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PALLIATIVE
CARE
OBJECTIVES
Know and understand:
• The roles of palliative and hospice care in caring for
seriously ill older patients
• Techniques for communicating effectively when
delivering bad news
• How to assess and manage pain
• Best methods for managing non-pain symptoms
Slide 2
TOPICS COVERED
• Facts about the Care of Persons with Serious
Illness in the United States
• Scope of Palliative Care
• Hospice Care
• Communicating Bad News
• Assessing and Managing Pain
• Assessing and Managing Non-pain Symptoms
Slide 3
STANDARDS OF EVIDENCE (SOE)
Rating
Basis of Rating
Studies Justifying Rating
A
Consistent and good quality patientoriented evidence
Large cohort studies for risk
factors/prognosis; RCTs for
diagnosis/treatment
B
Somewhat inconsistent or limited
quality patient-oriented evidence
Smaller or single cohort
studies for risk factors/
prognosis; small or single
RCTs or cohort studies for
diagnosis/treatment;
uncontrolled studies
C
Very inconsistent or very limited
patient-oriented evidence, consensus,
disease-oriented evidence, and/or
case series for studies of diagnosis,
treatment, prevention, or screening
Single small cohort study for
risk factors/prognosis; single
small cohort study or RCT for
diagnosis/treatment; case
series
D
Unstudied common practice or opinion No evidence
Slide 4
END-OF-LIFE DEMOGRAPHICS
IN THE UNITED STATES
• The majority of deaths occur in older adults
• Seriously ill patients spend most of their final
months at home, but most deaths occur in the
hospital or nursing home
• Location of death varies regionally:
 Portland: 35% in hospitals
 New York City: >80% in hospitals
Slide 5
QUALITY OF END-OF-LIFE
IN THE UNITED STATES
• Typical deaths are slow, associated with chronic
disease in persons with multiple problems
• Typical deaths are marked by  dependency and
care needs
• Quality of life during the dying process is often poor
because of inadequate treatment of distress;
fragmented care; strains on family, support system
• Difficult decisions about use of life-prolonging
treatments are commonly necessary
Slide 6
WHAT IS PALLIATIVE CARE?
• Interdisciplinary care that aims to relieve
suffering, improve quality of life, optimize
function, and assist with decision making for
patients with advanced illness and their
families.
• It is offered simultaneously with all other
appropriate medical treatment.
Slide 7
WHAT IS “HOSPICE”?
• The comprehensive care system for patients
with limited life expectancy at home or in
institutional settings.
Slide 8
THE HOSPICE MEDICARE BENEFIT
• For beneficiaries with an expected prognosis of 6
months if the disease follows its usual course certified
by a licensed physician
• Must give up curative treatments and agree that the
care plan with respect to the terminal illness will be
managed by the hospice program
• Includes: physician services, nursing care, medical
equipment and supplies, medications, short-term
inpatient care for symptom management & family
respite, PT or OT, bereavement services, home-health
aide services
Slide 9
OBSTACLES TO EFFECTIVE
HOSPICE CARE
• Limited access
• Lack of family support
• Late referral
• Difficulties in determining prognosis
Slide 10
STEPS IN COMMUNICATING
BAD NEWS
A systematic approach to delivering bad news can
improve the physician’s, patient’s, and family’s ability to
cope with the situation and plan for the future
• Prepare
• Establish the patient’s understanding
• Learn how much the patient wants to know
• Deliver the information
• Respond to the patient’s feelings
• Organize a plan and follow-up procedure
Slide 11
PREPARING TO DELIVER BAD NEWS
• Plan what will be discussed
• Ensure that all medical facts and
confirmations are available
• Choose an appropriate, comfortable setting
• Deliver the news in person, privately
• Allow time for discussion
• Minimize interruptions
Slide 12
ESTABLISH THE PATIENT’S
UNDERSTANDING
Ask questions such as the following:
• “What do you understand about your illness?”
• “When you first had symptom x, what did you
think it might be?”
• “What have other doctors told you about your
condition or procedures that you have had?”
Slide 13
HOW MUCH DOES THE PATIENT
WANT TO KNOW?
