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Nutrition and Digestion in Palliative Care with Sarah Franklin · Wellness by Designs - Practitioner Podcast

• 0:00
  Speaker 1: cancer and went to palliative care or a palliative care unit.
• 0:03
  Speaker 1: But palliative care extends to people with kidney failure, liver failure, congestive heart failure, your neurological conditions like MS Huntington's, parkinson's, dementia.
• 0:18
  Speaker 1: So all of those conditions are a life-ending condition that will require palliative care at some point and the conditions can vary a lot so from condition to condition.
• 0:32
  Speaker 1: So you know, people with end-stage liver failure will have a lot of bloating and ascites.
• 0:37
  Speaker 1: People with dementia will struggle with cognitively being able to eat or all those things.
• 0:43
  Speaker 1: And I think the other complex thing with these palliative patients is, you know they're still on a lot of medications to try to support their quality of life.
• 0:53
  Speaker 1: So they're still on a lot of medications which then have an impact on nutrition, on their digestion, and although those medications might not be life-extending, they're there to try to provide further quality of life.
• 1:09
  Speaker 1: So, for example, with congestive heart failure, they might still be on medications for fluid retention to help reduce the fluid load on the heart as a measure to improve their quality of life, but it's not going to extend greatly.
• 1:24
  Speaker 1: That.
• 1:26
  Speaker 1: But, in coming with that.
• 1:27
  Speaker 1: You have these nutritional issues that you come across with these medications, where they strip you of particular minerals or we have particular medication interactions, and that's where today, I guess we're looking at.
• 1:39
  Speaker 1: You know, there's a few products here that we can use to help patients in that end stage, because we have complexities when it comes to digestion and swallowing and all those sort of things.
• 1:54
  Speaker 2: Okay, so is there.
• 1:56
  Speaker 2: I know this is a piece of string question, but is there an expected life expectancy where they move people over into palliative care, like, for instance, 12 months, 24 months?
• 2:10
  Speaker 1: uh, no, no, not really.
• 2:12
  Speaker 1: It just depends on how the patient's deteriorating.
• 2:15
  Speaker 1: So you can normally tell when the patient's deteriorating and that's for some diseases that's a very slow process and for others that's quite rapid.
• 2:24
  Speaker 1: But normally when you start to see, you know increased pain, a lesser level of consciousness, because these diseases affect their ability to think through calcium or different things.
• 2:38
  Speaker 1: So you know progressive cerebral changes where they can't cognitively look after themselves anymore.
• 2:45
  Speaker 1: Obviously, with pathology you'll start to see the kidney function, the liver function.
• 2:52
  Speaker 1: In some cases the bone marrow is starting to fail, where you'll start to see changes in bone marrow production as far as from a hematology point of view.
• 3:01
  Speaker 1: So no, there's no piece of string, because a patient with pancreatic cancer might be in palliative care within three months.
• 3:09
  Speaker 1: Um, a patient with alzheimer's could have it for for 10 years.
• 3:15
  Speaker 1: So, and some of these diseases are very slow, generally, as a clinician, we're often treating these patients for a period of time before they reach that palliative phase.
• 3:25
  Speaker 1: I think the problem is that naturopaths and not good, or nutritionists are not good enough at spotting when that change occurs in the patient's care, management of care.
• 3:35
  Speaker 1: So you'll know, because you'll start to see changes in medication rapidly, or you'll start to see the patient come in and say that you know they're talking about referring me to the palliative care team, so that should be your first sign that okay, we're now.
• 3:49
  Speaker 1: They're now withdrawing treatment.
• 3:51
  Speaker 1: And then what tends to happen is the their medical team becomes smaller.
• 3:58
  Speaker 1: So normally you know, if you looked at a cancer patient, they've got an oncologist, they've got radiation oncologist, they've got their gps, they're having blood tests and scans, and then all of a sudden it's like, oh, okay, I don't need to go, I've been discharged from the oncologist, um, and they can have a sense of abandonment, which isn't true.
• 4:16
  Speaker 1: They haven't abandoned them, it's just that there's no, they can't provide any more treatment for you anymore.
• 4:21
  Speaker 1: So generally they then get moved on to either back to the gp or back to the palliative care team, and that's often when a patient will come to you and want you to perform a miracle which you won't be able to do.
• 4:33
  Speaker 1: And that's where you need to have that integrity around having an honest conversation with your client about not offering hope.
