Year 4C GP Revision Lecture – Palliative Care

Year 4C GP Revision Lecture - Palliative Care

that's good those you don't know me I'm Caitlin I'm one of the final years the topic I've been given for today is to talk about palliative care which is end-of-life care is sort of part but not all of palliative care and then caring for people with a disability and I picked this topic because I thought that it was taught really badly for us in fourth year so I've tried to structure any way that I hope is helpful for the exams in the asti and also a bit for real life so why are we learning about this stuff really it's important in real life regardless of what specialty you're interested in and what you end up doing you will have people who've got incurable illnesses that are going to steadily get worse over time you will have people who are dying and you will have people with disability so you need to deal with as well so you need to know these kind of skills for real life it can come up in the exam and anything that I think is like good exam content I've tagged with this book and it did last year we had some multiple-choice questions in our exam on palliative care stuff in the GP section and I can come up in the Oskie as well and it would be a really good way for the faculty to test your interpersonal skills and how you communicate and all that kind of stuff because obviously that's really important when you're having these kinds of discussions with patients and Families so the majority of the lecture is going to be on palliative care and I think the first thing we can do is debunk a few myths about palliative care so it is quite poorly understood and underutilized by patients and sometimes by health professionals as well because someone's palliative receiving palliative care doesn't mean that they can't have active treatment at the same time they don't have to be actively dying and it's not just for people with cancer either it can be anyone with any kind of life limited and chronic illness really what it is about is symptom management and trying to maximize quality of life as opposed to quantity of life although sometimes those things will go together and it can be practiced by lots of people in different settings so as if you have done your GP placements this year then you'll find some GPS do lots of palliative care you might have seen a lot of it and some won't do very much so hopefully between that and then new medical rotations last year you've seen a little bit of how this actually works in real life and a communal hospital can be at home you mean a hospital or an aged care facility so it was really applicable across lots of settings and there are some medical aspects that we're going to talk about that are quite different to where you think about in other areas of Medicine because the goals of care diff we really talked about symptom control is not about cure and what I've done throughout this lecture is I linked down the bottom some useful resources for you guys who don't have a look at later so the first thing we'll do is go through common symptoms empower care patients I think who says the stuff that's likely to come up on the written exam anything that you've got those difficult to control should be discussed with her specialist palliative care teams that's a good thing to throw out there in the Askia if you're getting stuck on how you might manage it don't just refer them to palliative care and you probably get marks for doing that so the first thing to think about is pain and this really nice diagram came from the therapeutic guidelines there's a whole section on palliative care that I'd really recommend you go look at because it's got most of the medication related stuff and also sort of general concepts about treatment in palliative care and I think the important thing to recognize here is that the physical stimulus is only one aspect of what's actually causing the pain in a patient and in someone in a palliative care setting this is really important because there can be lots of social and cultural things that are going on at the same time and the patient might have lots of other symptoms they might be struggling psychologically so you need to think about the whole patient and a holistic care and that's really what general practice is about and palliative care is a good example of how that can be used so in terms of mounting pain and palliative care the first thing you should do is try to find out as much pain as you you can take a really thorough history does it sound like it's know susceptible neuropathic pain is more of a chronic pain kind of problem how they tried anything to work and what impact is that having on their quality of life is really the thing that's important to assess in this situation and this little diagram here is just to remind you of the classification of pain chronic pain is sort of a separate entity and is not really included on this one but you can go over that in your own time because I think we're going to run out of time today so in terms of considering management of pain we should think about whether we can identify and treat a cause and this could involve drugs surgery radiotherapy or sorts of different things depending on the course there might be lifestyle and non pharmacological interventions that can help and then we should think about what kind of pain medication is likely to be effective based on the course of the pain so nociceptive pain responds well to really conventional analgesics like paracetamol and NSAIDs and opioids and neuropathic pain tends to respond well to some of the other drugs that you might have seen like Penton and pregabalin which is lyrica and try cyclic antidepressants as well and I've highlighted the next point