Make no assumptions; remember that:
• Patients have the right to be told the truth but
also to decline to learn unwanted information
• A patient may not want to know full details
• A patient may wish to have a family member
informed instead
Slide 14
DELIVERING BAD NEWS
• Use a sensitive, straightforward manner
• Avoid technical language or euphemisms
• Check for understanding and clarify difficult
concepts
• Use phrasing that sends a “warning shot” to
prepare the patient:
eg, “Mr. X, I feel bad to have to tell you this,
but the growth turns out to be cancer.”
Slide 15
AFTER DELIVERING BAD NEWS
Respond to feelings
• Use active listening
• Encourage the expression of emotion
• Acknowledge the patient’s emotions
Organize a plan and follow-up
• Address patient’s concerns in immediate plan
• Set an appointment for a follow-up visit
• Discuss additional tests, referrals, sources of
support
• Provide information on how you can be reached
for additional questions
Slide 16
EFFECTIVE PAIN MANAGEMENT
• Know the types of pain
• Assess the patient’s level of pain
• Minimize pain with nonpharmacologic techniques
• Add pharmacologic analgesia when needed
• Avoid analgesics harmful for older adults
• Anticipate and manage the side effects of opioids
Slide 17
PAIN INTENSITY SCALES
• Unidimensional scales:
 Numeric Rating Scale—0 is no pain, 10 is worst pain
imaginable
 Faces Pain Scale—patient chooses a facial expression
that corresponds to the pain
 Verbal Descriptor Scale—“no pain” to “pain as bad as it
could be”
• Multidimensional scales:
• McGill Pain Questionnaire
• Pain Disability Scale
Slide 18
PAIN IN COGNITIVELY
IMPAIRED PERSONS
• Observe for possible pain-related behaviors and
ask caregivers for their observations
 Consider trial of analgesia for patients exhibiting
pain-related behaviors
• Validated scales (eg, Hurley Discomfort Scale,
Checklist of Nonverbal Pain Indicators) require
training
• Provide empiric analgesia during procedures and
conditions known to be painful
Slide 19
3 TYPES OF PAIN SYNDROMES
• Nociceptive—pain due to activation of nociceptive
sensory receptors; often adequately treated with
common analgesics
 Somatic—well localized in skin, soft tissue, bone
 Visceral—due to cardiac, GI, or lung injury
• Neuropathic—from irritation of components of the CNS
or peripheral nervous system; may respond well to
nonopioid therapies; responds unpredictably to opioids
• Mixed or unspecified—has characteristics of both
nociceptive and neuropathic pain; common in older
adults
Slide 20
TYPES OF PAIN, EXAMPLES,
AND TREATMENT (1 of 3)
Type of Pain
and Examples
Source of Pain
Typical Description
Table 15.1
Effective Drug Classes
and Non-Pharmacologic
Treatments (SOE Rating)
Nociceptive: somatic
Arthritis, bone
metastases
Tissue injury
(eg, bones,
soft tissue,
joints,
muscles)
Well localized, constant;
aching, stabbing, gnawing,
throbbing
Acetaminophen (A), opioids
(B)
Diffuse, poorly localized,
referred to other sites,
intermittent, paroxysmal; dull,
colicky, squeezing, deep,
cramping; often accompanied
by nausea, vomiting,
diaphoresis
Treatment of underlying
cause
Physical and cognitivebehavioral therapies (B)
Nociceptive: visceral
Renal colic,
constipation
Viscera
Physical and cognitivebehavioral therapies (C)
Slide 21
TYPES OF PAIN, EXAMPLES,
AND TREATMENT (2 of 3)
Type of Pain
and Examples
Source of
Pain
TypicalTable
Description
15.1
Effective Drug Classes
and Non-Pharmacologic
Treatments (SOE Rating)
Peripheral
or central
nervous
system
Prolonged, usually constant, but
can have paroxysms; sharp,
burning, pricking, tingling,
squeezing; associated with other
sensory disturbances (eg,
paresthesias and dysesthesias);
allodynia, hyperalgesia, impaired
motor function, atrophy, or
abnormal deep tendon reflexes
Tricyclic antidepressants
(A), anticonvulsants (A),
serotonin-norepinephrine
reuptake inhibitor
antidepressants (A),
opioids (B), topical
anesthetics (C)
Neuropathic
Cervical or lumbar
radiculopathy,
post-herpetic
neuralgia,
trigeminal
