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Palliative Care – An Overview Mike Harlos MD, CCFP, FCFP Professor and Section Head, Palliative Medicine, University of Manitoba Medical Director, Winnipeg Regional Health Authority Palliative Care Program What Is Palliative Care? Surprisingly difficult to define Not defined by: – Body system (compare with dermatology, cardiology) – What is done (compare with anesthesiology, surgery) – Age (compare with pediatrics, geriatrics) – Sex of patient (such as with gynecology) – Location of Care (compare with ER, critical care) Any illness, any age, any location… Myth 1: Palliative Care is what happens when there’s nothing more that can be done Myth 2: Palliative Care is a place What Is Palliative Care? (a personal definition) Palliative Care is an approach to care which focuses on comfort and quality of life for those affected by life-limiting/life-threatening illness. Its goal is much more than comfort in dying; palliative care is about living, through meticulous attention to control of pain and other symptoms, supporting emotional, spiritual, and cultural needs, and maximizing functional status. The spectrum of investigations and interventions consistent with a palliative approach is guided by goals and expectations of patient and family and by accepted standards of health care, rather than being boundaried by preconceptions of what is or is not "palliative". “Thank you for giving me aliveness” Jonathan – 6 yr old boy terminally ill boy Ref: “Armfuls of Time”; Barbara Sourkes Palliative Care… The “What If…?” Tour Guides Can Help Inform The Choice Of Not Intervening • What would things look like? • Time frame? “What if…? • Where care might take place • What should the patient/family expect (perhaps demand?) regarding care? • How might the palliative care team help patient, family, health care team? Disease-focused Care (“Aggressive Care”) PHYSICAL SUFFERING PSYCHOSOCIAL EMOTIONAL SPIRITUAL CHALLENGEAlleviate Suffering for a Condition Which: • Ultimately will affect every one of us: • • • • • • - Large numbers - We have our own “death issues” as care providers Only approximately 10% of Canadians have access to specialty care Few physicians or nurses have even basic training Clinicians don’t intuitively know when they need advice… They don’t know what they don’t know The process & outcome are expected to be terrible… after all, it is death How can you tell when something inherently horrible goes badly? Has a tremendous impact on those close to the individual… “collateral suffering” No chance of feedback from patient “after the fact” • Don’t confuse “Palliative Care” – the philosophy of approach to care in the context of life-limiting illness with “Palliative Care service delivery”…. • the latter is the application of the broad philosophy within the constraints of existing (limited) resources • Services are focused on the most needy, which tends to be in the final months of life Increase capacity through education, advocacy, partnerships Palliative Care as a philosophy of care Formal Program Potential Palliative Conditions “The Usual Suspects” – progressive life-limiting illness – Incurable cancer – Progressive, advanced organ failure (heart, lung, kidney, liver) – Advanced neurodegenerative illness (ALS, Alzheimer’s Disease) Sudden fatal medical condition – Acute stroke – Withholding or withdrawing life-sustaining interventions (ventilation, dialysis, pressors, food/fluids…) – Trauma – eg. head injury – Ischemic limbs, gut – Post-cardiac arrest ischemic encephalopathy – etc… Potential Palliative Care Interventions Generally Not Palliative Palliative Support • Emotional • Spiritual • Psychosocial Variable CPR Ventilation Transfusions Infections Control of • • • • Pain Dyspnea Nausea Vomiting Hypercalcemia Tube Feeding Dialysis Highly burdensome Interventions Potential Palliative Care Settings Anywhere Key Considerations In Remote Areas Anticipate – Potential concerns around functional decline, food & fluids, decreased LOC, “treatable” complications, sudden change, – Loss of oral route of administration – End-of-life development of pneumonia, delirium with potential for dyspnea, congestion, agitation Plan – Medication supplies – Rehearse (ie. think through the steps with patient, family, health care team) the “what to do when…” scenarios Communicate – Ongoing dialogue, availability for questions/concerns – Preemptive discussions COMMUNICATION ISSUES IN PALLIATIVE CARE • Don’t assume that the absence of question reflects an absence of concerns • Upon becoming aware of a life-limiting Dx, it would be very unusual not to wonder: – “How long