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  <head>
    <title>068-01 Foundations</title>
    <ownerName>Integrated Medical Foundations</ownerName>
  </head>
  <body>
    <outline text="Palliative medicine foundations">
      <outline text="Scope and identifying need">
        <outline text="Symptoms, decisions, coordination, whole-person needs"/>
        <outline text="Begins alongside disease treatment">
          <outline text="Not limited to cancer or final days"/>
        </outline>
        <outline text="Recognising dying shifts effort to comfort"/>
        <outline text="Triggers: progression, admissions, decline, carer strain"/>
        <outline text="Surprise question finds unmet planning">
          <outline text="Not a prognosis"/>
        </outline>
        <outline text="Trajectories differ by disease">
          <outline text="Cancer may decline predictably"/>
          <outline text="Organ failure fluctuates with crises"/>
          <outline text="Frailty or dementia declines slowly"/>
        </outline>
      </outline>
      <outline text="Goals and shared decisions">
        <outline text="Understanding, detail wanted, what matters now"/>
        <outline text="Hope shifts from cure to achievable priorities"/>
        <outline text="Compare benefit, burden, uncertainty, alternatives"/>
        <outline text="Time-limited trial">
          <outline text="Intervention, markers, duration, plan if no benefit"/>
        </outline>
        <outline text="Record substitute, directives, resuscitation, place"/>
      </outline>
      <outline text="Communication and prognosis">
        <outline text="Warn, speak plainly, pause, acknowledge emotion"/>
        <outline text="Prognosis is a range, not a date">
          <outline text="Best, worst, and likely scenarios"/>
        </outline>
        <outline text="Patient declines details: identify a recipient"/>
        <outline text="Conflict reflects facts, values, grief, trust">
          <outline text="Shared goals, second opinion, mediation"/>
          <outline text="Recommend when treatment cannot meet goals"/>
        </outline>
      </outline>
      <outline text="Holistic symptom assessment">
        <outline text="Symptoms are multidimensional"/>
        <outline text="Investigate only if management changes"/>
        <outline text="Non-drug care: explanation, positioning, fan, mouth care"/>
        <outline text="Stop preventive drugs mismatched to prognosis">
          <outline text="Avoid withdrawal of dependence-producing drugs"/>
        </outline>
      </outline>
      <outline text="Pain">
        <outline text="Identify pain type, treat cause if proportionate"/>
        <outline text="Steroids, bisphosphonates, radiotherapy, nerve blocks"/>
        <outline text="Opioids central but not the only treatment"/>
        <outline text="Transdermal systems adjust slowly">
          <outline text="Unsuitable for rapidly escalating pain"/>
        </outline>
        <outline text="Conversion tables are estimates">
          <outline text="Reduce for incomplete cross-tolerance"/>
        </outline>
        <outline text="Respiratory depression: escalation, interaction, renal failure, error"/>
        <outline text="Fear of addiction must not leave pain untreated"/>
      </outline>
      <outline text="Breathlessness">
        <outline text="Multiple mechanisms, including anxiety and perception"/>
        <outline text="Oxygen helps hypoxaemia, adds little otherwise"/>
        <outline text="Upright, handheld fan, pacing, calm coaching"/>
        <outline text="Low-dose opioid alters central perception"/>
        <outline text="Benzodiazepine only for severe associated anxiety"/>
        <outline text="Non-invasive ventilation needs explicit purpose">
          <outline text="Relieves symptoms or prolongs life"/>
        </outline>
      </outline>
      <outline text="Nausea, bowel, and secretions">
        <outline text="Manage obstruction according to goals">
          <outline text="Avoid prokinetics in complete obstruction"/>
        </outline>
        <outline text="Constipation causes pain, nausea, delirium">
          <outline text="Stimulant plus osmotic for opioid constipation"/>
          <outline text="Avoid rectal measures in neutropenia, low platelets"/>
        </outline>
        <outline text="Noisy secretions distress family more than patient">
          <outline text="Antimuscarinics do not remove existing fluid"/>
          <outline text="Deep suction distresses without lasting benefit"/>
        </outline>
      </outline>
      <outline text="Delirium, agitation, and distress">
        <outline text="Delirium: infection, retention, drugs, organ failure">
          <outline text="Familiarity, orientation, sleep cues, safety"/>
          <outline text="Antipsychotics for danger, may worsen some syndromes"/>
        </outline>
        <outline text="Terminal agitation: pain, bladder, fear, withdrawal"/>
        <outline text="Catastrophic bleed: dark towels, rapid sedation"/>
        <outline text="Sadness does not exclude depression"/>
        <outline text="Meet desire for hastened death with curiosity"/>
        <outline text="Antidepressant onset may exceed prognosis"/>
      </outline>
      <outline text="Nutrition and hydration">
        <outline text="Treat mouth pain and nausea without forcing intake"/>
        <outline text="Preferred foods over calorie targets"/>
        <outline text="Cachexia not reversed by calories alone"/>
        <outline text="Artificial nutrition for selected reversible states">
          <outline text="Often no benefit in advanced dementia or dying"/>
        </outline>
        <outline text="Assisted hydration may worsen oedema, secretions">
          <outline text="Mouth care often relieves dryness better"/>
        </outline>
      </outline>
      <outline text="Last days, death, and grief">
        <outline text="Signs: bedbound, minimal intake, mottling, no swallow"/>
        <outline text="Stop observations, tests, devices not aiding comfort"/>
        <outline text="Anticipatory medicines by a usable route"/>
        <outline text="Resuscitation decisions are not abandonment"/>
        <outline text="Withholding and withdrawing are ethically equivalent"/>
        <outline text="Palliative sedation: minimum required, reviewed"/>
        <outline text="Verify death, certification, time with the body"/>
        <outline text="Grief is not linear">
          <outline text="Risk: traumatic death, isolation, low support"/>
          <outline text="Follow up without medicalising normal sorrow"/>
        </outline>
      </outline>
    </outline>
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