because I think it's kind of unique to palliative care the opioids tend to get dragged in earlier and they stay as part of the management longer term where you've probably been taught that we don't like to keep people on opioids because they tend to get tolerant and they get dependent on them and then you can't get them off them we're less worried about that in a palliative care setting because they are really effective for controlling symptoms and often these people will be on them for the rest of their lives anyway so a typical pain regime propellent care patient would be having a long-acting opioids for kind of baseline pain control then a PRN opiod for breakthrough pain plus minus and adjuvant and you should also always consider an apparent and an antiemetic to manage the common side effects of opioid medications so non pharmacological treatments there's not an exhaustive list at all this is just some ideas that you're thinking about the kinds of things that can be offered to patients they're not just medication so I think psychological support is really important for these patients it's might be counseling I might be considering if the patient has depression along with whatever medical illness they do have and if they've got social and financial concerns and then psychotherapy and complementary and alternative medicine and a really useful in this sort of setting and there's a variety of physical therapy interventions we can use as well so I'm non-opioid analgesics and we first learned for most things is paracetamol which is really good for mild to moderate and especially kind of soft tissue and musculoskeletal pain and the considerations here are really liver function we know that paracetamol in overdose causes dysfunction of the liver so if someone's got really terrible liver already you'd be careful about how much paracetamol that you would giving them and often if you give paracetamol with no period you'll find that maybe the paracetamol is not actually providing much extra benefit it's just giving the patient more terrorist attack so you could consider taking it off and seeing if the situation gets any worse without the paracetamol another option here are in terms these are things like ibuprofen I Clos for neck and these are good particularly for inflammatory type of pain and metastasis considerations here are all of your common things that you know already about inserts in terms of side effects so what the renal function is like if they've got peptic ulcer disease hypertension and heart failure and we further older patients are more likely to have adverse effects associated with inserts as well something you could consider here if you're worried about someone getting gastroesophageal reflux with that and said would be to put them on a PPI as well to try to inhibit that so opioids are probably the main analgesic that you'll see used in a palliative situation there's a good for moderate to severe pain of essentially any course what you should think about when choosing an opioid is whether you want it for maintenance so whether it needs to be long-acting and kind of cover a baseline level of pain across the whole day or whether it's for breakthrough pain so it's when the patient is moving they get a lot more pain or whether maybe it's needed for both that will determine whether you want an immediate or a modified release formulation of the opioid and you should consider the route of administration as well an oral opioid is a really good start for most patients but in palliative care as people get more unwell and they're not really able to take things orally it sort of in the end-of-life stage then you can consider subcutaneous opioids as well in renal impairment opioids and their metabolites can accumulate and this causes more adverse effects and the best one to choose in this sort of situation is fentanyl and if it's in bold I've highlighted it because I think you should know that for the exam so that's a good one to know and in any patient with hepatic impairment you just want to be careful to start at a really low dose and then just go and titrate up slowly we don't give Teijin because the the naloxone component now can cause accumulation of metabolites in palliative care opioids have been shown to improve quality of life and you might have some issues sometimes with patients not wanting to start on an opioid because people hear lots of things about getting addicted to opioids or being given an opioid meaning that they're in the end stage or you think they're going to die so sort of being able to debug some of those concerns from patients can be really important as well with any drug you should start with a small dose see if it's working monitor for adverse effects so then you can always increase it if you need to so there's this really useful document that helps you compare all of the opioids this is just our Worf into other oral opioids but there's also IV and different IV formulations compared to each other and I don't think you need to memorize any of this by any stretch but knowing that it's there as a resource for you to use is a good thing and something to highlight on here is that a lot of opioids there's there's a real variation in the in the strength of the drug but you're giving here so if you look at oral morphine to oral codeine for example you need to have a lot more codeine to get these same same effect as the oral morphine and then if you look at something like 2 pentothal 300 milligrams of 2 pension dollars the same as a hundred milligrams of morphine which is a lot of morphine so I think you need to make sure that you when you look at a patient's drug chart you can have a concept of how much that actually is compared to other opioids the type of