• 4:41
  Speaker 1: When there's not hope, there it's more.
• 4:43
  Speaker 1: I'm here for you, I'm here to support you.
• 4:45
  Speaker 1: I'll follow you through this journey or process, um, and then looking at what you can do to help support them in a palliative way, which might be pain, it might be digestive, it might be sleep, it might be anxiety, um, that all these things that you.
• 5:00
  Speaker 1: There's lots of stuff that we can provide for these patients, but it's being able to spot it early enough.
• 5:05
  Speaker 1: Otherwise, what happens is you just end up getting they think there's nothing more you can do for them, so they stop seeing you.
• 5:11
  Speaker 1: And then all of a sudden you're like three months or six months down the track, going.
• 5:14
  Speaker 1: I wonder what happened to so and so, um, when there wasn't a part there where you could have kept treating them and you could have improved their quality of life and you could have supported their carers and the people around them to have an active role to support this person emotionally and physically through this process.
• 5:36
  Speaker 2: Part of what you spoke about before about the medical team shrinking because there's nothing more they can offer them.
• 5:44
  Speaker 2: I do believe that part of that issue has got to do with communication.
• 5:49
  Speaker 2: I was reading a story on Australian Doctor recently and it was saying now, forgive me, I think this was, I'm going to get this wrong, but regional Queensland, and there was some huge amount of patients who were discharged from hospital without discharge planning, without effective communication to other healthcare practitioners, whoever they may be.
• 6:13
  Speaker 2: So it is an issue.
• 6:16
  Speaker 2: You know, who do you blame?
• 6:19
  Speaker 2: Everybody's overworked, everybody's under extreme pressure.
• 6:22
  Speaker 2: There's not enough staff, I get it.
• 6:24
  Speaker 2: The fact of the matter is the patient's in the centre of this and they need care.
• 6:28
  Speaker 2: So should it be part of our care to maybe take the baton and say I'm not going to wait for this to happen.
• 6:39
  Speaker 2: I'm going to say, hey guys, I noticed, you know, mr Oncologist, mrs GP, whatever.
• 6:46
  Speaker 2: I've noticed that patient X has, you know, been discharged.
• 6:53
  Speaker 2: I, you know, haven't received any communication.
• 6:57
  Speaker 2: Or here's some communication to you.
• 6:59
  Speaker 2: I'd like to be part of this healthcare team.
• 7:02
  Speaker 2: Blah, blah, blah.
• 7:03
  Speaker 2: Is that part of what you do Like?
• 7:06
  Speaker 2: You're used to this as an RN, working in the hospital system but working outside of that.
• 7:10
  Speaker 2: Do you communicate with these doctors and other healthcare professionals at all?
• 7:17
  Speaker 1: Yeah, I mean I'm lucky enough in that I've got relationships with the medical team because I've come from that industry, so I've got relationships there.
• 7:24
  Speaker 1: But do I think as a naturopath or nutritionist, you have a responsibility to support that patient?
• 7:31
  Speaker 1: Absolutely so, and I think if you don't, you're not doing your job that you should be.
• 7:36
  Speaker 1: So I think the buck does stuff with everybody.
• 7:38
  Speaker 1: I think if you're a part of that healthcare team, if you feel like the patient doesn't have the support services and if they don't have those things there, then I think you do have a responsibility to know who those services are and how to refer them, who they are and how to make it happen.
• 7:54
  Speaker 1: You don't need to be a doctor to go.
• 7:55
  Speaker 1: Maybe you need to get back to your GP and discuss a referral to a palliative care team or community services so that you don't have that care of burnout.
• 8:03
  Speaker 1: So I think that's a part of your role as a clinician to know when to refer, who to refer and how to refer.
• 8:10
  Speaker 1: And I think you know you brought up the rural thing before.
• 8:14
  Speaker 1: Absolutely, there's complexities in both.
• 8:16
  Speaker 1: I think in the urban environment it's complex.
• 8:19
  Speaker 1: It's a far more complex system to navigate.
• 8:21
  Speaker 1: People are busy People you know support support structure don't have time and finances to look after each other.
• 8:29
  Speaker 1: Often they're more isolated in an urban environment.
• 8:32
  Speaker 1: One of the advantages of remote is that those guys tend to stick together and they have a better support structure around them and around the town.
• 8:39
  Speaker 1: They tend to look after each other in a rural setting better than an urban setting.
