The passage discusses the importance of protecting personal data and privacy as technology advances. It notes that while technology provides benefits, it also creates new risks to how data is collected and used that were not issues in the past. Overall it argues that laws and regulations need to modernize to ensure privacy protections keep up with changing technology to prevent misuse of people's information.
Children are given palliative care in tertiary hospitals and even at home also. This topic includes which are the pediatric conditions require palliative care and what are the common symptoms children are facing and how to manage these symptoms.
This is an undergraduate presentation on failure to thrive in Pediatrics. In this presentation I mentioned about Diagnosis, Etiology, Etiology, Diagnostic Evaluation and Management.
https://orcid.org/0000-0001-9306-2267
https://1drv.ms/p/s!Am9GQ5GMX-WyjmOfgcNpov4RewVL
Pamudith Karunaratne
Children are given palliative care in tertiary hospitals and even at home also. This topic includes which are the pediatric conditions require palliative care and what are the common symptoms children are facing and how to manage these symptoms.
This is an undergraduate presentation on failure to thrive in Pediatrics. In this presentation I mentioned about Diagnosis, Etiology, Etiology, Diagnostic Evaluation and Management.
https://orcid.org/0000-0001-9306-2267
https://1drv.ms/p/s!Am9GQ5GMX-WyjmOfgcNpov4RewVL
Pamudith Karunaratne
This presentation is all about how to run a high risk follow up clinic for newborns discharged from a level II/III newborn care unit. It has been prepared mainly based on NNF protocol & AIIMS protocol.
Through palliative care, we change the role of a patient into a whole human being.
Through palliative care, we transform the stages leading to death into times filled with life
This presentation is all about how to run a high risk follow up clinic for newborns discharged from a level II/III newborn care unit. It has been prepared mainly based on NNF protocol & AIIMS protocol.
Through palliative care, we change the role of a patient into a whole human being.
Through palliative care, we transform the stages leading to death into times filled with life
Do Adolescents with Eating Disorders Ever Get Well?Dr David Herzog
Dr. David Herzog presents a slideshow regarding adolescents and their struggle with eating disorders. Do they ever get better and move past their eating disorders?
During our chapter reading group facilitation, my partner and I prepared an hour long presentation on the topic End of Life and Palliative Care. The basis of the presentation was from the weekly assigned chapters in our class textbook. We were required to present an engaging lecture, presentation, and/or hands-on activity for the class.
Senior Healthcare Consultant (Geriatric) class at Piedmont Hospitalsnomadicnurse
The first of a 2-day class on Geriatric issues for nursing staff at all 4 Piedmont hospitals funded by a HRSA Comprehensive Geriatric Education Grant 2009-2012.
Chief compliant(CC) Joshuas hyperactive and attentional difficultJinElias52
Chief compliant(CC) Joshua's hyperactive and attentional difficulties have been exhibited both at school and at home.
HISTORY: Joshua is a Hispanic or Latino 10-year-old boy. This evaluation was requested because
mother is worried about patient's aggressive behavior toward his younger brother and ADHD
symptoms. Mother report that patient was diagnosed at age 6 by pediatrician with ADHD,
medication was started at that time (mother unable to remember name) until age 9. Mother stopped
administering medication because it caused decrease appetite, insomnia and weight loss. Patient
is not currently taking any medication at this time.
Behavior Described In:
Symptoms/ behavior Joshua exhibits symptoms of inattention. He reports difficulty sustaining attention. His mind
wanders or he forgets. He does not seem to listen when spoken to directly. He often needs
directions repeated. Joshua is easily distracted by noises. by the radio. by other people. Joshua
needs supervision or frequent redirection. He has a short attention span.
Joshua exhibits signs of hyperactivity. He exhibits restlessness or fidgety behavior. This
behavior is evident during school hours. He tends to frequently leave his seat. He is
easily bored and changes activities frequently. Joshua 's excessive movement has been noted. He
is fidgety or squirms when required to sit still for a period of time. He frequently jumps or climbs.
Joshua exhibits signs of impulsive behavior. He frequently interrupts others. He often acts
in a reckless manner. He has difficulty accepting limits.
Joshua has other exhibited symptoms.
He exhibits stubborn or willful behavior.
