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  <head>
    <title>068-02 Advanced symptom reasoning, opioid safety, treatment withdrawal, and care in the final phase</title>
    <ownerName>Integrated Medical Foundations</ownerName>
  </head>
  <body>
    <outline text="Advanced palliative reasoning and final-phase care">
      <outline text="Symptom reasoning and total suffering">
        <outline text="Do not dismiss symptoms as inevitable"/>
        <outline text="Useful only if comfort, function, or goals improve"/>
        <outline text="Ask mechanism, reversibility, burden, time, impact">
          <outline text="Prevents neglect and reflex intervention"/>
        </outline>
        <outline text="Dimensions of total suffering interact">
          <outline text="Breathlessness and panic amplify each other"/>
        </outline>
        <outline text="Scores track but cannot replace narrative"/>
      </outline>
      <outline text="Pain assessment and opioid prescribing">
        <outline text="Background versus incident and breakthrough pain"/>
        <outline text="Recognise cord compression, fracture, retention">
          <outline text="Targeted treatment may prevent catastrophe"/>
        </outline>
        <outline text="Start from exposure, route, organ function, frailty"/>
        <outline text="Repeated rescue: uncontrolled pain or new cause">
          <outline text="Blind escalation worsens hyperalgesia, delirium"/>
        </outline>
        <outline text="Conversions are population estimates">
          <outline text="Reduce for cross-tolerance, then titrate"/>
        </outline>
        <outline text="Kidney failure accumulates active metabolites"/>
        <outline text="Transdermal onset and offset are delayed"/>
        <outline text="Syringe infusion does not imply imminent death"/>
      </outline>
      <outline text="Opioid toxicity and home safety">
        <outline text="Drowsiness, hallucination, myoclonus, touch pain">
          <outline text="Suspect accumulation, not only progression"/>
          <outline text="Reduce dose, switch drug, or trial fluid"/>
        </outline>
        <outline text="Reassess arousal, breathing depth, pain"/>
        <outline text="Teach family the signs of overdose"/>
        <outline text="Plan storage, error prevention, returns"/>
      </outline>
      <outline text="Bowel and nausea">
        <outline text="Prophylaxis accompanies regular opioids"/>
        <outline text="Overflow diarrhoea may conceal impaction"/>
        <outline text="Distinguish partial from complete obstruction">
          <outline text="Prokinetic worsens colic in complete block"/>
        </outline>
        <outline text="Treat nausea by mechanism"/>
        <outline text="Combine complementary agents">
          <outline text="Stacking similar receptor effects adds harm"/>
        </outline>
      </outline>
      <outline text="Breathlessness and secretions">
        <outline text="Severity correlates imperfectly with saturation"/>
        <outline text="Airflow and calm plan reduce threat perception"/>
        <outline text="Oxygen for symptomatic hypoxaemia">
          <outline text="Tubing may burden non-hypoxaemic patients"/>
        </outline>
        <outline text="Careful opioid titration is not euthanasia"/>
        <outline text="Secretion sounds may not mean suffering">
          <outline text="Avoid deep pharyngeal suction"/>
        </outline>
        <outline text="Judge distress by face, tension, restlessness"/>
      </outline>
      <outline text="Delirium, family, and sedation">
        <outline text="Delirium fluctuates, hypoactive often missed">
          <outline text="Seek pain, retention, infection, withdrawal"/>
        </outline>
        <outline text="Picking behaviour is brain failure, not rejection"/>
        <outline text="Exhausted vigil: share tasks, respite, contacts"/>
        <outline text="Ask the patient directly how much to know"/>
        <outline text="Agitation near death: reassess reversible causes"/>
        <outline text="Palliative sedation only for refractory suffering">
          <outline text="Minimum effective depth, titrated to relief"/>
        </outline>
      </outline>
      <outline text="Deprescribing, nutrition, and hydration">
        <outline text="Deprescribing is an active intervention"/>
        <outline text="Distant prevention adds burden without benefit"/>
        <outline text="Taper drugs where abrupt stopping harms"/>
        <outline text="Explain stopping to prevent sense of abandonment"/>
        <outline text="Feeding symbolises care">
          <outline text="Reduced intake reflects metabolism, not neglect"/>
        </outline>
        <outline text="Tube feeding adds aspiration and line infection"/>
        <outline text="Mouth care, ice, sips often relieve thirst"/>
        <outline text="Hydration trial needs endpoints and stopping rule"/>
      </outline>
      <outline text="Recognising dying and arrest plans">
        <outline text="Trajectory and repeated review, not one sign"/>
        <outline text="Reversible causes may mimic dying"/>
        <outline text="Guide family on breathing, cool limbs, contacts"/>
        <outline text="Arrest plan defines each treatment separately">
          <outline text="Not resuscitating is not stopping care"/>
        </outline>
        <outline text="Home death: verifier, contacts, documents"/>
        <outline text="Anticipatory orders with ranges and maximums"/>
      </outline>
      <outline text="Withdrawing life-sustaining treatment">
        <outline text="Same question as withholding: benefit to goals"/>
        <outline text="Stage reduction of ventilation, pressors, dialysis"/>
        <outline text="Titrate analgesia and sedation pre-emptively"/>
        <outline text="Add medication for observed distress">
          <outline text="Not for numbers or timing of death"/>
        </outline>
        <outline text="Delayed death is not necessarily a wrong decision"/>
      </outline>
      <outline text="After death, planning, and handover">
        <outline text="Verification, respectful handling, certification"/>
        <outline text="Correct guilt about medication, food, withdrawal"/>
        <outline text="Proportionate bereavement follow-up">
          <outline text="Assess suicidality, isolation, disabling yearning"/>
        </outline>
        <outline text="Plan before crisis, prescribe before swallow lost"/>
        <outline text="Palliative medicine is not less medicine"/>
        <outline text="Handover: goals, capacity, medicines, contacts">
          <outline text="Amounts used in the previous 24 hours"/>
        </outline>
        <outline text="Patient should not repeat a distressing account"/>
      </outline>
    </outline>
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