• 8:42
  Speaker 1: So urban settings have have more services but it's a more complex system to navigate where rural have less services but they've got these benefits of a sense of community and a better social generally, a better social support, because they're used to probably having a lack of services, that they've learned how to navigate that better, whereas in an urban environment where we've got that expectation that we can just present to an ED that's going to have a specialist available which they don't.
• 9:15
  Speaker 2: Let's face it, they're just tougher.
• 9:18
  Speaker 1: Yeah.
• 9:18
  Speaker 2: It's just tougher.
• 9:25
  Speaker 1: And respect to the rural.
• 9:26
  Speaker 1: Shout out to the rural naturopaths and nutritionists because they do a lot of heavy lifting out there, because they really do bridge the gap between there's some huge gaps out there and they really do bridge those gaps out there.
• 9:34
  Speaker 1: So rural naturopaths and naturopaths and nutritionists really do do a lot more heavy lifting.
• 9:41
  Speaker 1: You know they're counsellors, they're, you know they play a much more physical role in, you know, checking blood pressure and everything.
• 9:48
  Speaker 1: So they definitely do, you know, and they're a part of the community.
• 9:53
  Speaker 1: So it's harder for boundary setting all those sorts of things.
• 9:57
  Speaker 1: So you know, huge respect for guys that work in those rural communities with the services that they've got.
• 10:05
  Speaker 2: What are the issues with the activities of daily living that you see and you treat?
• 10:10
  Speaker 2: You've mentioned pain.
• 10:11
  Speaker 2: You've spoken about swallowing.
• 10:12
  Speaker 2: Can we delve into these a little bit more?
• 10:16
  Speaker 1: Yeah, so often what you start to see is, you know, with some of the neurological conditions et cetera, you definitely get those digestive issues.
• 10:25
  Speaker 1: So you know you might have a patient with throat cancer or you might have a patient with, you know, throat cancer or radiation.
• 10:37
  Speaker 1: You might have a patient with stroke yeah, that can't swallow effectively.
• 10:40
  Speaker 1: You might have a patient with dementia or Alzheimer's that doesn't know how to swallow cognitively.
• 10:44
  Speaker 1: You might have a patient with dementia or Alzheimer's that doesn't know how to swallow cognitively.
• 10:44
  Speaker 1: So I think when you're looking at these palliative care age and that's why I guess I'm grouping them a little bit, because we tend to, in geriatric care, see a lot of the same conditions as palliative care, because we tend to see more palliative conditions in the aging community so the main things we sort of see is like oral health.
• 11:03
  Speaker 1: So a lot of these older people or you know, depending what's going on, they might have, you know, dentures, or they haven't got dentures or they're not able to chew their food properly.
• 11:13
  Speaker 1: So you've got oral issues.
• 11:14
  Speaker 1: You've got digestive issues, where you've got, you know, stretches or narrowing of the esophagus, so they're an increased choking risk.
• 11:22
  Speaker 1: So then you're needing to use thickened or grade.
• 11:24
  Speaker 1: You know you'll have speech pathologists involved to review what you can use.
• 11:31
  Speaker 1: You've got poor appetite because they're not moving as much.
• 11:35
  Speaker 1: They're more sedentary, they're losing muscle mass, their metabolism's slowing down, so they're often not hungry.
• 11:41
  Speaker 1: They're often dehydrated.
• 11:43
  Speaker 1: They're often nutrient deficient.
• 11:45
  Speaker 1: They tend to want to eat foods that are crap, that are high calorie but, you know, low nutritional content value.
• 11:52
  Speaker 1: So there's a lot more education around what type of foods would be beneficial.
• 11:57
  Speaker 1: And then if they are in an aged care facility or if they're in a palliative care unit, then it's.
• 12:05
  Speaker 1: The obstacle for us is how do we communicate that so that that can be implemented in a environment that you're not in control of, because it's all governed by.
• 12:13
  Speaker 1: You know those institutions.
• 12:16
  Speaker 1: So then how can you communicate to the charge nurses or the family or the doctor so that you can implement nutritional changes or implement supplementation that's safe, because you're not going to be able to get anything through without the family or the doctor basically ticking off at it on the end.
• 12:33
  Speaker 1: So that's communication um.
• 12:37
  Speaker 2: So with regards to things, I mean you could start with appetite and and oral indeed.
