Tony Duffy

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 ⭐️

Okay, palliative pals. The chance to join a great team in Glasgow Please retweet for greater coverage @drol007 @Existential_Doc @laird_barry @drkathrynmannix @AllyMedic apply.jobs.scot.nhs.uk/Job/JobDetail?…

Hypercalcaemia of malignancy 🧵 It is relatively common and commonly mistaken as opioid toxicity or even dying. Always keep it in mind as treatment can improve quality of life significantly. P.S. Zoledronic acid is the correct spelling, my Glaswegian dialect to blame

Lithium: end of life considerations A short thread Lithium carbonate is used as a mood stabilising agent in uni and bipolar affective disorder. It can be life changing for patients and is generally well tolerated. It needs blood level monitoring to maintain a therapeutic range

@kittythephysio @bigbaddoctor @coulty78 @drkathrynmannix @ProfMarkTaubert @mrsbiffy @drol007 That’s a useful thing to know. I tend to use dermacool 1%, applied onto the back of the hand and waft. The 5% cream vapours are something else, certainty wakes you up. I remember using crystals when i was younger with hot water when I had a cold- wow!!!!

@Existential_Doc @bigbaddoctor @coulty78 @drkathrynmannix @ProfMarkTaubert @mrsbiffy @drol007 Although menthol can be irritating to vocal cords, causing them to narrow. We advise patients with vocal cord dysfunction to avoid it.

Hello twitter world. Im sort of back.... Anyone got any great suggestions for sob management in ILD but no access to morphine or benzos? Patches i feel risky... thank u loads @drkathrynmannix @Existential_Doc @bigbaddoctor @ProfMarkTaubert @mrsbiffy @drol007 paul k?

@drkathrynmannix @bigbaddoctor @mrsbiffy @coulty78 @ProfMarkTaubert @drol007 Clothes peg bags seem to work for some too. We had a lovely volunteer once who customised peg bags for patients. Everything from poems to Harley Davidson badges ☺️

@bigbaddoctor @mrsbiffy @Existential_Doc @coulty78 @ProfMarkTaubert @drol007 I was taught by district nurses: always ask patient to supply a very large sock as a holder for their SD, which should then be secured to ambulant patient's clothing above their waist by enormous nappy pin. Doesn't get left behind when walking, nor interfere with toileting.

@ClearThinker66 @mgtmccartney @marion_mcnaught However I think the term “cancer” can be misleading as the range of organ failure and presentations that can occur with the vast array of varied advanced malignancies does go a long way to justify the high proportion of palliative care input.

@mgtmccartney @marion_mcnaught I couldn’t agree more. My year in adult palliative care showed me that specialist input both in the community and in hospices/hospitals seemed to be reserved only for cancer patients. I truly hope things have changed. DNs are amazing and not paid enough.

I completely agree HOWEVER the vast majority of excellent palliative care is provided not in hospices/ specialist services but in homes by amazing DISTRICT NURSES, the unsung sheros here. yet their numbers have been decimated and working arrangements trashed. RESTORE THE DNs.

@ClearThinker66 @mgtmccartney @marion_mcnaught May depend on where you worked. In the past year I have been involved with care for people with MND, pulmonary fibrosis, heart failure, sepsis, traumatic brain/spinal injury, intreacerebral bleeds, dementia, skin conditions, renal failure, liver disease and genetic conditions

@MaryOToole10 @mgtmccartney Thats not uncommon due to huge limitations in the number of hospice community nurses. It has traditionally been a supportive and advisory role however there are now more hospice at home services that provide practical care alongside DNs. Funding is the issue

Yes! The palliative care nurses provided by a local charity did none of the practical useful stuff the DNs did…even down to recording the death and helping with the last care of the body….they just sat and ‘advised’: (. NB maybe this was all the GP had delegated to them…but we didn’t see a GP much either)

Thanks to our fantastic audience who came along to enjoy an evening of conversation and reflection in aid of East Cheshire Hospice, and to @WaterstonesMacc for providing books for sale. Kind hospitality by @kingsmac.