neuralgia, diabetic
neuropathy, poststroke syndrome,
herniated
intervertebral disc
Physical and cognitivebehavioral therapies (C)
Slide 22
TYPES OF PAIN, EXAMPLES,
AND TREATMENT (3 of 3)
Type of Pain
and Examples
Source of
Pain
TypicalTable
Description
15.1
Effective Drug Classes and
Non-Pharmacologic
Treatments (SOE Rating)
Poorly
understood
No identifiable pathologic
processes or symptoms
out of proportion to
identifiable organic
pathology; widespread
musculoskeletal pain,
stiffness, and weakness
Antidepressants (B), antianxiety
agents (C)
Undetermined
Myofascial pain
syndrome,
somatoform
pain disorders
Physical, cognitive-behavioral
and psychological therapies (B)
Slide 23
NON-PHARMACOLOGIC THERAPIES
• Patient education and involvement in decisions
 Teach patients to take medications properly and how to
use assessment instruments
 Provide partner-guided pain management training to
caregivers
• Cognitive-behavioral therapy
• Regular physical activity
 Or supervised rehabilitation for frail patients, or regular
repositioning and gentle massage for bed-bound patients
• Referral to an interdisciplinary pain clinic
Slide 24
PRINCIPLES OF
PHARMACOLOGIC THERAPY
• Besides pain relief, the goals are improved function
and enhanced adherence with rehabilitation
• Individualize the initial dose and rate of titration
• In general, start opioids at lowest dose and titrate
slowly, but if patient is in pain crisis, do not withhold
medications
• Try nonsystemic or non-pharmacologic therapies
first if appropriate
Slide 25
TREATING MILD TO MODERATE PAIN
• Acetaminophen
 Particularly for musculoskeletal pain
 No more than 4 g every 24 h
 Lower the dose by 50%, or avoid, in patients at risk of liver
dysfunction, especially with history of heavy alcohol intake
 Know all medications the patient is taking, as acetaminophen
is a common ingredient in prescription and OTC drugs
• NSAIDs
 Many significant adverse effects
 Use COX-2 inhibitor with extreme caution, if at all, in older
persons
 Use judiciously, if at all, only after acetaminophen has been
tried and only in highly select individuals
Slide 26
TREATING MODERATE TO SEVERE PAIN
• To estimate opioid requirements, conduct a trial of a
short-acting opioid
• Treat continuous pain with 24-hour opioids in longacting or sustained-release formulations
 To cover breakthrough pain, combine with fast-onset
medications that have short half-lives
 Breakthrough pain typically requires 5%–15% of the
daily dose, offered q2h orally
• In general, different opioids are similarly efficacious
 Cost and route of delivery can help guide the choice
Slide 27
USING OPIOIDS IN RENAL FAILURE
• To reduce the risk that the active metabolites
of morphine will accumulate, increase the
dosing interval and reduce the dose
• Hydromorphone is many experts’ first choice
for this population
• Safety of oxycodone in this population is still
controversial
Slide 28
COMBATTING FEAR OF TOLERANCE
AND ADDICTION TO OPIOIDS
• Avoid withdrawal symptoms by tapering carefully over
days to weeks
• If rapid upward titration is required to reduce pain,
suggesting that tolerance has developed:
 Evaluate the cause of pain, including searching for new
pathologies and exacerbation of known sources of pain
 Consider nonphysical causes of pain
• There is limited cross-tolerance between opioids
 When switching a patient from one opioid to another, reduce
the dose to 50%–65% of the equivalent dose
Slide 29
MANAGING THE ADVERSE
EFFECTS OF OPIOIDS (1 of 2)
• Constipation
 Educate patient about probable need for long-term
laxative treatment
 In most cases, start with a stimulant laxative
 Encourage exercise and hydration
 Consider methylnaltrexone for patients with opioidinduced constipation despite laxative therapy
• Nausea and vomiting—evaluate for reversible
causes, then try a different opioid or treat with
chronic antiemetics
Slide 30
MANAGING THE ADVERSE
EFFECTS OF OPIOIDS (2 of 2)
• Sedation, fatigue, mild cognitive impairment
