A Musical Interlude

The Gospel According to myself

Just things for the heart and soul (Celtic Soul) John(1:1)

Pain In my heart

Into to the Mystic

Help me make it through the Night

Precious Love


Sweet Thing



Pain – Dolore


Fractured both heel bones in 2008 – No pain

Before today,yesterday didn’t know what it was.

Now I know and it’s real real real……………..

Even to my worst enemy, would’nt want them to have th pain

Healing the pain

Must be like this to heal the suffering

This morning woke up (thanks) about 6:30
Some light thru the shutters DAWN
Strange images in my thoughts:

No strength to get up
Hazed Dazed

SMS’s to friends thanking them all …………… Pain

Some shopping food,drink……….

img_41[1]Let’s go to the Petanque Club
Still PAIN but also
Went the same
Glad to get out,glad to meet,glad to share Pain
Said, If a friend of mine (of all ) Bisio comes I’ll play

A Natural player without thinking, if he thinks the problems begin……………
Never listen to what he tells you about the game (generally wrong) he could do the great play, but we’re not Bisio

Everybody with 2 balls (Just like humans)

2 Games

Gianni il boxeur,Bisio il natural,Alberto il falegname,Paolo,Pierluigi, and myself.

Lost 1
Won 1

Play exactly here on the left side of the road


Life must go on


Pallative Care

As my wife said/says to me The people who  make cigarette tabacco are all liars, they say “Smoke Kills”, but you’re still alive” ?????????????????????????????????????????????????????????????????????????????????????

Associazione Gigi Ghirotti


Gigi Ghirotti

I myself am not suffering from a terminal illness or in need of end of life care (at this very minute)  but a person very close to me is (my wife):

People from the Associazione Gigi Ghirotti (and a 1000…. thanks to them) are helping the patient, myself,  my family and friends


Palliative care

What is it ?

Palliative care, which is defined as ‘the active total care of patients whose disease is not responsive to curative treatment’ traditionally  associated with the care of cancer patients.

Emphasis should be placed on improving quality of life for the patient and relieving troubling symptoms rather than prolonging life. Good palliative prescribing is important but drugs are rarely the total answer for the relief of pain and other symptoms. Always consider the psychological, social and spiritual needs of the person. The use of nondrug measures is as important as medication in relieving suffering.


General principles

Try to follow a systematic approach to symptom control in palliative care:

  • Individualised treatment: the patient should determine treatment priorities. Set realistic goals of treatment together. Take precise drug histories – what is being taken currently, what has been tried before, problems with medication and concerns affecting concordance.
  • Supervision: regular monitoring of symptom control is important in order to ensure that the treatment goals are being achieved and to avoid unacceptable side-effects.

Other important palliative care prescribing issues:

  • Written advice – reinforce spoken instructions – a chart is usually helpful for the patient and family to work from, with timing, names of drugs and dose (as quantity of liquid, number of tablets, etc.) and purpose outlined.
  • Continuity of care – communication is essential between all prescribers (GP, out-of-hours service, palliative care specialists), nursing teams and pharmacists so all are aware of changes and so that the patient and family are not confused by any alterations to medication made. Availability of equipment and drugs needs to be assured, particularly out-of-hours, and changes in prescriptions should be anticipated to avoid delays in obtaining vital medication.
  • Progressive disease – will alter how drugs are handled. In particular, worsening renal failure will lead to an accumulation of morphine-6-glucuronide (active metabolite of morphine). Signs of morphine toxicity may develop (increasing drowsiness, myoclonic jerksdelirium) and the morphine dose should be reduced down or the dose interval increased. Severe hepatic insufficiency will affect the metabolism of morphine and similarly may necessitate a dose reduction.[3]
  • Individual differences – some patients may require very high doses of morphine compared with others – this may reflect age (older patients tend to require less), use of adjuvant drugs and nondrug measures, pharmacokinetic differences (absorption, hepatic and renal function), pain tolerance threshold, previous use of strong opioids, duration of treatment and adequacy of management of other symptoms.

Care of patients in the dying phase

Diagnosis of dying

One of the biggest barriers to good care of the dying is healthcare professionals’ reluctance to diagnose dying. Recognising the key signs and symptoms is an important clinical skill. In cancer patients, usually death is preceded by a gradual deterioration in functional status:

  • The patient becomes bed bound.
  • The patient is semicomatose.
  • The patient is able to manage sips of fluid only.
  • The patient can no longer manage oral drugs.