EXAM: Joshua appears flat, inattentive, distracted, normal weight, He exhibits speech that is
normal in rate, volume, and articulation and is coherent and spontaneous. Language skills are
intact. Affect is appropriate, full range, and congruent with mood. Associations are intact and
logical. There are no apparent signs of hallucinations, delusions, bizarre behaviors, or other
indicators of psychotic process. Associations are intact, thinking is logical, and thought content
appears appropriate. Suicidal ideas or intentions are denied. Homicidal ideas or intentions are
denied. There are signs of anxiety. A short attention span is evident. Judgment appears to be
poor. Insight into problems appears to be poor. He is easily distracted. Joshua is restless. Joshua is
fidgety. There is physical hyperactivity. Joshua displayed defiant behavior during the examination.
Joshua made poor eye contact during the examination. Vocabulary and fund of knowledge indicate
cognitive functioning in the normal range. Cognitive functioning and fund of knowledge are intact
and age appropriate. Short- and long-term memory are intact, as is ability to abstract and do
Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation
Comprehensive psychiatric evaluations are a way to reflect on your practicum experiences and connect the experiences ...
Cancer Patients Awareness of Extent of Disease-Association with Psychological...Dr. Liza Manalo, MSc.
What is already known on this topic
►► In Southeast Asian cultures, the fear that should patients know their poor prognosis, they might become depressed, worry excessively, or lose the will to live has traditionally led families to request physicians for non-disclosure of diagnosis and prognosis.
►► The Asian Patient Perspectives Regarding Oncology Awareness, Care and Health (APPROACH) studies in other Asian countries revealed that patients who were aware or unsure of their prognosis reported higher levels of anxiety and depressive symptoms.
What this study adds
►► One of the most important findings in this study was the absence of an association between advanced cancer patients’ awareness of the extent of the disease and psychological morbidity.
►►Contrary to what might be expected, awareness of advanced cancer was associated with higher social well-being.
How this study might affect research, practice, or policy
►► The results of this research could impact how doctors in this cultural context communicate with cancer patients and allay concerns among families that sharing a cancer diagnosis and prognosis with the patient could lead to distress or worry. Future studies could focus on examining the effect of cultural beliefs and values, such as faith and spirituality, and social support networks on the well-being of cancer patients.
Discusses human life & human dignity, beginning of life issues like abortion and In Vitro Fertilization, as well as end of life issues like euthanasia, physician assisted suicide and
allowing natural death
Care of persons in the critical and terminal phases of life. With quotes from Samaritanus bonus, letter of the Congregation of the Doctrine of the Faith
Climate change protection of the environment-biosphere-biodiversity-laudato siDr. Liza Manalo, MSc.
Bioethics 1- Protection of the environment, biosphere and biodiversity in relation to the Sustainable Development Goals, climate change, conflict, health, and education.
The anthropological, philosophical and Christian teaching on human sexuality, marriage and the family. The Injustices of the Surrogacy Industry based on Catholic teaching on surrogacy is receiving reinforcement from current research.
End of life issues in advanced heart failure manalo palliative careDr. Liza Manalo, MSc.
Why aren’t countries accountable to commitment on end of life (#EOL) care for vulnerable people?
For lack of know-how. This presentation aims to teach cardiologists how to provide good palliative care to their patietnts.
Considerations when deciding about withholding or withdrawing life-sustaining...Dr. Liza Manalo, MSc.
Towards the end of life, physicians face dilemmas of discontinuing life-sustaining treatments or interventions. In some circumstances, these treatments are no longer of benefit, while in others the patient or family no longer want them. The physician plays an essential role in clarifying the goals of medical treatment, defining the care plan, initiating discussions about life-sustaining therapy, educating patients and families, helping them deliberate, making recommendations, and implementing the treatment plan. Communication is key. It should be clarified that when inevitable death is imminent, it is legitimate to refuse or limit forms of treatment that would only secure a precarious and burdensome prolongation of life, for as long as basic humane, compassionate care is not interrupted. Agreement to DNR status does not preclude supportive measures that keep patients free from pain and suffering as possible. Acceptable clinical practice on withdrawing or withholding treatment is based on an understanding of the medical, ethical, cultural, and religious issues. There is a need to individualize care option discussions to illness status, and patient and family preferences, beliefs, values, and cultures. The process of shared decision making between the patient, the family, and the clinicians should continue as goals evolve and change over time.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
3. DOMAINS OF QUALITY PALLIATIVE CARE
Domain 1: Structure and Processes of Care
Domain 2: Physical Aspects of Care
Domain 3: Psychological and Psychiatric Aspects of Care
Domain 4: Social Aspects of Care
Domain 5: Spiritual, Religious and Existential Aspects of Care
Domain 6: Cultural Aspects of Care
Domain 7: Care of the Imminently Dying Patient
4. DOMAINS OF QUALITY PALLIATIVE CARE
Domain 2:
Physical Aspects
of Care
Symptom Control
6. Opioids for Palliation of Dyspnea
The exact mechanism is unclear.