do I have?” – “How will I die” • Waiting for such questions to be posed may result in missed opportunities to address concerns; consider exploring preemptively When Families Wish To Filter Or Block Information • Don’t simply respond with “It’s their right to know” and dive in. • Rarely an emergent need to share information • Explore reasons / concerns – the “micro-culture” of the family • Perhaps negotiate an “in their time, in their manner” resolution • Ultimately, may need to check with patient: “Some people want to know everything they can about their illness, such as results, prognosis, what to expect. Others don’t want to know very much at all, perhaps having their family more involved. How involved would you like to be regarding information and decisions about your illness?” 19 “Set the Stage” • In person • Sitting down • Minimize distractions • Family / friend possibly present 20 Seek Permission • “Many people in this situation wonder about / are concerned about …[fill in blank]. Would you like to talk about that?” • “Are you comfortable discussing these issues?” 21 Be Clear Make sure you’re both talking about the same thing There’s a tendency to use euphemisms and vague terms in dealing with difficult matters… this can lead to confusion “Euphemasia” 22 Being Clear When you think people are asking about prognosis… • “How long do you think I have?” • “What kind of time frame am I looking at?” … they might well be asking about discharge “Do you mean how long do you have stay in hospital, or are you wondering about how long you might have to live”? 23 Being Clear ctd “Am I going to get better?” • Seems like a straightforward question, but… • Might be referring to specific symptoms, or to overall illness (“big picture”) 24 Acknowledge / Validate / Normalize • This is a biggie! • People can spend an entire lifetime without hearing others talk about dying… their worries, fears • End up feeling as if they are cowards for their concern – alone in being worried about dying 25 Explore “The Who” What is the context / frame of reference into which this information in being received ? • Understanding of illness • Expectations / hopes / goals • Concerns / worries / fears • Cultural / Spiritual factors that may influence individual’s approach to illness / dying / communication “Micro” (family) vs. “Macro” cultures 26 Preemptive Discussions “You might be wondering…” Or “At some point soon you will likely wonder about…” • Food / fluid intake • Meds or illness to blame for being weaker / tired / sleepy /dying? 27 Titrate information with “measured honesty” “Feedback Loop” Check Response: Observed & Expressed The response of the patient determines the nature & pace of the sharing of information Debriefing • Clarifications, further questions • Are other supports wanted/needed (SW, Pastoral Care) • Do they want help in discussing with relatives/friends? • Plans for follow-up • Do they want you to call someone to pick them up? 29 Specific Communication Issues 1. 2. 3. 4. 5. 6. 7. 8. 9. Prognosis Unrealistic hopes Desire for early/hastened death Close calls Talking about dying Substituted judgment Just one more day Sudden Change Can they hear us? Bedside dynamics 30 DISCUSSING PROGNOSIS “How long have I got?” 1. Confirm what is being asked 2. Acknowledge / validate / normalize 3. Explore “frame of reference” (the “Who”… understanding of illness, what they are aware of being told. 4. Check if there’s a reason that this is has come up at this time 5. Tell them that it would be helpful to you in answering the question if they could describe how the last month or so has been for them 6. How would they answer that question themselves? 7. Answer the question 31 Close Calls • After a resolved pain / dyspnea crisis • People experiencing such bad symptoms often believe that they are dying • While they may be glad that you’ve made them feel better… … if that wasn’t dying… and it was the worst experience that I could possibly imagine… what will dying be like? 32 TALKING ABOUT DYING “Many people think about what they might experience as things change, and they become closer to dying. Have you thought about this regarding yourself? Do you want me to talk about what changes are likely to happen?” 