The predictability of the dying phase is not as clear in some other chronic incurable diseases. Where a patient is recognised by his healthcare team to be in the dying phase (within days or hours of death), this can be communicated to the patient, if appropriate, and to the relatives. Appropriate care goals and prescribing can also be put into place to facilitate a ‘good death’.

Prescribing when providing end of life care

  • Review current medication – stop all non-essentials. Also, stop any inappropriate monitoring (such as blood tests and vital signs).
  • Conversion to continuous subcutaneous infusion (CCSI) – see also separate article Syringe drivers. Essential drugs, eg opioids, anxiolytics, and antiemetics, should be converted to the SC route via a syringe driver in most instances. It is slightly more complicated where a patient has previously been using opioid transdermal patches (see below). The use of a ‘just in case’ box has been instituted in some areas, enabling these drugs to be prescribed in advance and stored at home until needed, once the dying trajectory has been recognised.
    • Restlessness and confusion:
      • Haloperidol (little sedative effect).
      • Levomepromazine.
      • Midazolam (useful where a patient is restless or fitting).
  • ìAs required medication should be prescribed and available, including:
    • Analgesics: eg diamorphine/morphine (as required dose will depend on regular dose).
    • Antiemetics: eg metoclopramide or levomepromazine.
    • Sedative: eg midazolam.
    • Antisecretory drug: eg hyoscine butylbromide.
    • Delirium: haloperidol.
  • Anticipatory prescribing should ensure that there is no delay in responding to a symptom if it occurs. All patients starting the Care Pathway for the last days of life at home should have diamorphine (or alternative), cyclizine, midazolam and hyoscine available in the home, with sufficient for use over a weekend (plus bank holidays). Do not omit water for injection.[10]
  • Patient comfort – consider, for example, the need for mouth care and urinary catheterisation or pads where the patient is incontinent.
  • Monitoring – regular checks should be made to ensure good symptom control is maintained and to assess response to any changes in medication. Also important is regular monitoring of syringe drivers to check for precipitation, discoloration and to ensure the driver is running at the correct rate. If there is evidence of an injection site reaction, if the infusion is running too slowly or if there is pain or obvious inflammation, the injection site should be changed.

Pain control

See  Pain control in palliative care.

Nausea and vomiting

See  Nausea and vomiting in palliative care.



  • Pain/discomfort – the patient may not be able to communicate the source. Treat any reversible causes, eg catheterisation for urinary retention, bowel care for constipation, hyoscine to dry up excess secretions in the throat.
  • Opiate toxicity – the dose of morphine may need to be reduced as the patient’s renal function deteriorates.
  • Biochemical abnormalities such as hypercalcaemia and uraemia may cause restlessness but, in the end of life phase, it is not usually appropriate to check for them. They may be associated with delirium.
  • Psychological or spiritual distress.

Management options:

  • Haloperidol – less sedating.
  • Midazolam – sedating.
  • Levomepromazine – highly sedating; use in place of haloperidol if the patient remains agitated despite haloperidol and midazolam.


See  Dyspnoea in palliative care.

  • Usually multifactorial, as anxiety is almost always associated.
  • General measures – reassurance and explanation, upright positioning, good ventilation (fan, open window), chest physiotherapy and relaxation exercises.
  • Drug measures – nebulised saline, oral or SC morphine (start with oral morphine or equivalent), benzodiazepines (eg diazepam), oxygen (variable effect).

Palliative sedation and the doctrine of double effect

Prescribing for patients at the end of life is often full of ethical anxiety for the prescriber, particularly in situations where a person at the end of life faces refractory symptoms. Palliative sedation is the poorly defined practice of continuous deep sedation used in patients at the end of life where normal medical treatment is failing to relieve severe symptoms of pain or agitation, and the ultimate option is to sedate beyond perception of these symptoms.

Doctors are duty-bound to relieve suffering but not to cause the patient’s death. The use of medication to end someone’s life constitutes euthanasia and is currently illegal in the UK. However, the doctrine of double effect is widely accepted and refers to the use of higher doses of opioids and sedatives to relieve end of life suffering without the intention of causing the patient’s death, even though the risk of hastening death is foreseen. In reality, evidence suggests that palliative sedation in the last hours of life is not associated with shortened survival overall so that the doctrine of double effect need not routinely be invoked to excuse this aspect of end of life care.[14]

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