 Educate the patient that these changes generally
subside days to weeks after dose adjustment
 Warn against driving or operating heavy equipment
when medication is initiated
 Warn of the risk of falls
 For incessant fatigue, try a stimulant such as low-dose
methylphenidate or rotation to a different opioid
• Respiratory depression—use naloxone sparingly,
at the lowest dose, and titrate carefully
Slide 31
NONOPIOID MEDICATION
• TCAs (off-label) are the best-studied drugs for
neuropathic pain
• Optimal analgesia requires treatment of depression
 SSRIs are less well studied than TCAs as analgesics, but they
are better tolerated in antidepressant doses
 Duloxetine is approved as both an antidepressant and for
treatment of pain from diabetic neuropathy
• Antiepileptics are commonly used for neuropathic pain
• Corticosteroids are useful adjuvants for neuropathic
pain and pain associated with swelling, inflammation,
and tissue infiltration (SOE=C)
Slide 32
MEDICATIONS TO AVOID
IN OLDER PERSONS
• Propoxyphene
• Meperidine
• Mixed agonist-antagonists such as nalbuphine
and butorphanol
• COX-2 inhibitors
• Other NSAIDs and use rarely if ever
Slide 33
PALLIATION OF NONPAIN SYMPTOMS
• Constipation
• Delirium
• Nausea and
vomiting
• Depression
• Diarrhea
• Anorexia and
cachexia
• Dyspnea
• Cough
• Loud respiration
Slide 34
CONSTIPATION
• Common for terminally ill patients
• Caused by opioids, immobility, poor fluid intake
• Treatment
 Use prophylactic laxatives: stool softener & bowel
stimulant (docusate sodium & senna or bisacodyl)
 If ineffective, add osmotic laxative (sorbitol, lactulose,
polyethylene glycol)
 If no bowel movement in 4 days, consider enema
 If impaction occurs: disimpact manually or with
enemas before starting laxative therapy
Slide 35
NAUSEA AND VOMITING
Key Facts
• Occur in 40%–70% of patients with advanced
cancer
• May be caused by disease or its treatment
Treatment
• Select antiemetic agent on the basis of:
 Likely cause
 Pathway mediating the symptoms
 Neurotransmitters involved
Slide 36
EMESIS CAUSED BY DRUGS & TOXINS
Common Causes
• Drugs: opioids, digoxin
• Biochemical disorders: hypercalcemia, uremia
• Toxins: tumor-produced peptides, infection, radiotherapy,
abnormal metabolites
Pathway
• Chemoreceptor trigger zone in vomiting center
• Receptors: dopamine, serotonin, histamine acetylcholine
receptor
Treatments
• Dopamine antagonists (eg, haloperidol)
• Prokinetic agents (eg, metoclopramide)
• Serotonergic antagonists (eg, ondansetron, granisetron)
Slide 37
EMESIS ORIGINATING IN THE GUT
Common Causes
• Gastric irritation, gastric distension, liver capsule stretch
• Opioid stasis, constipation, tumors, peritoneal inflammation
• Upper bowel, genitourinary, biliary stasis
Pathway
• Gut
• Receptors: serotonin, histamine receptor type 1
Treatments
• Motility agents for stasis (eg, metoclopramide)
• Serotonin antagonists, antihistamines
Slide 38
EMESIS OF OTHER ORIGINS
Vestibular Apparatus
• Receptors: muscarine, acetylcholine, histamine receptor
type 1
• Common causes: drugs (aspirin, opioids), motion
sickness (Ménière’s disease, labyrinthitis), local tumors
(acoustic neuroma, brain tumors, bone metastases to
base of skull)
• Treatment: scopolamine, hydrobromide, meclizine
Cerebral Cortex
• Common cause: raised intracranial pressure
• Treatment: dexamethasone
Slide 39
DIARRHEA
• Affects 7%‒10% of patients with cancer being
admitted to hospice
• Consider fecal impaction presenting as watery
diarrhea in immobile older patients on opioids
• Review medications for excessive laxative
therapy
Slide 40
ANOREXIA AND CACHEXIA
Loss of appetite is almost universal among
terminally ill patients
• Anorexia in actively dying patients who do not
wish to eat should not be treated
• Symptoms of dry mouth should be treated
• Appetite stimulants (eg, corticosteroids) may
benefit patients in early stages
• Encourage patients to eat whatever is most
appealing, without dietary restrictions
Slide 41
DELIRIUM
Common and distressing for both terminally ill