• 12:43
  Speaker 2: So we've got anywhere.
• 12:45
  Speaker 2: From, as you say, dentures, you get atrophy, atrophication, atrophy of the jaw.
• 12:51
  Speaker 2: So the dentures that once used to fit well, now don't they cause ulceration, pain, lack of chewing.
• 12:59
  Speaker 2: There's a whole sequelae that comes from that.
• 13:03
  Speaker 2: You've got the changes in just the appetite and, as you say, you know they have.
• 13:08
  Speaker 2: They tend to crave the sweet things.
• 13:10
  Speaker 2: The sweet um sensation, um, the sense of taste of sweet comes back in, if you like.
• 13:18
  Speaker 2: Yeah, so they like their desserts, but this is at a time when they're very often suffering from psychopenia.
• 13:26
  Speaker 2: So you really need to look at protein.
• 13:28
  Speaker 2: So these are real big issues.
• 13:30
  Speaker 2: You know.
• 13:31
  Speaker 2: Defecation, lack of control of defecation, incontinence, urinary and fecal yeah, you mentioned before about, you know, as they get older, as these patients get older, you know they've got a lack of mobility.
• 13:49
  Speaker 2: So you haven't just got things like bone mineralization, things like that.
• 13:55
  Speaker 2: You've got to say, okay, well, what happens to that calcium?
• 13:57
  Speaker 2: Because it goes out.
• 13:58
  Speaker 2: So there, have you got a kidney problem?
• 13:59
  Speaker 2: Have you got bed sores?
• 14:01
  Speaker 2: Have you got?
• 14:01
  Speaker 2: Have you got vitamin D, lack of vitamin D?
• 14:06
  Speaker 2: There's so many rabbit holes.
• 14:08
  Speaker 2: Your mind busts me like.
• 14:11
  Speaker 1: Swiss cheese, sarah, luckily I love it.
• 14:13
  Speaker 1: I love it and I love as much as it's an area that people go.
• 14:17
  Speaker 1: Oh, that's really odd that you're passionate about that.
• 14:21
  Speaker 1: But you really can make an impact on these guys and you can really improve their quality of health and you can really help the family to feel supported, because they often feel lost and they don't know if what they're doing is right or wrong.
• 14:34
  Speaker 1: So just having someone to help them, run alongside them, to give them a purpose and to keep that connection, you know it's complex.
• 14:43
  Speaker 1: There's role changes.
• 14:44
  Speaker 1: There's, you know, partners becoming parents there's.
• 14:48
  Speaker 1: You know you've got so many social issues.
• 14:50
  Speaker 1: You've got kids that are.
• 14:51
  Speaker 1: You know you might be navigating a palliative care with a child that's involved.
• 14:55
  Speaker 1: So you might be navigating how does a child process a parent passing away or getting them prepared and ready for what they need to do?
• 15:02
  Speaker 1: Or you know how can you keep the child involved with the palliative care?
• 15:06
  Speaker 1: You know, can you give them a little task that they could do with the parent to keep a connection there that is purposeful but at the same point appropriate for that child, depending on their personality and their age development?
• 15:18
  Speaker 1: Of how you can sort of, you know, because often you don't want to just exclude them out of the picture.
• 15:23
  Speaker 1: But it needs to be done in a way that's appropriate for that child.
• 15:29
  Speaker 2: That's very thoughtful of you.
• 15:30
  Speaker 2: I never, ever, would have thought of that.
• 15:32
  Speaker 2: Absolutely brilliant.
• 15:34
  Speaker 2: Can we go through, sarah, what this instigation of your care with palliative care looks like?
• 15:44
  Speaker 2: Like what sort of things do you actually say with regards to, let's say, poor nutrition, multivitamin or vitamin D, when they've got, say, a swallowing risk, a swallowing issue?
• 15:58
  Speaker 1: Yeah.
• 15:58
  Speaker 1: So if there's a swallowing issue, normally they'd be referred to by speech.
• 16:02
  Speaker 1: Normally you'll have a speech therapist involved and the speech therapist role is to assess their swallowing, to make sure that, because there's a risk, as they start to lose that swallowing effect or you can't chew your food properly, there's a risk that you'll choke on your food and then you'll aspirate and the food will go into the lung and then you'll have pneumonia.
• 16:19
  Speaker 1: So that's our biggest risk is aspiration.