opioids that's available this is really just a resource for you to look back at later this is one of situations in which you'll see brand names use a lot unfortunately rather than generic names and that's because a lot of the generic names are really really similar and it's easy to get confused between drugs so if you've seen any of these medications and you can come up and have a look at this table and that will help you work out what they actually are and you'll see that I've divided into short acting and long-acting forms and then you can see the various formulations of the drugs as well so there's lots of tablets in there oral medication some come as a liquid some come as a patch some come as a long-acting tablet so how to choose an opioid think about allergies and adverse effects and if a mild adverse effect could be managed so often you'll find on someone's drug chart that it'll say that they're allergic to morphine but when you ask them about it it'll turn out that they actually vomited when they had morphine and we know that that's a really common side effect of opioids so you can give them an antiemetic with that and that might control that well you should choose an oral opioid where possible and you should think about whether the medication regime is something that the patient can actually adhere to and not make it overly complicated if you don't have to and think about renal impairment and if there's renal impairment then we use that you should start with wine or period and morphine is first-line unless there's a reason not to use it the breakthrough dose should be 1/10 to 1/6 of the 24-hour dose you should prescribe a regular apparent at a PRN antiemetic and that just gives you in the corner some kind of common starting doses of morphine that you might see or Dean is the liquid short acting or a morphine MS Contin is the long-acting oral morphine so common side effects of opioids the ones that are in bold here sorry it's a bit hard to see in this font other ones that I think come up a lot so things like nausea and vomiting sedation and particularly respiratory depression urinary retention and constipation and probably the ones that you hear of the most but just the wear of this in patients who are on an opioid that complained of any of these symptoms could actually be due to the drug so adjuvant analgesics are really useful in the situation of neuropathic pain and also if you've got pain of any source that's not really responding well so conventional analgesia that you've tried and usually that's used in conjunction with an opioid and this table you can probably tell it's come directly from the therapeutic guidelines it includes some of the common drugs that we would use in these sorts of situations so you can see that there's some try cyclic antidepressants at the top then we have gabapentin and pre double in here and then we've got clonazepam which is a benzodiazepine here and then we've got another things to think about other gabapentin pregabalin arenal e excreted so you'd want to start with a small dose in a patient with renal impairment or a frail patient and with any of these medications introduced at a low dose that increases slowly if you look at their some table it gives you a bit of a guide as to how that might be done in practice and that's just to minimize the likelihood of adverse events so it's actually really common in palliative care to have a refractory pain that has not responded to whatever treatment you've tried so in this sort of situation which could be a thing that comes up in the Oskie that you've got a palliative patient who has pain and they've been on the certain pain regime and it's not working and it's really bothering them that they can't get control of it you should start by thinking about whether the drug is actually appropriate for the likely mechanism of pain whether the patient is actually taking the drug of the appropriate dose in frequency and there could be a number of reasons why they're not doing that they're not maybe it's due to adverse maybe it's because they're worried about adverse effects or addiction or tolerance the regimen might be too complicated if there's too many different drugs if the dosing is too frequent or if there's lots of variable dosing instructions say in the event of this do this or anything event of that do that that might be just too much for some patients to actually and get a handle on instructions that vary depending on different situations and it might also be that the patient just doesn't understand what they're supposed to do which might be due to a language barrier or an intellectual impairment or maybe they've just been given really bad instructions by whoever prescribing the drug which is not actually that uncommon or it might be there's anxiety or depression or some other kind of social psychological barrier that some preventing the patient from actually taking their medication there might also be a physical cause such as a pathological fracture for payments being worsening so but where is that and think about it and it might also be that some of those other things in that first diagram with all the things influencing pain have been exacerbated it's not actually the physical source of the pain that's getting worse but it might be a psychosocial problem or maybe they're not sleeping well something like that and and this is the time when you would definitely consider there is palliative care referral if someone's got pain and you just can't get on top of it so the next symptom to talk about is nausea and vomiting and I think the thing to distinguish in the history here is whether it's actually nausea or its vomiting or it's both because it's very common to have nausea without vomiting it's