Tony Duffy
@Existential_Doc
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Palliative care 🩺 Dad 👶🏻 Gomez 🐶 Music 🎵 Guinea pigs 🐹 Personal account Threads 🧵to encourage discussion. “Be a voice of comfort in the silence of pain”
Scotland, United Kingdom
Joined January 2017
Every palliative care thread 🧵 I’ve ever done in one place. Just click on the box below and you will find them in the replies section- updated every month ⭐️
⚡️ “Palliative care threads” https://t.co/uPImzkvlqw
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Hundreds of hospice beds and staff cut in England amid funding crisis. And cue the lip service stating “we recognise that palliative care is vital” The NHS 10 year plan and Scottish operational plan mention Palliative Care ONCE between them
theguardian.com
National Audit Office reports nearly two-thirds of independent hospices in deficit in 2023-24 as demand increases
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Fastest rising population in Scotland. Eye hospital and cancer centre on hold, medications budget under pressure and demand on GPs rising with no additional resource. Watch this space
One of Scotland's biggest health boards says it faces a funding gap of more than £140m by the end of the decade. Gordon Chree reports https://t.co/ylEaFRAhd1
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As I suspected our community hospice referrals and reviews have increased by 33% in the last 2 years. That’s still not meeting the need that exists which is going to tidal wave further with transition of more hospital care to community. Careful planning is needed ahead
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https://t.co/k8SJnW6yWw Great opportunity to join the consultant team at @strathcarron1 @strathcarron1 @ailsaherd @UK_PRC @DonnaWakefield_ @doctor_oxford @dbuch17 @Existential_Doc @howell_annabel @Palliative_Scot @Paul_Howard_IoW @pharmacopallia @RichardLehman1 @veladconmigo
bmj.com
Due to retirement, we have an exciting opportunity for a Consultant in Palliative Medicine to join our team
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Edinburgh’s Firework chaos with a highly reactive dog and a tired 10 month old baby is not a good combination. Given we live very near Edinburgh Zoo I really worry what the animals there go through every year. Impossible to police an exclusion zone.
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Clonidine in palliative care Helpful tool in the box
Clonidine in palliative care- A thread 🧵 Clonidine is not a new drug. Developed in the 1960’s it has been used to manage hypertension, hot flashes, migraine and even ADHD. Use perioperatively and in ITU for pain relief has been fairly common inc via spinal and epidural route
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Palliative care learning- Buprenorphine
Buprenorphine- the only “British opioid” 🧵 Invented by John Lewis in Norwich while working for Reckitt and Coleman (yes, the mustard people) First tested in the Glasgow Western Infirmary on 3 volunteers one of which was John Lewis - that’s belief in your own invention folks!
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One of the most important threads I’ve ever tried.
Naloxone in palliative care 🧵 Naloxone can save lives in people with opioid induced respiratory failure or apnoea. It’s use only indicated when there is a fall in respiratory rate with evidence of significant ventilatory failure
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The aim of this & previous Governments is to move care into the independent sector Driven by the influence of corporations & wealthy investors The failure to understand is the problem
🩺 Over 6.15 million tests & operations were delivered by independent providers this year for NHS patients free of charge. Nearly 500,000 more than last year. By using spare capacity in the independent sector, we've cut NHS waiting lists by 200,000 and treated patients faster.
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One of the most important threads I’ve ever tried.
Naloxone in palliative care 🧵 Naloxone can save lives in people with opioid induced respiratory failure or apnoea. It’s use only indicated when there is a fall in respiratory rate with evidence of significant ventilatory failure
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This article explains everything in the thread and so much more. It is vital reading for anyone who works with patients approaching end of life or receiving palliative care https://t.co/4F5sWn0mPA
pubmed.ncbi.nlm.nih.gov
Patients with advanced, life-limiting illness might develop pain or breathlessness, requiring opioids. Opioid neurotoxicities, like sedation and delirium, overlap with signs of natural dying....
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Important Once a palliative care patient experiences naloxone reversal with acute pain, sudden fear, restlessness and agitation- it can make them fearful of ever taking opioids again, even when these drugs were providing good pain relief. This can lead to unnecessary suffering
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Remember Naloxone is not used to treat opioid toxicity Naloxone is used to treat life threatening opioid induced respiratory depression with ventilatory failure Naloxone should not be given to people who are dying peacefully
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It is only when opioid effects overwhelm this compensatory rise in tidal volume and reduce chemoreceptor sensitivity that ventilatory failure occurs. For palliative care patients established on opioids this is a very rare event! Opioid toxicity on the other hand is more common
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These are some of the most common scenarios that may occur. Opioids do slow down breathing and make it irregular. They act on the brainstem Pre-Botzinger complex even at safe therapeutic levels. We compensate for this by increasing tidal volume normally.
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NO definitely not! This person is dying. He is peaceful and settled. The changes in conscious level and breathing are normal signs of dying. Pauses in breathing are very common in the last hours of life. Myoclonic jerks also can occur near end of life. Reassurance is needed
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His RR varies between 4/min up to 12/min. Oxygen sats are 82%, his hands are cool to touch. He is unrousable. He looks comfortable. Family have asked if the morphine is causing him to present this way. Give some Naloxone? Even a small dose?
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He has cancer cachexia and is jaundiced due to liver metastases. It is noted by a family member that his breathing has slowed and become more shallow in the last few hours. There are periods when he stops breathing for up to 20seconds. He has some myoclonic jerking of his arms.
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Scenario 3 A 92 year old man is admitted to a hospice with widespread metastatic renal cancer. He is receiving 100mg oxycodone and 400micrograms of clonidine per day via a syringe driver for severe bone pain. He has been sleeping more over the last week and appeared comfortable.
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Should the small doses not work then Naloxone dose must be increased gradually and repeated until a ventilatory response is seen. With any dose of Naloxone be prepared that the patient may come round in a fearful or agitated way. Reassurance and support is vital at this time.
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