@kittythephysio @bigbaddoctor @coulty78 @drkathrynmannix @ProfMarkTaubert @mrsbiffy @drol007 Fan should i direct air onto the upper 2 thirds of the face. The cooling effect via trigeminal nerve reduces tidal volumes. I’ve found some people get even more relief if they are able to inhale menthol vapour along with fan therapy.

@bigbaddoctor @coulty78 @drkathrynmannix @Existential_Doc @ProfMarkTaubert @mrsbiffy @drol007 I suggest a desk fan on something nearby instead, so that the shoulders aren’t tense, which feeds back into the adrenaline loop of breathlessness. Pillows under upper limbs to take the weight off is a cheap win, too.

@mrsbiffy @coulty78 @drkathrynmannix @bigbaddoctor @ProfMarkTaubert @drol007 Definitely, 11th hour referral when dyspnoea impacts significantly on communication and becomes the main focus can make it really difficult to get things for the person and their family at end of life. The therapeutic benefit of continuity and a familiar face is undervalued

@Existential_Doc @coulty78 @drkathrynmannix @bigbaddoctor @ProfMarkTaubert @drol007 I have found this group of patients live with this disease then decline quickly and then referred rapidly to us. Have had more referrals in the past 2 years with much input needed. Trying to get resp to get us in sooner....especially in my neck of the woods ⚓️🚢

@mbrodeurpharmd pmc.ncbi.nlm.nih.gov/articles/PMC58… I really should have referenced properly. Thank you ☺️

@Existential_Doc Could you please provide the citation for this chart? Great thread thank you

Methadone: A palliative care thread

@coulty78 @drkathrynmannix @bigbaddoctor @ProfMarkTaubert @mrsbiffy @drol007 I tend to use benzos when anxiety/ panic components worsening, mainly in advanced disease and not responding to non-pharmacological approaches. Evidence lacking but not great quality of trials unlike with opioids. Opioid evidence for dypsnoea is interesting to say the least

@coulty78 @drkathrynmannix @bigbaddoctor @ProfMarkTaubert @mrsbiffy @drol007 Drug free approaches have good evidence but not sure of availability locally? In theory any opioid will work just that studies have focused on morphine. Oxy, hydromorphone or dare I say it Codeine all might work. Any Access to buprenorphine patches?

@coulty78 @drkathrynmannix @bigbaddoctor @ProfMarkTaubert @mrsbiffy @drol007 Its an opioid I guess. 50mg trammy is approx 5mg morphine equivalent. Smallest Buprenorphine patch 5mcg/hr is equivalent of 100-150mg tramadol/day. Sounds like a campaign for morphine is needed brother

@Existential_Doc @drkathrynmannix @bigbaddoctor @ProfMarkTaubert @mrsbiffy @drol007 Thanks buddy. Tramadol and i thought of a patch butrans but not sure risk as every1 worried about fragile respiratory system but in theory i think be ok???

Agreed 100% its a travesty and the results are felt every day. Those DNs also deserve ready advice and practical support from community palliative care teams. That integrated combination is the most potent, synergistic and sustainable formula for relieving distress

@Poppyjuice The “protocol” I just can’t

FFS The New Dark Age™

Why do we give older people drugs that make their mental functioning worse? Ms Davies, 80, came in with pneumonia. Within a day she was lethargic, not eating, barely responding. The team put it down to the infection. The term 'delirium' was never mentioned. But somebody had also started her on a benzodiazepine overnight for "mild anxiety." Nobody connected the two. On the ward round I noticed her responsiveness kept shifting - partly alert one moment, not responding the next. Both the drowsiness and the fluctuation suggested delirium. Screening test positive. We stopped the benzodiazepine, and continued the treatment for the pneumonia with antibiotics, fluids, and oxygen. The next day she later she was sitting up in her chair eating. She was able to participate in physiotherapy. The lesson here isn't complicated. If you start a sedative in an older person and they get more confused, stop the sedative. Don't add another drug on top. Check your prescribing before you check anything else. #delirium #medicationsafety

An old thread for an old and seriously misunderstood drug. Immensely helpful for managing pain in palliative care when used correctly and in the right situations