uncommon to have vomiting without nausea but it can occur in certain situations so it's good to make that distinction and you want to know whether it's intermittent or whether it's persistent and if it's intermittent if there's a particular thing that triggers it all the time that will really help you to get control of that symptom you should choose a drug based on the likely mechanism of the nausea vomiting which we'll talk about in a minute and often if someone's getting fairly frequent nausea and vomiting it can be better to prescribe a regular drug well in a PRN drug because if you wait every time for them to vomit and then you tell them to take medication they're going to be feeling nauseous a lot of the time and that can be pretty miserable so if it's only very very occasionally by all means you could give them a pair in drunk but if it's fairly regular give them something regular so I think this is probably the one slide if you can remember anything from this lecture is the one to learn when to use different antiemetics and essentially this is based on the mechanism of action of each drug and how they interact with the cause I've highlighted in bold the ones that I think are really important for you to know because these are definitely things that have been known to come up on exams in the past so if someone's got poor gastric emptying prokinetic drug to help things move through the stomach what really helps so these are things like metoclopramide and on paradeen which had dopamine antagonists gastroesophageal reflux can be treated with your standard treatment for reflux constipation can be treated with a prokinetic drug like metoclopramide or also held paradol which is a typical antipsychotic central causes these are things that affect their chemoreceptor trigger zone in the brain which might be related to drugs and chemotherapy or metabolic disturbances things like haloperidol medical provider and prochlorperazine work really well in this situation for vestibular or vertiginous kind of nausea and vomiting then things like prochlorperazine and promethazine and haloperidol are the most effective sometimes vomiting can actually have a psychological cause so this is definitely definitely come up as a question before in some of the release past papers and I think the situation is that someone is on chemotherapy for breast cancer or something and then every time before they go to chemo they get really nauseous in the morning and they start bobbity you can actually just give them something to calm them down like a benzodiazepine just on that day to help mitigate that for intracranial causes like raised intracranial pressure or a direct effect of an intracranial tumor dexamethasone is the first light and drug there because it will actually help to reduce tumor edema and decrease the size of that tumor and that can help to reduce the pressure and therefore the vomiting and then you can give hel apparel as well in that situation for chemotherapy or radiotherapy introduced nausea and vomiting ondansetron is probably the most effective one and then if that wasn't working you could try dexamethasone sorry ass so spinal cord compression usually occurs in cancer patients and a student vertebral metastases they extend into the epidural space and push on the court usually occurs in the thoracic region but can be anywhere along the spine and the presentation of this is usually worsening or new back pain it might be worse with things like coughing and bending and sneezing that are causing that compression on the cord to become worse there might be a lower limb neurological symptoms present and bowel and bladder dysfunction and there might be an anesthesia around the perianal region so if anyone is describing kind of bilateral lower limb new neurology and worsening back pain you should have spinal cord compression really high up on your list of differentials this is an important one to recognize because if you don't treat it can obviously result in serious neurological damage and the treatment will depend a little bit on the patient and how well they are so we can consider things like surgical decompression and radiotherapy which will be appropriate for people who've got a reasonably good quality of life or they're not sort of expected to die very soon and then there's more of a palliative kind of treatment we can give dexamethasone again to reduce the swelling in the size of that tumor in order to believe some of the pressure on the cord bowel obstruction is also really common in palliative care again usually in cancer patients and it could be due to a tumor in the bowel or something outside the bowel that's pushing on it or peristaltic dysfunction and the classic one where that occurs is in ovarian cancer and sometimes it might be that they've got bowel obstruction that has absolutely nothing to do with the cancer that they've got which could be due to adhesions from previous surgery or volvulus or anything else that can cause bowel obstruction and the management really depend on the goals of care and whether or not an invasive treatment is appropriate that patient but um even if it can actually relieve the bowel obstruction patients can still sometimes survive for weeks so we need to have a method of being able to keep them comfortable so active intervention of bowel obstruction would be things like surgery chemotherapy radiotherapy depending on the patient's situation and advice from specialists and palliative things we can do it to give dexamethasone higher scene which is Buscopan to relieve cramping pain we can give ranitidine which has a h1 receptor Antechinus or one of your all kind of sedating antihistamines that inhibits secretion of fluid and electrolytes into the gastrointestinal