• 16:22
  Speaker 1: So generally, if the patient's coming in all the family and saying, oh, we're noticing when they're drinking they're coughing, or when they're eating food they're coughing a lot, it's usually because they're choking.
• 16:32
  Speaker 1: So then you go.
• 16:33
  Speaker 1: Well, again, your responsibility is to go.
• 16:36
  Speaker 1: You need to go back to your gp because we probably need a speech therapy review to check the gag reflex, which this the gps or specialists will refer off to um, and then what happens is the speech therapist will come back and give you a grading.
• 16:48
  Speaker 1: They'll give you a thickening, grainy grading because I'll be able to assess the swallowing to show you what's important.
• 16:53
  Speaker 1: So I guess that's where, with supplementation, you know, you might go.
• 16:58
  Speaker 1: Well, you know if you, if you're trying to increase your absorption of their food and their tummy's not very well and they're nauseous and they're bloated.
• 17:05
  Speaker 1: So what liquids could you use or what powders or liposomal forms could you use?
• 17:10
  Speaker 1: Um, because these people are going to be deficient in b12 folate.
• 17:14
  Speaker 1: They're probably not eating any green leafy stuff.
• 17:16
  Speaker 1: They're not eating enough protein.
• 17:18
  Speaker 1: They're probably vitamin deficient because they're sitting inside all day and there's some medications that decrease vitamin D as well as.
• 17:27
  Speaker 1: B12 folate.
• 17:28
  Speaker 1: They're probably magnesium deficient, which would then increase cardiac risk.
• 17:32
  Speaker 1: So what powders could you use?
• 17:35
  Speaker 1: Or liposomal or liquids could you use, because you're going to have to mix it in whatever that swallowing whatever you've been approved for.
• 17:43
  Speaker 1: But it's also if the patient is yeah, describing those issues swallowing whatever you've been approved for.
• 17:46
  Speaker 1: So, but it's also if the patient is yeah, describing those issues swallowing water.
• 17:49
  Speaker 1: Water is normally the the main one that you see, so you'll you'll often go, you know you'll see them drinking water, and then I'll start coughing um that's usually a sign that it's too thin and, um, the the muscle reflex is just it's not.
• 18:03
  Speaker 1: It's not fast enough to register with the brain and they're choking on the water.
• 18:07
  Speaker 1: And that's where you've got to think outside the box and go okay, we've got a nutrient deficient person.
• 18:12
  Speaker 1: They're not going to be able to tolerate a lot of supplements.
• 18:15
  Speaker 1: So what can I do in a powder or a liquid or liposomal form that's going to be able to have an impact but be able to tolerate, because tablets will usually become something that you can't use, or tablets or capsules at this point.
• 18:29
  Speaker 1: Or if it is a capsule, can you open it up and use it?
• 18:33
  Speaker 2: Yeah, do you tend to look for?
• 18:35
  Speaker 2: You know, let's say, for instance, there's some great tasting protein powders nowadays.
• 18:40
  Speaker 2: You know whey protein with a good nutrient profile.
• 18:42
  Speaker 2: Do you tend to sort of look at that?
• 18:44
  Speaker 2: I guess you knowey protein with a good nutrient profile do you do you tend to sort of look at that, I guess you know?
• 18:47
  Speaker 2: Naturopathically, we tend to like to avoid dairy products, but in summits I'm not that scared of whey, I actually like it.
• 18:54
  Speaker 1: Um, yeah, and I think I think you just gotta be a bit realistic at the end stage.
• 18:59
  Speaker 1: You're not.
• 19:00
  Speaker 1: Oh, you know, we've got to be totally on point with nutrition and sugar.
• 19:04
  Speaker 1: So, yeah, absolutely, there's some really good, nice protein powders out there.
• 19:08
  Speaker 1: Um, if you're younger and you're healthier, you can be a bit more.
• 19:12
  Speaker 1: Yep, this is what I want you to eat.
• 19:14
  Speaker 1: And let's be stricter around sugars and process stuff.
• 19:16
  Speaker 1: Like, obviously, we'd all prefer patients to use less processed stuff because we know that it it's it's not good for you and and the associated.
• 19:24
  Speaker 1: But when you're a palliative patient, it's like being, oh, I don't want to take morphine because I'll get addicted.
• 19:29
  Speaker 1: It's like, well, that's the least of your issues being addicted to morphine.
• 19:33
  Speaker 1: So it's the same thing with the sugar.