The drugs' cardiovascular effects are thought to be most likely
responsible for relieving dyspnea.
Therapeutic doses of opioids:
produce peripheral vasodilation
reduce peripheral vascular resistance
inhibit baro receptor responses
decrease brainstem responsiveness to carbon dioxide
(the primary mechanism of opioid induced respiratory
depression)
lessen the reflex vasoconstriction caused by increased
blood PCO2 levels so that the perception of dyspnea is
reduced
Furthermore, opioids reduce the anxiety associated with
dyspnea.
7. CONSTIPATION
Due to use of opioids
MAINSTAYS OF THERAPY
Stimulant (e.g. senna syrup)
Bisacodyl: 1 mo. – 2 yr 5 mg as single daily dose, oral or PR
2-12 yrs = 5 mg as single daily dose , oral or PR
>12 yrs=10 mg as single daily dose , oral or PR
Osmotic Laxatives
Lactulose: 1 mo. – 1 yr =2.5 ml/24 hr 12 hrly divided doses
1-2 yrs= 5 ml/24 hr 12 hrly divided doses
2-5 yrs = 5 ml/24 hr 12- hrly divided doses
5-12 yrs = 10 ml/24 hr 12- hrly divided doses
>12 yrs = 20 ml/24 hr 12- hrly divided doses
- Himelstein et al, N. Engl. J. Med, 2004
http://fohs.bgu.ac.il/inpact/images/Documents/commondrugs.pdf
8. NAUSEA
Prochlorperazine - 0.1 to 0.15 mg/KBW orally
or PR q6-8h
Ondansetron
for children 2-12 yrs: 0.15 mg/KBW orally or
IV q6-8h PRN
- Himelstein et al, N. Engl. J. Med, 2004
http://fohs.bgu.ac.il/inpact/images/Documents/commondrugs.pdf
9. AGITATION
Lorazepam
Midazolam (SC)
Children (1 mo - 12 yrs): 150 microgram/kg as a
single loading dose; 1 mg/kg/24 hr continuous SC
infusion
Haloperidol (oral, SC)
Children (1 mo – 12 yrs) 25 microgram /kg/ 24 hr
12- hrly divided doses
>12 yrs = 1 mg as single daily dose
- Himelstein et al, N. Engl. J. Med, 2004
http://fohs.bgu.ac.il/inpact/images/Documents/commondrugs.pdf
10. Pruritus
Diphenhydramine
Children 2-12 yrs: 5 mg/kg/day divided q4-6h
IV/PO
- Himelstein et al, N. Engl. J. Med, 2004
http://fohs.bgu.ac.il/inpact/images/Documents/commondrugs.pdf
11. Seizures
Diazepam
Infants (1 mo
– 2 yrs): 200 microgram/kg/24hr, 12 hrly divided dose, oral
400 microgram/kg, IV, titrated
Children 2-12 yrs = 1mg/24 once daily, oral
>12yrs=3-5mg /24hr once daily, oral
2-12 yrs= 400 microgram/kg IV, titrated
>12 yrs=5-10 mg IV, titrated
Maximum
10 mg as a single dose. Repeat after 5-10 mins if necessary.