33 First, let’s talk about what you should not expect. You should not expect: – pain that can’t be controlled. – breathing troubles that can’t be controlled. – “going crazy” or “losing your mind” If any of those problems come up, I will make sure that you’re comfortable and calm, even if it means that with the medications that we use you’ll be sleeping most of the time, or possibly all of the time. Do you understand that? Is that approach OK with you? You’ll find that your energy will be less, as you’ve likely noticed in the last while. You’ll want to spend more of the day resting, and there will be a point where you’ll be resting (sleeping) most or all of the day. Gradually your body systems will shut down, and at the end your heart will stop while you are sleeping. No dramatic crisis of pain, breathing, agitation, or confusion will occur we won’t let that happen. OBTAINING SUBSTITUTED JUDGMENT • Avoid making families feel as though they are making a choice, when the illness has dictated that no choice exists • Ideally, phrase the discussion in terms of their thoughts on what the patient would want • Avoid presenting the “letting die” vs. “prolonging suffering” choice to families. 38 PHRASING REQUEST: SUBSTITUTED JUDGMENT “If he could come to the bedside as healthy as he was a year ago, and look at the situation for himself now, what would he tell us to do?” Or “If you had in your pocket a note from him telling you that to do under these circumstances, what would it say?” 39 Sudden Change Steady decline Accelerated deterioration begins, medications changed Rapid decline due to illness progression with diminished reserves. Medications questioned or blamed 40 The Perception of the “Sudden Change” When reserves are depleted, the change seems sudden and unforeseen. However, the changes had been happening. That was fast! Melting ice = diminishing reserves Day 1 Day 2 Day 3 Final Pain Management In Palliative Care Clinical Terms For The Sensory Disturbances Associated With Pain Dysesthesia – An unpleasant abnormal sensation, whether spontaneous or evoked. Allodynia – Pain due to a stimulus which does not normally provoke pain, such as pain caused by light touch to the skin Hyperalgesia – An increased response to a stimulus which is normally painful Hyperesthesia - Increased sensitivity to stimulation, excluding the special senses. Hyperesthesia includes both allodynia and hyperalgesia, but the more specific terms should be used wherever they are applicable. Approach To Pain Control in Palliative Care 1. Thorough assessment by skilled and knowledgeable clinician – History – Physical Examination 2. Pause here - discuss with patient/family the goals of care, hopes, expectations, anticipated course of illness. This will influence consideration of investigations and interventions 3. Investigations – X-Ray, CT, MRI, etc - if they will affect approach to care 4. Treatments – pharmacological and non-pharmacological; interventional analgesia (e.g.. Spinal) 5. Ongoing reassessment and review of options, goals, expectations, etc. TYPES OF PAIN NOCICEPTIVE NEUROPATHIC Visceral Somatic • bones, joints • connective tissues • muscles • Organs – heart, liver, pancreas, gut, etc. Deafferentation Sympathetic Maintained Peripheral Somatic Pain • • • • Aching, often constant May be dull or sharp Often worse with movement Well localized Eg/ – Bone & soft tissue – chest wall Visceral Pain • • • • Constant or crampy Aching Poorly localized Referred Eg/ – CA pancreas – Liver capsule distension – Bowel obstruction FEATURES OF NEUROPATHIC PAIN COMPONENT Steady, Dysesthetic DESCRIPTORS • Burning, Tingling • Constant, Aching • Squeezing, Itching • Allodynia EXAMPLES • Diabetic neuropathy • Post-herpetic neuropathy • Hypersthesia Paroxysmal, Neuralgic • Stabbing • trigeminal neuralgia • Shock-like, electric • may be a component of any neuropathic pain • Shooting • Lancinating Pain Assessment “Describing pain only in terms of its intensity is like describing music only in terms of its loudness” von Baeyer CL; Pain Research and Management 11(3) 2006; p.157-162 PAIN HISTORY Description: severity, quality, location, temporal features, frequency, aggravating & alleviating factors Previous history Context: social, cultural, emotional, spiritual factors Meaning Interventions: what has been tried? Example Of A Numbered Scale Medication(s) Taken • • • • • • Dose Route Frequency Duration Efficacy Adverse effects Physical Exam In Pain Assessment Inspection / Observation “You can observe a lot just by watching” Yogi Berra Overall impression… the “gestalt”? Facial expression: Grimacing; furrowed brow; appears anxious; flat affect Body position and spontaneous movement: there may be positioning to protect painful areas, limited movement due to pain Diaphoresis – can be caused by pain Areas of redness, swelling Atrophied muscles Gait Myoclonus – possibly indicating opioid-induced neurotoxicity Physical Exam In Pain Assessment Palpation Localized tenderness to pressure or percussion Fullness / mass Induration / warmth Physical Exam In Pain