• 19:35
  Speaker 1: I think you've got to be realistic that sticking to your guns on some of this stuff isn't going to work.
• 19:41
  Speaker 1: But absolutely could you try chia puddings with protein powder.
• 19:48
  Speaker 1: Or could you do, um, smoothies with vegetables and juices and then somehow blend them into, you know, like, basically, like children, where can you make them?
• 19:58
  Speaker 1: Into little ice blocks?
• 19:58
  Speaker 1: Yes, or, you know, you've got to probably be prepared, you know, could you do a jelly with some gelatin, some collagen powder and make like a little jelly or something where you can make some fruit juices or blend something up and put a bit of collagen powder to thicken it up.
• 20:13
  Speaker 1: And you know you do these little things along the way to help build their nutrition, but in a way that's healthy, but it's also being realistic about.
• 20:21
  Speaker 1: You know that you're there to help their quality of life at this point.
• 20:25
  Speaker 2: You're not there to extend it sarah, moving on from swallowing, when we're talking about mobility, muscle mass, institutionalization, a lack of appetite, do you tend and and indeed the swallowing issues as well do you tend to to utilise, you know, maybe a whey protein concentrate or something with a good nutrient profile?
• 20:50
  Speaker 2: What do you tend to favour?
• 20:54
  Speaker 1: I think you know when you're at this point, at that palliative point, it really comes down to texture and it comes down to taste.
• 21:01
  Speaker 1: So they're not going to be hungry, they're not really going to want to do anything, they're going to be depressed to a degree.
• 21:08
  Speaker 1: So you know, you've also got the challenges of someone who's really struggling at the moment.
• 21:14
  Speaker 1: So asking them to take a really yucky powdered drink is not going to go well, yeah, no way, um, so yeah.
• 21:23
  Speaker 1: So to be honest, at this point, yes, do I look for something?
• 21:26
  Speaker 1: But basically we, we almost move in to that.
• 21:29
  Speaker 1: I guess you know it sounds terrible.
• 21:32
  Speaker 1: But you just start really looking at the how much protein, how many calories, how much carbs have you got in it?
• 21:39
  Speaker 1: Um, how much fat's in it.
• 21:41
  Speaker 1: So you really start breaking down to what nutrition is in there so, and what vitamins and minerals are in there.
• 21:48
  Speaker 1: So it hasn't got enough of what we want.
• 21:49
  Speaker 1: So definitely I look at whey protein, um, but I also look at, you know, yes, it's nice to use, you know, rice based or soy based or different pea proteins, whatever, um, but generally your whey proteins are the better tolerated on taste.
• 22:06
  Speaker 1: So if a patient prefers to have a whey protein with banana in there and honey, and you might be able to put some other things in there to help build it up.
• 22:14
  Speaker 1: You know your collagen, you know you could put liquid iron in there.
• 22:17
  Speaker 1: You could put, um, you know, b vitamins, whatever.
• 22:20
  Speaker 1: You could put different things, magnesium, so you can put little bits in there.
• 22:24
  Speaker 1: Obviously you've got to do it around taste, but, um, yeah, so that's where I'd be going, I you know.
• 22:31
  Speaker 1: To be honest, it's really I'm looking at the nutritional panel and I'm trying to.
• 22:35
  Speaker 1: You know it's almost.
• 22:36
  Speaker 1: Look, I'm going to use a protein powder that I would use for a bodybuilder who wants to gain muscle mass, so I'm going to be using something that's as strong as what's the most I can get in the smallest amount of volume, because they're not going to be able to tolerate much.
• 22:49
  Speaker 1: So that's where, again, you're looking at your.
• 22:51
  Speaker 1: You know, your protein powders.
• 22:54
  Speaker 1: Um, you know there are other formulas on the market that are high calorie, what we call very high calorie um, dense liquids, um, that we obviously use in the hospital sector and that's what we use with um tubes, ng tubes, and some of these patients might even have a nasogastric tube or a PEG feed in their stomach and sometimes even these things.
• 23:14
  Speaker 1: As long as you're okay with the doctors, they're happy.
• 23:16
  Speaker 1: As long as you're blending it down properly, you can use these things.
• 23:19
  Speaker 1: You know, particularly through PEGs, that you can sort of supplement through the PEG feed with your liposomals and your magnesiums, and you know bits and pieces so you can, if they do, if they are eating through another mean other than through their mouth, um, again, that's something that you can discuss with your medical team to go.