- Himelstein et al, N. Engl. J. Med, 2004
http://fohs.bgu.ac.il/inpact/images/Documents/commondrugs.pdf
12. Secretions
Hyoscine butyl bromide (SC)
Infant (1 mo – 2 yrs): 1.5 mg/kg/24 hr
Children 2-5 yrs=15 mg/24 hr
6-12 yrs = 30 mg/24 hr
q6h- q8h divided doses or as
continuous SC infusion
- Himelstein et al, N. Engl. J. Med, 2004
http://fohs.bgu.ac.il/inpact/images/Documents/commondrugs.pdf
13. Domain 5: Spiritual, Religious and Existential
Aspects of Care
DEVELOPMENT OF DEATH CONCEPTS & SPIRITUALITY IN
CHILDREN
>6-12 years old
Characteristics: Has concrete thoughts
Predominant concepts of death:
Development of adult concepts of death
Understands that death can be personal
Interested in physiology and details of death
Spiritual Development
Faith concerns right and wrong
May accept external interpretations as the truth
Connects ritual with personal identity
Himelstein et al, N. Engl. J. Med, 2004
14. Domain 5: Spiritual, Religious and Existential
Aspects of Care
DEVELOPMENT OF DEATH CONCEPTS & SPIRITUALITY
IN CHILDREN
>6-12 years old
Interventions:
Evaluate child’s fear of abandonment
Be truthful
Provide concrete details if requested
Support child’s efforts to achieve control and mastery
Maintain access to peers
Allow child to participate in decision-making
Himelstein et al, N. Engl. J. Med, 2004
15. Realities of Childhood Grief
Dying children know they are dying; adult denial
is ineffective in the face of children’s emotional
perceptiveness
Dying children experience fear, loneliness, &
anxiety
Dying children worry, may try to put their affairs
in order, may strive to protect their parents, &
fear being forgotten
Dying children need honest answers and
unconditional love and support
Himelstein et al, N. Engl. J. Med, 2004
16. COMMUNICATION
Communication skills
Appropriate and effective sharing of information, active
listening
Empathic and effective communication skills are essential
Organized and effective procedure for communicating bad
news with 6 steps goes by the acronym SPIKES
17. SPIKES Protocol for Breaking the Bad News
Setting
Perception of the patient and/or family: Find out how
much the patient and/or family knows
Invitation: Find out how much the patient wants to know
Knowledge: Share the information
Empathy
Strategy/Summary
- Buckman RA, Community Oncology
March/April 2005
18. Advance Care Planning
Part of the standard of care involved in the care of
patients with life-threatening conditions
It is our responsibility to initiate these discussions, rather
than wait for patients and family members to ask.
These discussions should occur early and regularly
throughout the course of treatment, ideally before crises
arise, and as the goals of care are clarified or change
over time. Decisions should be reviewed and revised on
a regular basis as the medical condition and knowledge
of treatment and prognosis evolve.
19. Advance Care Planning
Clarification of wishes regarding emergency and lifesustaining therapies including CPR vs. DNR should be
obtained and documented so that these advance
directives can be communicated with others, such as
home care workers and schools.
Paediatric palliative care professionals should be
involved early in discussions of treatment goals.
Discussions about palliative care should take place well
before the paediatric patient is at imminent risk of dying.
20. Any life-sustaining treatment…
Resuscitation (CPR)
Diagnostic tests
Elective intubation,
Artificial nutrition,
mechanical ventilation
Surgery
Dialysis, Hemofiltration
Blood transfusions, blood
products
(parenteral or enteral) or
hydration (IVF)
Antibiotics
Vasopressors
Future hospital, ICU
admissions
…aimed at maintaining organ function that only
prolong death may be withdrawn or withheld
21. POPE JOHN PAUL II :
Clarify the substantive moral difference between
Discontinuing medical
procedures that may be
burdensome, dangerous, or
disproportionate to the
expected outcome
> "the refusal of 'over-zealous'
treatment"
Taking away the proportionate
means of preserving life, such as
ordinary feeding, hydration, and
normal medical care
22. DOMAINS OF QUALITY PALLIATIVE CARE
Domain 7: Care of the Imminently Dying Patient
Communication
Site of care
Resuscitation
Nutrition and fluids
Cessation of oral medications
Adequacy of analgesia
Management of distress
& unrelieved symptoms
Noisy breathing
Care issues
Duties after patient death
23. Overview of Care of Patients Imminently Dying
from Advanced Cancers
Learn to enjoy small accomplishments, and
teach that skill to patients and their families.
It is not always possible to eradicate every
symptom, but it is usually possible to bring some
degree of relief.