patients and their families
• Identify potentially reversible causes (infection,
impaction, uncontrolled pain, urinary retention,
hypoxia)
• Use low doses of nonsedating antipsychotic
• Actively dying, nonambulatory patients may
benefit from sedating antipsychotic
• Avoid benzodiazepines
Slide 42
DEPRESSION
Under-recognized and undertreated in terminally ill
• Vegetative symptoms (insomnia, anorexia,
weight change) may not be reliable because of
underlying illness
• Be alert for mood change, loss of interest,
suicidal ideation
• Treat aggressively: antidepressants, psychiatric
consultation, cognitive-behavioral therapy are
appropriate
Slide 43
DYSPNEA
Assessment
• Patient self-report is only reliable measure
• Respiratory rate and lab tests often do not correlate
Management
• Treat underlying cause, but do not delay symptom
management
• Use O2 if saturation < 90% but use cautiously with
patients who retain CO2
• Use fan, open window to stimulate 5th cranial (trigeminal)
nerve & reduce dyspnea
• Benzodiazepines control anxiety but not dyspnea
• Opioids reduce respiratory drive, dyspnea
Slide 44
COUGH
Causes
• Production of excess fluids
• Inhalation of foreign material
• Stimulation of irritant receptors in the airway
Management
• Treat underlying cause
• Add opioids if underlying disease not resolvable
 Dextromethorphan: suppresses cough with few
sedative effects
 Codeine, hydrocodone elixirs
 Methadone syrup for longer duration of action
• Nebulized anesthetic for irritated pharynx of local
infection or malignancy
Slide 45
LOUD RESPIRATION (1 of 2)
• The inability to clear secretions from the
oropharynx, resulting in loud or “rattling”
respirations
• Caused by secretions oscillating up and down
during inspiration and expiration
• Treatment:
 Family education prior to its occurrence
 Postural drainage, positioning, and suctioning
Slide 46
LOUD RESPIRATION (2 of 2)
• Treatment (continued):
 Anticholinergics to dry up secretions
• Hyoscine (scopolamine patch) every 72 h
• Hyoscyamine 0.125 sublingually
• Glycopyrrolate 0.2 mg SC every 8 h
• Atropine ophthalmic solution, 1–2 drops
sublingually every 4–6 h
Slide 47
SUMMARY (1 of 2)
• Palliative care aims to relieve suffering, improve
quality of life, optimize function, and assist with
decision making for patients with advanced illness
and their families
• Palliative care is offered simultaneously with all
other appropriate medical treatment
• Communicating bad news requires preparation,
sensitivity to patient’s understanding and needs,
and an organized plan and follow-up
Slide 48
SUMMARY (2 of 2)
• Pain should be assessed in all patients, and
adequate treatment may combine drugs with
nonpharmacologic interventions
• Opioids should be used as needed, with careful
attention to dosing and side effects
• Clinicians should watch for and treat other
symptoms: constipation, nausea & vomiting,
diarrhea, anorexia & cachexia, depression,
delirium, dyspnea, and cough
Slide 49
CASE 1 (1 of 3)
• An 86-year-old woman is hospitalized for abdominal pain,
poor appetite, and weight loss that have progressed over
the last 3 months. Her history includes coronary artery
disease and type 2 diabetes mellitus.
• She can walk only a few steps and is dependent in all
ADLs except feeding.
• CT of the abdomen and chest strongly suggest metastatic
pancreatic cancer. The patient has undergone multiple
procedures and hospitalizations, and she states that she
does not want further diagnostic studies or interventions.
• The patient and her daughter are interested in hospice.
Slide 50
CASE 1 (2 of 3)
Which of the following services is/are covered
under the Medicare Hospice Benefit?
A. Room and board in a long-term-care facility
B. Nursing care in a postacute-care nursing facility
C. Hospital bed and bedside commode for home
D. Private-duty caregiver at home
E. Medications for diabetes mellitus and coronary
artery disease
Slide 51
CASE 1 (3 of 3)
Which of the following services is/are covered
under the Medicare Hospice Benefit?