tract which can help reduce sort of volume and frequency of vomiting because if there and if there's a total bowel obstruction and fluid can't go down it's gonna have to come back up again so if you can minimize the fluid that's going into the gut then that will help reduce the nerve vomiting and we can give haloperidol as well to reduce nausea and vomiting as I mentioned before in a ballad structure we don't want to give prokinetic and he makes things like medical open-minded domperidone because actually that can actually kind of impact the obstruction and make it worse so it's not we use it in constipation but we don't use it in total obstruction so it's a good idea to kind of make that distinction and sometimes something like a nasogastric tube can be helpful to relieve ongoing vomiting but it depends a bit on patient situation and whether or not they're likely to tolerate that if you consider it delirium I'm not going to talk about today because I think someone will talk about it in Psych lectures tomorrow but just in brief environmental what okay modification is the first fine thing to do and then if you can't get control of it with that you can use pharmacological management the key thing here is that pharmacological management needs to be used when it's for the benefit of the patient and to keep them calm and not because they're annoying the nursing or the medical staff which i think does sometimes happen in practice and probably really shouldn't hypocalcemia is fairly common in palliative care usually in the context of malignancy which might be to youtube bony metastasis causing breakdown at the bone structure or paraneoplastic syndrome's particularly in lung cancers or sometimes as the cancer itself if it's severe and this is your corrected calcium here if it's more than three million moles per liter the first thing we do is fairly aggressively rehydrate the patient with lots of normal saline nothing that has calcium in it and then you can also give an IV bisphosphonate and selca tonin which is salmon calcitonin I never heard of I put it in here because literally the hormone that they take from salmon which I thought was a bit strange and can be used in a life-threatening situation with a bisphosphonate I don't know if anyone's actually ever seen that used theoretically it's possible longer-term treatment might sometimes be necessary if someone's got a cancer causing ongoing hypercalcemia and in that case you would give them either an oral bisphosphonate everyday or you can give them an IV bisphosphonate every couple of weeks just to help keep their calcium level down over a longer period of time so this would be at the top here sort of your emergency management someone's got really high calcium now and then this is your longer-term treatment and you should remember from some time maybe third-year Styron's bones moans groans and psychiatric overtones yeah I can see some nodding that's good and that's the sort of symptoms that you associate with hypercalcemia so remember to think about it in these kinds of patients and providers I think this is the last symptom based one is really common in cancer and in non and non cancer advanced illness like end-stage chronic kidney disease and hepatic diseases and cholestasis can also be drug-related can just be related to dry skin and poor skin care I think is it easy to kind of an underestimate this is a symptom but it can actually be really distressing and stop people from sleeping and in some situations that can actually be worse than pain so don't don't underestimate it think about it and there's lots of things we can do to treat it so the first thing to do would be to treat the underlying cause if possible so if it's really obvious that the patient has got dry skin or that might be a side effect of the medication that they're on that's pretty easy one to manage good skin care is really key and then systemic therapy might be required and what you choose depends on why you think they have achieved skin so there are some examples of different causes of each here and then in medications that you can use some of these are really strange things that you wouldn't actually think would make any difference like rifampicin you might remember is an antibiotic that's used for treatment of tuberculosis but it's actually very useful in cholestasis as well and adding on denser onto an opioid are changing the opioid is good for opioid induced itch as well sometimes you'll have an itch that sort of doesn't really seem to have any particular source or and it's not resolving with any other treatment and these drugs down the bottom here which are mainly antidepressants and then a benzo for sleeping can be really helpful in that situation so I've just got a few Dorsky tips of palliative care because I absolutely think this is some it could come up as an auskey station it didn't last year but maybe that means you guys will get it this year and these are just some ideas of things that I thought might come up as a possible palliative care oski so I think regardless of what the topic is there will be a big focus on communication skills so make sure that you practice how you got to deal with and upset her a grieving patient or someone who's angry and how to handle uncertainty about things like diagnosis and prognosis and how to explain things to patients in a way that is really easy to understand so I won't go through these scenarios now this is sort of something for you to look at later when you're citing an auskey practice to give you a bit of a starting point as to where you might go with palliative care type stations so the next thing I thought I'd talk about briefly is advanced care directives and I think this is a fairly likely one to come up