Assessment Neurological Examination Important in evaluating pain, due to the possibility of spinal cord compression, and nerve root or peripheral nerve lesions Sensory examination – Areas of numbness / decreased sensation – Areas of increased sensitivity, such as allodynia or hyperalgesia Motor (strength) exam - caution if bony metastases (may fracture) Deep tendon reflexes – intensity, symmetry – Hyperreflexia and clonus: possible upper motor neuron lesion, such as spinal cord compression or cerebral metastases. – Hyoporeflexia - possible lower motor neuron impairment, including lesions of the cauda equina of the spinal cord or leptomeningeal metastases. Sacral reflexes – diminished rectal tone and absent anal reflexes may indicate cauda equina involvement of by tumour Physical Exam In Pain Assessment Other Exam Considerations Further areas of focus of the physical examination are determined by the clinical presentation. Eg: evaluation of pleuritic chest pain would involve a detailed respiratory and chest wall examination. Pain Treatment Non-Pharmacological Pain Management Acupuncture Cognitive/behavioral therapy Meditation/relaxation Guided imagery TENS Therapeutic massage Others… W.H.O. ANALGESIC LADDER 3 By the Strong opioid +/- adjuvant 2 Clock 1 Non-opioid +/- adjuvant Weak opioid +/- adjuvant STRONG OPIOIDS • most commonly use: – morphine – Hydromorphone (Dilaudid ®) – transdermal fentanyl (Duragesic®) – oxycodone – Methadone • DO NOT use meperidine (Demerol) long-term – active metabolite normeperidine seizures OPIOIDS and INCOMPLETE CROSS-TOLERANCE • conversion tables assume that tolerance to a specific opioid is fully “crossed over” to other opioids. • cross-tolerance unpredictable, especially in: – high doses – long-term use • divide calculated dose in ½ and titrate Drug Hydromorphone Oxycodone Codeine Daily Morphine Dose Methadone 30 – 90 mg 90 – 300 mg > 300 mg Fentanyl Approximate Equipotency with Morphine (Morphine:Drug) 5:1 1.5:1 to 2:1 1:12 3.7:1 7.75:1 12.75:1 80:1 to 100:1 (for subcutaneous dosing of each) NB: Does not consider incomplete cross-tolerance TITRATING OPIOIDS • dose increase depends on the situation • dose by 25 - 100% EXAMPLE: (doses in mg q4h) Morphine Hydromorphone 5 10 15 20 25 30 40 50 60 1 2 3 4 5 6 8 10 12 http://palliative.info http://palliative.info TOLERANCE PSYCHOLOGICAL DEPENDENCE / ADDICTION PHYSICAL DEPENDENCE TOLERANCE A normal physiological phenomenon in which increasing doses are required to produce the same effect Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3 PHYSICAL DEPENDENCE A normal physiological phenomenon in which a withdrawal syndrome occurs when an opioid is abruptly discontinued or an opioid antagonist is administered Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3 PSYCHOLOGICAL DEPENDENCE and ADDICTION A pattern of drug use characterized by a continued craving for an opioid which is manifest as compulsive drug-seeking behaviour leading to an overwhelming involvement in the use and procurement of the drug Inturrisi C, Hanks G. Oxford Textbook of Palliative Medicine 1993: Chapter 4.2.3 Changing Route Of Administration In Chronic Opioid Dosing po / sublingual / rectal routes reduce by ½ SQ / IV / IM routes Using Opioids for Breakthrough Pain •Empirically titrated… The correct dose is “the one that works” The dose range is somewhere between “not enough” and “too much” •Patient must feel in control, empowered •Use aggressive dose and interval Patient Taking Short-Acting Opioids: • 50 - 100% of the q4h dose, given q1h prn Patient Taking Long-Acting Opioids: • 10 - 20% of total daily dose given, q1h prn with short-acting opioid preparation Opioid Side Effects Constipation – need proactive laxative use Nausea/vomiting – consider treating with dopamine antagonists and/or prokinetics (metoclopramide, domperidone, prochlorperazine [Stemetil], haloperidol) Urinary retention Itch/rash – worse in children; may need low-dose naloxone infusion. May try antihistamines, however not great success Dry mouth Respiratory depression – uncommon when titrated in response to symptom Drug interactions Neurotoxicity (OIN): delirium, myoclonus seizures Spectrum of Opioid-Induced Neurotoxicity Opioid tolerance Mild myoclonus (eg. with sleeping) Delirium Opioids Increased Severe myoclonus Seizures, Death Hyperalgesia Agitation Misinterpreted as Pain Opioids Increased Misinterpreted as Disease-Related Pain OIN: Treatment Switch opioid (rotation) or reduce opioid dose; usually much lower than expected doses of alternate opioid required… often use prn initially Hydration Benzodiazepines for neuromuscular excitation Adjuvant Analgesics first