• 23:38
  Speaker 1: Well, if we make it up and if the family are comfortable to do it and it's all dissolved and it's all broken down and it's all soft and there's no risk of it blocking the tube, then is that something that we could sort of look at.
• 23:48
  Speaker 1: Or the same, if your liposomal products you know your liposomal different nutritions that you can get with magnesium or your other you know there's lots of liposomals available is, you know they would be fine to put down an ng tube or like a thinner tube because you're using such a low volume um that that's something that you could do as well.
• 24:07
  Speaker 1: So there's lots of ways if you can think outside the box.
• 24:11
  Speaker 1: But again, all of these things need to be done around communication and discussion and that everybody's happy with what you're doing, because generally these patients are going to be in an acute setting and if they're not in an acute setting they're at home and they're being managed by palliative care nurses.
• 24:29
  Speaker 1: So then it's communicating with our palliative care team to go other nurses happy with what we're doing, because you don't want to be doing something that creates an issue because you didn't know, and then the medical team are a bit perplexed as to something's changed or something's deteriorated or something's gone wrong and it's like oh you know.
• 24:47
  Speaker 1: So if everyone knows what each other's doing, then everyone can work around that.
• 24:54
  Speaker 1: And I think naturopaths are starting to build a better role in that allied health sector.
• 25:01
  Speaker 1: So I think we've been the you know the poorer, you know the very poor sibling in the healthcare sector.
• 25:07
  Speaker 1: But we're now seeing a lot more naturopaths and nutritionists in GP clinics and playing a bit more of a role.
• 25:14
  Speaker 1: So I think through the formal education system that we're under, where now it is a four-year bachelor degree or they've got master's degrees that I think they're starting to take us more seriously.
• 25:25
  Speaker 1: So I think in time it's only going to our role in that is going to increase, where we'll continue to work with dietitians and nutritionists or you know, whatever that may be speech therapists to have input on, because you know our view is so holistic in their care.
• 25:44
  Speaker 1: It's not just, you know, like a dietitian that might be more focused on the macronutrients or we're not focused on one little bit, we're focused out at the beauty of what we do is we're so holistic in our approach that we can really pull together lots of different allies that they're using psychologists and speeches and OTs, and there's so many allies that we can communicate with to bring together, if you can see a deficit that we can really play that role if we have more time in the GPs, yeah, yeah.
• 26:15
  Speaker 2: Okay, so earlier on you mentioned medication issues.
• 26:18
  Speaker 2: Let's go through these.
• 26:20
  Speaker 2: What's the typical sort of thing that you see?
• 26:23
  Speaker 2: I think we mentioned, you know, swallowing a tablet earlier, but obviously there's other medication issues with oh gosh, leaky blood-brain barriers as we age and toxicity, if your liver isn't functioning correctly or your kidneys aren't functioning correctly.
• 26:39
  Speaker 2: With regards to biotransformation of medications, tell us what you see in your clinic with regards to this.
• 26:48
  Speaker 1: Tell us what you see in your clinic with regards to this.
• 26:50
  Speaker 1: Probably the main things I see are either yes, definitely like potassium, magnesium, I definitely see a lot of magnesium deficiency because of chemotherapy, because I do love oncology patients, so there's certainly a lot of medications that drop your magnesium down.
• 27:11
  Speaker 1: You also see that the magnesium drop in a lot of autoimmune, like some of your rheumatoids and those guys, because of the medications that they're using, um can drop drop magnesium.
• 27:18
  Speaker 1: Um, calcium, um is another one and obviously when your magnesium calcium goes out, then you you can you know, from a nursing perspective you can end up with some pretty serious medical emergencies in regards to the heart that happen quite quickly.
• 27:33
  Speaker 1: Your potassium with your, you know, some of the medications that you're using for fluid, so you congestive heart failure patients and those guys or some of your livers might be on medications that affect the potassium levels.
• 27:50
  Speaker 1: So do you need to then be increasing, you know, potassium and yes, there are medications to increase all these things.
• 27:56
  Speaker 1: But there's also foods and you know, yes, you can supplement, but you know you can.
• 28:01
  Speaker 1: You know you can try and increase potassium through through diet as well.
• 28:05
  Speaker 1: Um, vitamin d is a big one that we see, just because you know, a lot more people are spending a lot more time inside and we're now understanding the key role that vitamin D plays.