at some point in the exam or gossipy because the laws around this have changed in the last couple of years so what an advanced care directive is the legal document part of advanced care planning so advanced care planning is a discussion based thing really where you talk with the patient about what they would like to happen to them in the event that they become unwell and they can no longer make medical decisions for themselves and then the advanced care directive is at the place where that is actually written and can therefore be followed if that situation eventuates and there's two types it can be an instruction or a values directive and they can be made by anyone as long as they've got decision-making capacity at a time once it has been made if the patient wants to they can revoke it or that I can change things on it as long as they've still got capacity to make decisions so it's not something that has to exist but absolutely forever if the patient changed changes their mind about the kinds of treatment they would or wouldn't want so an instructional neural directive is a legally binding document that specifically says what treatments someone does or does not want and the requirement for health professionals is to make a really good effort to find whether one of these exists and if they found that they must follow it and not give anything other patients that they don't want and give anything that the patient says they do want if it's many clear reasonable to do that and a various directive is a bit less and it's if he can really it talks about values and preferences and it's useful as a guide for the medical treatment decision maker which might be the power of attorney or it might be to be a guardian to make a decision in the patient's best interest so it's talking about in general the types of things that the patient would or wouldn't want are their beliefs but not sort of specifically yes I want to go to ICU now I don't want to be intubated that kind of stuff that those things would be an instructional directive to make an advance care directive you have to complete their correct paperwork and it can be witnessed by a doctor and then a second person and the responsibility of the two witnesses is to make sure that the person has capacity and they're voluntarily making this directive so end-of-life care is kind of a subset of palliative care and really the goals here are about keeping the patient comfortable which involves a lot of the symptom management stuff that we just talked about and some environmental things like having a quiet room aiming for out of hospital care if that's something that the patient and the family would prefer which often is informing the patient and the family of what they can expect to happen within the next few days because that can be really scary for both the patient and the family especially if they've deteriorated very suddenly and there wasn't a lot of advanced care planning and kind of discussions about this sort of thing before the event that someone's actually hope died and we want to encourage the family to spend time with them to talk to the patient even if they're not responding verbally because there's some evidence that the person actually does recognize that there are people there even if they're not sort of verbally able to respond to us it's nice for both the patient and their family to encourage them to spend some time together in those last few days I think something that I've been taught and there's some very wise people it's a good idea to ask a patient or their family about what questions do you have rather than do you have questions and that's a very subtle difference but I think this first phrase of what questions do you have is really opening it up to the patient or the family to be like I know that you have questions please ask me your questions I want to listen to your questions rather than do you have questions it's very easy for someone to say no no it's fine and then go home and think about it and say actually I have all of this stuff that I to ask that so making sure that you keep the door open people to ask questions because this is a really kind of scary and confronting situation for people is a really good thing to do um end-of-life care is really as much about not doing as it is about doing so often you can see below the patient's regular medication including any oral medication if they're not eating or drinking not giving certain treatments is often appropriate check if there's an advanced care plan otherwise the discussion should be had as to what will and will not happen in those last few days and then usually if their patients in hospital the nursing staff will stop taking fighting vital signs on them but I think the important thing to remember is that still means you have to go and check on the patient and make sure they're okay and make sure that they're not in pain just because you don't have to sort of regularly go into Dubai to us every four hours so that mean that you can just kind of leave them there anymore them so I think something that's hard unless you've seen is how you know if someone's likely to die within the next few days and I think that there's a phase that sort of leads up to this terminal event over a few weeks that you might be able to identify and if you identify that someone was in this stage and this is where you would want to have a discussion about the dying process and whether the patient would like to be cared for what kind of help the family is going to need in order to facilitate that before you get to the point where they're actually likely to die sort of within the week so you might say that their disease is progressing faster there's a tumor that's getting a lot bigger they're