A. Room and board in a long-term-care facility
B. Nursing care in a postacute-care nursing facility
C. Hospital bed and bedside commode for home
D. Private-duty caregiver at home
E. Medications for diabetes mellitus and coronary
artery disease
Slide 52
CASE 2 (1 of 4)
• A 76-year-old woman with end-stage heart failure has
worsening dyspnea at rest and is dependent in all ADLs
except feeding. She sometimes feels as though she is
suffocating and becomes very anxious.
• She began home hospice care 4 months ago. She had
been feeling relatively well since an increase in her
furosemide dosage and the addition of supplemental
oxygen last month.
• The cardiologist believes she would not benefit from
increased dosages of carvedilol, enalapril, or
spironolactone, and she has been compliant with her
medication regimen and diet.
Slide 53
CASE 2 (2 of 4)
• On a home visit by the hospice nurse, the patient is alert,
oriented, and in mild distress. Temperature is 36.5°C
(97.7°F), BP is 126/64 mmHg, HR is 105 bpm, respiratory
rate is 24 breaths per minute, and O2 saturation is 97% on
4 L/min oxygen by nasal cannula.
• She has decreased breath sounds at the right base with
dullness on percussion approximately one-fourth of the
way up; a few crackles are heard at the left base.
• Jugular venous pressure is 12 mmHg. Hepatojugular
reflex is positive, and leg edema is minimal.
• The nurse suggests increasing the furosemide dosage.
Slide 54
CASE 2 (3 of 4)
Which of the following is the most appropriate
next step for this patient?
A. Admit to the hospital for inpatient diuresis.
B. Increase dosage of furosemide and arrange for
outpatient, ultrasound-guided pleurocentesis.
C. Increase dosage of furosemide and increase
oxygen to 6 L/min by nasal cannula.
D. Increase dosage of furosemide and add nebulized
albuterol 2.5 mL q4h as needed for dyspnea.
E. Increase dosage of furosemide and start morphine
5 mg po q3h as needed for dyspnea.
Slide 55
CASE 2 (4 of 4)
Which of the following is the most appropriate
next step for this patient?
A. Admit to the hospital for inpatient diuresis.
B. Increase dosage of furosemide and arrange for
outpatient, ultrasound-guided pleurocentesis.
C. Increase dosage of furosemide and increase
oxygen to 6 L/min by nasal cannula.
D. Increase dosage of furosemide and add nebulized
albuterol 2.5 mL q4h as needed for dyspnea.
E. Increase dosage of furosemide and start morphine
5 mg po q3h as needed for dyspnea.
Slide 56
CASE 3 (1 of 4)
• A 79-year-old man is brought to the office by his daughter;
both are concerned about his recent deterioration and
want to know his prognosis
• The patient has hypertension, peripheral vascular disease,
and stage IV colon cancer. Poorly differentiated
adenocarcinoma of the colon, metastatic to liver and
peritoneum, was diagnosed 2 years ago.
• He did well after surgical resection of his tumor and
treatment with bevacizumab. However, now there is
increased involvement of his liver and peritoneum along
with new pulmonary nodules.
Slide 57
CASE 3 (2 of 4)
• The patient has constant abdominal pain that is well
controlled with a fentanyl patch and oxycodone as
needed for breakthrough pain.
• He has become increasingly debilitated over the last
6 months.
• Because of fatigue and pain, he is unable to do most
IADLs, and in the last 4 weeks he has become
dependent in all ADLs except feeding.
Slide 58
CASE 3 (3 of 4)
Which of the following patient characteristics is
most predictive of a poor prognosis?
A. Low performance status
B. Advanced tumor stage
C. Multiple comorbidities
D. Advanced age
E. Opioid use
Slide 59
CASE 3 (4 of 4)
Which of the following patient characteristics is
most predictive of a poor prognosis?
A. Low performance status
B. Advanced tumor stage
C. Multiple comorbidities
D. Advanced age
E. Opioid use
Slide 60
ACKNOWLEDGMENTS
Editor:
Annette Medina-Walpole, MD
GRS7 Chapter Authors:
Stacie T. Pinderhughes, MD
R. Sean Morrison, MD
Section of this slide set drawn from Persistent Pain slides
(Author: Jennifer M. Kapo, MD)
GRS7 Question Writers:
Susan Charette, MD
Pharmacotherapy Editor:
Judith L. Beizer, PharmD
Medical Writers:
Beverly A. Caley, Faith Reidenbach
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2010 American Geriatrics Society
Slide 61