developed for non-analgesic indications subsequently found to have analgesic activity in specific pain scenarios Common uses: – pain poorly-responsive to opioids (eg. neuropathic pain), or – with intentions of lowering the total opioid dose and thereby mitigate opioid side effects. Adjuvants Used In Palliative Care General / Non-specific – corticosteroids – cannabinoids (not yet commonly used for pain) Neuropathic Pain – gabapentin – antidepressants – ketamine – topiramate – clonidine Bone Pain – bisphosphonates – (calcitonin) CORTICOSTEROIDS AS ADJUVANTS inflammation edema } tumor mass effects spontaneous nerve depolarization CORTICOSTEROIDS: ADVERSE EFFECTS IMMEDIATE Psychiatric Hyperglycemia risk of GI bleed gastritis aggravation of existing lesion (ulcer, tumor) Immunosuppression LONG-TERM Proximal myopathy often < 15 days Cushing’s syndrome Osteoporosis Aseptic / avascular necrosis of bone DEXAMETHASONE • minimal mineralcorticoid effects • po/iv/sq/?sublingual routes • perhaps can be given once/day; often given more frequently • If an acute course is discontinued within 2 wks, adrenal suppression not likely Treatment of Neuropathic Pain Pharmacologic treatment • Opioids • Steroids • Anticonvulsants – eg. gabapentin • TCAs (for dysesthetic pain, esp. if depression) • NMDA receptor antagonists: ketamine, methadone • Anesthetics Radiation therapy Interventional treatment • Spinal analgesia • Nerve blocks Gabapentin Common Starting Regimen – 300 mg hs Day 1, 300 mg bid Day2, 300 mg tid Day 3, then gradually titrate to effect up to 1200 mg tid Frail patients – 100 mg hs Day 1, 100 mg bid Day 2, 100 mg tid Day 3, then gradually titrate to effect Incident Pain Pain occurring as a direct and immediate consequence of a movement or activity Circumstances In Which Incident Pain Often Occurs • Bone metastases • Neuropathic pain • Intra-abd. disease aggravated by respiration » “incident” = breathing » ruptured viscus, peritonitis, liver hemorrhage • Skin ulcer: dressing change, debridement • Disimpaction • Catheterization Having a steady level of enough opioid to treat the peaks of incident pain... Pain ...would result in excessive dosing for the periods between incidents Incident Incident Time Incident Fentanyl and Sufentanil synthetic µ agonist opioids highly lipid soluble • transmucosal absorption; effect in approx 10 min • rapid redistribution, including in / out of CSF; lasts approx 1 hr. fentanyl » 100x stronger than morphine sufentanil » 1000x stronger than morphine 10 mg morphine 10 µg sufentanil 100 µg fentanyl INCIDENT PAIN PROTOCOL ctd... • fentanyl or sufentanil is administered SL 10 min. prior to anticipated activity • Eg/ 25 mcg – 50 mcg fentanyl SL prior to activity • See: http://palliative.info/IncidentPain.htm The Management Of Irreversible Delirium In The Imminently Dying Mike Harlos MD, CCFP, FCFP Professor and Section Head, Palliative Medicine, University of Manitoba Medical Director, Winnipeg Regional Health Authority Palliative Care Program Objectives 1. Be aware of the prevalence of delirium at the end of life 2. Recognize the factors that make a delirium “irreversible” 3. Consider options for the aggressive management of delirium in the imminently dying patient 4. Develop an approach to communication issues with families regarding delirium and its impact on their experience with a dying loved one What Is “Imminently Dying”? “What exactly constitutes ‘‘imminence’’ is somewhat vague in the literature but nonetheless roughly coherent…. it is stipulated as hours or days or, at most, weeks.” Cellarius V.; Terminal sedation and the “imminence condition” J Med Ethics. 2008 Feb;34(2):69-72. What Makes A Delirium Irreversible At End Of Life? 1. Clinical factors: Refractory to available interventions, eg. recurrent hypercalcemia after multiple bisphosphonate treatments No therapeutic options available – eg. end-stage liver failure 2. Directive from patient/proxy that no further investigations be done and that interventions focus strictly on comfort. 