And the new collaborative approach of my opinion and experience has made a huge benefit already to ICU. Thank you, the development of the new End of Life guidelines. That support with new referrals and improving the care of patients during the phase of withdrawal, sustaining treatment. Is there any other data experience from Scottish icus or even more wide UK wide units as the impact of post care in critical care units at the time of the straw? Um Yeah. Um so you're involved, we'd like to do M and MS to learn from each individual case. Yeah. II think we're more than happy to be involved in things like M and MS. Um the literature I scanned and Becky might help me there. I don't know of any that um said it was a definite um I think people are delving into it, but Becky, do you know of any? No, certainly from talking to um other colleagues across Scotland. And I see that didn't appear that there was any um really well established um links between palliative care. And I see it's more on a kind of referral basis and probably relatively low referral numbers across Scotland. Although it seems that there's more of an appetite across the board for, for more collaboration, which obviously um very exciting and I think there's potentially huge benefits there. Yeah, we didn't find anything in the lecture. I think luckily was anything. So this, I mean, you know, we're starting to gather that data and show and um yeah, and it may be something we could lead on, you know, over the coming year or two of how best to integrate and when to refer and um, and, and as I say, it's a very much a two way process. You know, we're learning, we're learning skills, um you know, really enjoying it. We are small and so that's the only thing. Um I think the nurses in our team are still a bit nervous of going in. Probably the more senior nurses are happy, but more junior nurses find it quite daunting. So it sits with the more senior nursing and, and there's only two doctors in the team and that is the two of us. So we don't have junior doctors as such. So, um yeah, there's a long way to go in terms of being able to provide that support regularly. But um we're very keen to see what we can do. Thank you so much, Abby can I and maybe to be as well. Can I ask a quick question? I guess if staffing were no, we're no constraint, I think, intensive to spend a lot of our time, uh almost in a pre icu environment going out to see to and trying to make complex decisions about escalation of care for patients, you know, often were presented with a surgeon who, you know, you know, give them the car, they really want to do the operation. But maybe you've got a patient who has complex comorbidity and be frailty in the background. And I guess my question is, do you think there's a role for palliative care to be involved in those conversations. Because often the alternative to something like surgical management is the end point is the patient's death. And I'm not really sure that we necessarily are good at kind of explaining what that process involves in detail. And so the patient, I'm not really sure is always left with all the information available to them to make a kind of a kind of considered opinion or a considered decision. I just thought, I wondered about your thoughts on that. Do you think you would want to get more involved in kind of active decision making about escalation of care? So, II think um not everyone wants us at that table at that point. Um And again, I think that goes back to the old adage of the we're there is the end of life care team. My hope would be over time in the more complex ones that people see that what we can bring, that we may just bring another viewpoint and it's not sort of advocating that this patient shouldn't get it. It, like you say, it's opening up all avenues making sure it's very clear and well expressed and, and I think over time, yes, that would be great. And I've certainly been around where a surgeons seen us and an ICU consultant seen us on the ward at the same time and they've grabbed us and said, what do you think? But I'm not sure that all of the perceptions are right at the moment to do that. Um, and I think part of it is developing our team in a way that we could support that, that we would be available. We can't, we just can't take that moment. Becky. I don't know whether you have any. Yeah, I think in the future in an ideal world where there is, as you said, unlimited staffing, there's certainly a role in certain situations to do that. I've been involved in um a couple of cases. One on ICU actually was a patient making decisions about um his extubation and what he wanted going forward where we were brought in to provide that. As you said, that kind of this is what palliation would look like to help him make that choice. And I think um that was valuable for him and he did decide to continue with active treatment and we then stepped back and that was fine. But I think it was, it was helpful having us at the table to explain what dying in that situation would look like because you're right. That's not necessarily the area that um it was a home bent team in ICU that were involved um would have um would have all of that information. I've got to say from my experience, I have found it very helpful when I've come along to see one of those patients afterwards. When an ICU um member has had a lot of those conversations about what intensive care, um why intensive care isn't appropriate? And then palliative care has been got involved and it's, it's always helpful on a particular in the surgical ward that, that has been discussed. I think, I suppose sometimes there might be a role for there, but sometimes it might just be saying actually if we're not taking them to ICU think about referring to palliative care because then we can come along and, and take that. Yeah, it might be the intensivist who says actually, um maybe, yeah, so it may be you guys that prompted and I think that that is quite helpful. Do you think it's very interesting that you can, you know, you can't consent to surgery having all the risks of an operation. And it feels very difficult to see that a patient could pick, you know, purely symptom based management without really having an expert, talk to them about what it would look. Absolutely perfect. I can't see any other questions coming through and I just want to take the opportunity to thank you both for coming along. I think the comments speak to how grateful we are for your involvement in the care of our patients in our unit. And I hope that those of you that are joining from other units that maybe have less well established relationships with your palliative care teams are inspired to go and um and reach out to them and see how you can build that relationship as well. Um, I am going to pop a link to the feedback form and the link to getting your CPD certificate in the chat box there. And, uh, and finally I just want to thank our speakers this evening, uh, for giving up their, uh, their Thursday evenings to educate us all. Uh, we will be back next month, um, with, uh, burns update from Dr Leah Payton and you'll see that advertised soon. Thank you everybody and have a good evening. Thank you. Goodbye. Goodbye.