starting to lose weight really rapidly their other symptoms are getting worse they'll be spending a lot of time in bed got no energy sleeping all the time and not very interested in eating or drinking and in the last few days the patient is usually completely bed bound and very much reliant on the care of other people often they have reduced conscious tone they're not very responsive they can usually not swallow properly and they're not really interested in food and drink and we don't really give oral medications during this time if the patient's not eating or drinking you cannot fill them food and drink and sometimes the family particularly will rather do this because they think that the patient is going to starve to death or that are going to become dehydrated because they're not drinking anything but it's sort of inappropriate to force someone to eat or drink if they don't want to in this situation usually the urine output will really drop off and there develop an altered breathing pattern which we'll talk about on the next slide and you'll see that they're peripherally kind of shutting down and becoming pale and cold so what we can do for the dying patient in terms of nutrition and fluids it's that we need to recognize that their oral intake is likely to be greatly reduced and they might be having nasal gastric or gastrostomy feeding and we should think about when the burden of having that and the discomfort of having a tube is actually outweighing the benefit of them being fed if they're likely to die within a couple of days anyway and stop it at that stage a good way to explain this to families is often that feeding can be quite unsafe and people might ask for rate and be really uncomfortable because they can't swallow probably so it can be a way to get around the family meeting like but they're not eating they're not drinking were worried about that particular aspect of things and have me a dry mouth is really common because the patient does sort of slowly become dehydrated and we can just moisten that with water in terms of breathing there can be lots of different breathing patterns that you might observe when someone is getting closer to dying might be slow or regular might be rapid and shallow kind of panting you probably heard of change Stokes respiration which is where you have alternating periods of apnea and then periods of rapid breathing and then going back to apnea again and what we can do to manage dyspnea is give opioids and benzodiazepines just to kind of reduce that respira to drive a little bit to reduce the distress that is causing the patient to be short of breath often you might notice that patients have kind of rattly breathing to to accumulation of respiratory secretions and this is another thing that families are often quite concerned about because it sounds like the patient's very uncomfortable because of this even though they might not be and what you can do to manage these anticholinergic drugs like Glac appear low and high C and can be useful and sometimes just repositioning the patient as well can help stop the accumulation of the secretions terminal restlessness is fairly common as well and usually a little dose of a benzo is enough to control this but if you can find an obvious cause like if they're in your interview attention put a catheter in and drain the urine that will usually resolve this sort of symptom in terms of prescribing as I said we tend to stop oral therapies but if anything is still required such as such as down or daisya and antiemetics we can give suppling woo still and we can also give things using a subcutaneous syringe driver usually you'll find that patients don't have an IV alignment at this stage because it's kind of more invasive or not providing a lot of benefit can slowly trickle in a lot of drugs subcutaneously to good effect and we're stopping anything that they don't need so in terms of what you should do once someone has died which could be another Oski I guess that you might have a grieving family member someone who's recently passed away you should try and allow time for the family to say goodbye make sure that you ask about whether there's any kind of special needs the requirements of the family don't sort of asking that way but to say is there anything that we can do for you what can we do to help you because there'll be a lot of cultural variation in funeral practices and I don't think you're really expected to know necessarily what those things are but just being open to it making sure that you offer the support that you can give is really important in this stage make sure that you do look after people who are grieving and there's also a requirement of medical practice you know to certify the death and then to complete the death City sometimes that's would need to be recorded reported to the coroner but usually in the situation that someone has been in palliative care for a while and you knew they were dying and it was just sort of a slow deterioration and they died very unlikely to be a coroner's case you guys should have been taught about this at some stage so I'm not going to go through it today so the last little bit of this lecture is about caring for a person with a disability and I think if palliative care is kind of hard to talk about in lecture form because it's sort of more concepts and not really content and this is even harder but I've tried to make kind of a practical guide to what you might do in the Oski so some terminology that does tend to come up which I personally find a bit confusing is a disability versus an impairment most of the handicapped so what a disability is is actually a restriction or a lack of ability to do an activity in this type of manner or the standard that would normally