1. Lessons from Palliative Care Dr Bill Lukin While we are waiting go to the APP store and load Opioid Calculator From ANZCA Faculty of Pain Medicine

3. Workshop Difficult Conversations Using OPIOIDS in palliative Patients Opioid Conversions Doctrine of double effect The Guardianship and Administration Act

4. Difficult Conversations What even are they? Why do we avoid them? What effect does this have on The patient? The System? This is a complex systems question?

5. Why do we find them so difficult?

6. The Power of Positive Thinking

7. The New Thought Movement

8. Phineas Quimby Mary Baker Eddy (Smile or Die. By Barbera Ehrenreich)

9. Questions for Casey Was here a difference between the conversations that were well done and those not well done? And what were those differences? Tell us about that conversation Brett had with the junior medical officer after the first ascetic tap.(he felt abandoned) What was it like to see young doctors afraid to talk to you?

10. MR B 34 yrs old Recurrent Ewings Sarcoma First recurrence Face Second Recurrence- skull Intra-abdominal deposit on last staging rescan Referred to Palliative Care

12. Progress

13. Difficult Conversations and how not to avoid them Why are we Here as Clinicians?

14. Why are We here? To Help People

15. What is People?

16. What is a person?

17. Are you the mechanic that fixes the machine that is a body? This is a complex question. If not then who are you? Evidence Based Medicine

18. What is Suffering ?

19. In A Medical Context?

20. and is it our business ? Is it our business as health professionals?

21. Eric Cassel 1982 NEMJ

22. Eric Cassell 1972

23. How do I(we) respond to Suffering?

24. Nurse Naming emotion Show Understanding Respect and reassure Supporting Exploring

25. Theraputic Presence That person thing again

26. Consent

27. Opioids and Opiophobia Hands up who has used an opioid for breathlessness in the last month.

28. Opiophobia ?

29. Google NGRAM Viewer

30. Opioids A 52 yr old man with metastatic renal cell carcinoma comes to your ED with uncontrolled pain. Fentanyl Patch 75 ug/hr Has taken 100 mg of endone since midnight How much of what drug are you going to give him for pain?

31. ANZCA Opioid Converter

32. Syringe Drivers When How Why?

33. Guardianship Act 63A Life-sustaining measure in an acute emergency (1) A life-sustaining measure may be withheld or withdrawn for an adult without consent if the adult’s health provider reasonably considers— (a) the adult has impaired capacity for the health matter concerned; and

34. (b) the commencement or continuation of the measure for the adult would be inconsistent with good medical practice; and (c) consistent with good medical practice, the decision to withhold or withdraw the measure must be taken immediately. (2) However, the measure may not be withheld or withdrawn without consent if the health provider knows the adult objects to the withholding or withdrawal. (3) The health provider must certify in the adult’s clinical records as to the various things enabling the measure to be withheld or withdrawn because of this section. (4) For this section, artificial nutrition and hydration is not a life-sustaining measure.

35. How is an EPOA supposed to act?

36. We apply the health care principle and the principle of substituted Judgement

37. 12 Health care principle (1) The health care principle means power for a health matter, or special health matter, for an adult should be exercised by a guardian, the public guardian, the tribunal, or for a matter relating to prescribed special health care, another entity— (a) in the way least restrictive of the adult’s rights; and (b) only if the exercise of power— (i) is necessary and appropriate to maintain or promote the adult’s health or wellbeing; or (ii) is, in all the circumstances, in the adult’s best interests.

38. Substituted Judgement (4) Also, the principle of substituted judgment must be used so that if, from the adult’s previous actions, it is reasonably practicable to work out what the adult’s views and wishes would be, a person or other entity in performing a function or exercising a power under this Act must take into account what the person or other entity considers would be the adult’s views and wishes.

39. Views and Wishes Views and wishes may be expressed orally, in writing or in another way, including, for example, by conduct.

40. What do I tell EPOAs