3. Limitations of care setting chosen by patient/family – eg. a steadfast commitment to remain at home to die Obtaining Substituted Judgment – Exploring Choices Our approach should be guided by how the patient would direct care if he/she could do so Families should not be put in positions of making impossible choices, such as… – “We can give sedation so he’ll be calm – but he might never wake up again. Or, we can let him stay alert and agitated, but at least you can still connect with him… what would you like us to do?” Phrasing Request For Substituted Judgment “If he could come to the bedside as healthy as he was a year ago, and look at the situation for himself now, what would he tell us to do?” Or “If you had in your pocket a note from him telling you that to do under these circumstances, what would it say?” Families will usually indicate that he would say “Just keep me comfortable… don’t let me be like that” 94 Agitated EOL Delirium Is A Medical Emergency Imagine in the last few hours of life being: – agitated, combative, striking out at caregivers – paranoid, saying hurtful things to family – children / grandchildren afraid to visit Loss of self / personhood / dignity Lifelong difficult memories for family No chance for a “do-over” if poorly managed 95 Implications Of Irreversibility Won’t get better… ever Interventions to sedate and calm the patient must be aggressive and ongoing until the patient’s expected death from their underlying condition • a “little bit” of sedatives will only further compromise the function of a failing brain and aggravate agitated state. • factors causing / contributing to the delirium are becoming worse with time – there is no expectation of spontaneous improvement that would allow decreasing the sedatives An overarching goal of care becomes the effective, consistent sedation of the patient until the condition's natural course unfolds, and the patient dies as expected from the underlying condition • i.e. the goal is to ensure that the patient does not waken again before dying 96 Implications Of Irreversibility ctd… The family must be informed of these implications, so they are not expecting that after pt is settled he will awaken and be clear and communicative Need to help family and care providers with concerns that the sedation is speeding up or contributing to the dying… perhaps more so when continuous infusions are used • This concern may not be overtly expressed, however it is important enough to strongly consider preemptive discussions “Sometimes people may wonder if the medications are speeding things up… is that something that you had wondered about? Would it be helpful to talk about that?” 97 Implications Of Irreversibility ctd… The literature evidence does not support that palliative sedation hastens the dying process when death is proximate due to the underlying condition1,2,3 1. Claessens P, Menten J, Schotsmans P, Broeckaert B.; Palliative sedation: a review of the research literature.; J Pain Symptom Manage. 2008 Sep; 36(3):310-33 2. Morita T, Tsunoda J, Inoue S, et al. Effects of high dose opioids on survival in terminally ill cancer patients. J Pain Symptom Manage 2001;21:282–9 3. Sykes N, Thorns A. The use of opioids and sedatives at the end of life. Lancet Oncol 2003;4:312–8. 98 Considerations Regarding Medications Used In Aggressive Sedation (Adult Patients) Sedatives (as with opioids) are titrated to empirical effect after an initial dose is selected… the correct dose is “the one that works” and the dose range is somewhere between “not enough” and “too much” Tend to use a neuroleptic +/- benzodiazepine; subcutaneous route is most common Methotrimeprazine (Nozinan®) commonly used due to its sedating effects, though be aware of anticholinergic effects potentially aggravating the delirium Can add a benzodiazepine such as lorazepam sublingually or midazolam subcutaneously Commonly need regular intermittently scheduled doses (eg. q4h or q6h) plus a prn dose of q1h prn prn Medication orders must allow nursing or family to “stack” doses… i.e. repeat a dose once its empirical effect should have been realized, yet before it has begun to lose effect 99 Supporting Families At minimum, effective sedation changes the beside dynamics from one in which people are afraid to visit and there is no meaningful interaction to one in which people can talk, read, sing, play favourite music, pray, tell stories, touch. Health care team has a role in facilitating meaningful visits… family/friends may not know “the right things to do” Individuals may want time alone but be reluctant to ask others (friends/family) to leave the room. The health care team can suggest that this might be something that the family can explore with each other 100 Supporting Families The question of “can they still hear us?” arises frequently… of course it’s not possible to know this, however: Hearing is a resilient sense, as evidenced by its potential to endure into the early phase of general anesthesia If not true “hearing”, the comforting/settling effect of the awareness of the presence of family can be remarkable The operative approach is that some nature of hearing/awareness/spiritual connection is maintained… this therefore must be considered when speaking about the patient in his/her presence. 101