be expected of a person so this is a functional limitation so this might be something like an inability to walk and this actually occurs as the result of an impairment so what the impairment is is a loss or an abnormality of a psychological physiological and anatomical structure or function which is kind of that underlying reason why someone can't do yeah so for example if someone can't move their legs properly that's the impairment and then the disability might be there as a consequence of that they're not able to walk and the third term that gets used is handicap which is a disadvantage for an individual that means that they can't do something that piers of their same sort of age would be expected to be able to do and this might be that because this person can't move their legs properly and they can't walk then they can't go and run with their friends or something along those lines so I think they have an example to put with each of these to kind of illustrate the difference between them is really helpful to try and remember what that is so sorry it's a bit of a busy slide in terms of caring for people with a disability I think the first thing to recognize is that all people with disabilities are going to be different so you need to make an effort to find out a bit about the person and what they can do and what they can't do so that you can care for them appropriately so things to ask about if you're meeting someone for the first time would be how they normally communicate and if they need any assistance with communication you need to try and find out what their cognitive capacity is like so do they make their own medical decisions or is someone making decisions for them are they likely to be able to understand things that you can explain to them or you're gonna have to modify how you explain things and what is their physical capacity like which might be relevant to the type of advice that you offer for example so I has kind of limited mobility you need to you need to alter what you offer in the way of an exercise regime for example and what aids they need to be able to mobilize and to take care of their ADL's I think it's a good idea to just sort of ask what life is like for the person and to try and initiate a discussion about what the barriers are that person living well so that might be pain might be mobility you might be cognitive might be other symptoms and that will give you an idea of the things that you can kind of target in order to make sure that they're living a reasonable quality of life and also make sure that you've asked if the patient or if the carer has any specific requests or concerns and the ware of care fatigue which tends to occur when people are looking after a lot of the time someone who's got quite a significant disability and know what it means and carers can get absolutely exhausted in these sort of situations I think you need to acknowledge that it's okay to be tired to feel like you're not coping to need to have a because people feel like they're indebted to their family or their friend that they're caring for but really everyone needs a break every now and again you can't deal with that sort of stuff all the time so I think in the Oskie make sure that you ask about this kind of stuff politely and be genuinely interested and most people will not be offended if you ask about it in that kind of way make sure you take into account what they say and then if y'all are then asked to explain something in the Askia then you can kind of tailor it to what you know about the patient and what's likely to be appropriate for them and do involve the patient even if the carer sort of doing all of the talk can you probably see this in real life as well particularly with pediatric patients that usually the care will do most of the talking but you still need to remember that the patient is the subject of the consult and the reason why actually having the discussions so do you involve them say hello to them smile look at them make sure that you show that you're actually interested in a patient that they are important to you so and the last type is just about surviving year four you guys can just read this some but please email me if you have any questions about this lecture or anything else and all the references are on this next slide as well most of it came from the therapeutic guidelines because there's a big section on palliative care on there anything else is just referenced on the relative relevance live and this question Bank if you guys don't know about it already you should get on that because there's a whole heap of free questions there and I just finished with this little YouTube video if it will let you hi we've got a call that this house is on fire how can we be helpful well the house is on fire but I'm worried if you go in there it might send the wrong message wait what I'm with the fire department yes I know I think you could be really helpful but I think the family might be worried something is wrong if the Fire Department shows up at their house but something is wrong their house is on fire do you think there's any way you could talk to them but not use the word fire what I just think if the family hears the word fire they might lose hope but I am with the fire department and I am here to help this family with their fire right right totally I think you could be really helpful but I'm just not sure this family is in a place where they're ready to meet the fire department right now can we call you the water support team so I don't know maybe that would change your perspective how you think about palliative care but actually misconceptions about what it is a really really common thanks everyone

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