24. “There is nothing more that can be done” does not exist
in the lexicon of palliative medicine
There is always something that can be done, even if it is
simply to sit beside the patient and hold her hand and
offer a few words of comfort and solidarity.
25. Recognition: “DIAGNOSIS OF DYING”
Signs & Symptoms of Death Approaching
Profound tiredness and weakness
Reduced intake of food & fluids
Drowsy or reduced cognition
Essentially bed bound
Reduced interest in getting out of bed
Needing assistance with all care
Less interest in things happening around
them
May be disoriented in time and place
Difficulty concentrating
Scarcely able to cooperate and converse
with carers
Gaunt appearance
Difficulty swallowing oral
medication
Guidelines for managing the last days of life in adults. 2006. The National Council for Hospices and
Specialist Palliative Care Services, London
26. Care During the Last Days and Hours of Life
Patients in the last days of life typically experience
extreme weakness and fatigue and become bedbound
“Death Rattle“ – noisy terminal respirations caused by the
presence of secretions in the airway (usually the upper
airway) in patients who are too weak to cough effectively
Hearing and touch
27. Care During the Last Days and Hours of Life
Patient decides whether to be cared for and to die in the
hospital, or at home
cardinal signs of death should be instructed to caregivers
Physician should establish a plan for who the family or
caregivers will contact when the patient is dying or has
died
Avoiding unnecessary admission
28. Care of the Imminently Dying Patient:
Medications
Oral medications that are no longer necessary (e.g.,
laxatives, antibiotics) should be stopped.
Medications that are needed to control ongoing
symptoms (e.g., pain, nausea, seizures) should be
given rectally or parenterally .
When patients become anuric close to death,
continuous dosing may be discontinued in favor of
bolus dosing to prevent metabolite accumulation
and agitated delirium. - Weinstein, Arnold & Weissman, Fast Fact and
Concept #54: Opioid Infusions (www.eperc.mcw.edu)
29. Care of the Imminently Dying Patient:
Nutrition & Hydration
During the last days of life, patients tend naturally to
take in less and less food and fluid.
Hunger is rare in the last days of life.
Thirst occurs more commonly, but without relation to
dehydration, and can usually be controlled by simple
measures (e.g., moistening the lips, giving small sips
of fluids or small amounts of crushed ice to suck).
Enteral feeding should be stopped when the patient
can no longer swallow reliably.
30. Care of the Imminently Dying Patient:
Hydration
In most cases, parenteral (IV) fluids should not be given in
the last hours of life.
Allowing the patient to become slightly dehydrated may
prevent or ameliorate many otherwise distressing problems in
the last hours:
Consequence of IV Hydration
Symptoms
↑ Respiratory secretions
Cough
Pulmonary congestion
Sensations of choking & drowning
↑ Urine Output
Bedwetting, bedpans, catheters
↑ Gastrointestinal secretions
Vomiting
↑ Total body water
↑ Edema, ascites, pleural effusions
↓ Serum urea
↑ Awareness
↑Distress, ↓Pain threshold
31. Psychosocial Support of the Patient and the
Family
In addition to anxiolytics, supportive counseling, spiritual
counseling, and family support can help counter feelings
of anxiety
At the moment of the patient’s death:
shock and loss and be emotionally distraught
assimilate the event and be comforted
32. Support of the Patient &
His Family During the Agonal Period
The nearer the patient approaches death, the more he
reaches out towards life…
Touch is often important, sitting close to him, holding his
hand, staying near him even without words…
All of these things make the chasm between the living and
the dead less terrifying and lonely...
- Hackett & Weisman, 1962
33. TASKS OF THE MULTIDISCIPLINARY
PALLIATIVE CARE TEAM
1) To see the patient & the family through
- the physical & emotional stages of terminal illness
2) To ease their burden along the way
- to walk alongside, not to give orders from above
3) To be there
- when symptoms arise, when hard questions have
- to be faced, when fear & loneliness threaten
34. TASKS OF THE MULTIDISCIPLINARY
PALLIATIVE CARE TEAM
To apply to the care of
the dying
the same high standards of
clinical analysis & decisionmaking as are demanded in the
care of patients expected to
get well
35. “Death is not extinguishing the light;
it is putting out the lamp because the Dawn has come.”
- Rabindranath Tagore