• 28:18
  Speaker 1: You know genetically how integral it is and how we synthesise things and how things work.
• 28:27
  Speaker 1: The same with your B vitamins, vitamins.
• 28:30
  Speaker 1: You know your methylation pathways and if you've got a genetic variant on that, that, how much more, how much you know, I wouldn't say it.
• 28:37
  Speaker 1: I'm obsessed with methylation, mthfr, but I certainly acknowledge that it plays a big role.
• 28:42
  Speaker 1: So if you do have that, then that's something you definitely need to consider as well.
• 28:47
  Speaker 1: So, because you know people are definitely not eating that great leafy stuff.
• 28:50
  Speaker 1: Um, I think protein.
• 28:54
  Speaker 1: Protein is definitely a big one that you'll see on their pathology.
• 28:56
  Speaker 1: When you're reading the pathology, you'll see that continual drop in protein and then, once you get that down, then you have a whole cannabolic effect in the body where, once it starts digesting itself, you have all sorts of troubles with the kidney and the liver at that point, because it's it's doing something it shouldn't be doing.
• 29:12
  Speaker 1: Um, and then, obviously, nutritionally, if you don't have enough iron, if you don't have enough b12, if you don't put enough folate, if you don't have those essential nutrients.
• 29:20
  Speaker 1: The bone marrow can't produce white cells and red blood cells and the bone marrow can't do its job.
• 29:25
  Speaker 1: So that's when you'll see that in their pathology you'll start to see that the hemoglobin and the white cell count and the platelet counts, and then when you start to see them all out of whack, you then know that it's probably an upstream issue, that it's not that they're being damaged in the blood.
• 29:40
  Speaker 1: They're not being produced in the first place.
• 29:43
  Speaker 1: So again, the kidneys can affect the bone marrow, so the kidneys can affect the bone marrow, so the kidneys talk to the bone marrow on how to produce these things.
• 29:50
  Speaker 1: So then if you've got a patient with kidney disease, you're going to see changes in hematology because of the way that they all talk together.
• 30:01
  Speaker 1: Or the same with the liver.
• 30:02
  Speaker 1: Once the liver starts to fail, then can it actually metabolise the medications.
• 30:06
  Speaker 1: You know a lot of cardiac medications that we use for congestive heart failure impact on the kidney and liver.
• 30:12
  Speaker 1: So you know, I know, in the nursing world it's a common debate between the cardiologist and the renal specialist on, you know, finding that fine balance between the heart and and the kidneys, because they, you know, they definitely have impacts on each other and trying to balance right is is very difficult.
• 30:33
  Speaker 1: But any patient with any of these copd, any of the neurological you know your neurological patients are going to be magnesium deficient zinc, deficient zinc for everyone.
• 30:45
  Speaker 1: Um, you know magnesium is a big one for the nervous system, for that myelin sheath and what's the you know?
• 30:51
  Speaker 1: And, um, I guess with your brain it's, you know, when you've got some of these inflammatory brain conditions, um, what actually does cross the blood barrier or not, um, and and understanding that and and how can you support that?
• 31:05
  Speaker 1: Um neural inflammation when there's chronic disease as well.
• 31:10
  Speaker 2: Can I ask about?
• 31:11
  Speaker 2: You know, when we're dealing with palliative care, we're talking about moving towards the end of life.
• 31:18
  Speaker 2: So, with regards to that, do you have hurdles, resistance by the healthcare team, even the family, to say what's the point?
• 31:32
  Speaker 2: You know, how far do we go with this sort of thing, how much money do we throw at this?
• 31:36
  Speaker 2: Do you ever have that sort of, or have to have an uncomfortable conversation about listen, this is worthwhile, but this actually, you're not going to get much bang for buck from it.
• 31:46
  Speaker 2: We can give it to you, sure, but it's not going to change, um, it's not going to have a great impact on their activities, uh, their daily activities of living yeah, um, I think there's probably two, two answers to that question.
• 32:01
  Speaker 1: One is definitely yes.
• 32:02
  Speaker 1: So if there's products that we're using that aren't of benefit, why would we use them?
• 32:06
  Speaker 1: We're just increasing load, we're wasting, we're wasting money and what they're going to be able to tolerate is going to be minimal.
• 32:13
  Speaker 1: So you've really got to condense what you're doing.
• 32:16
  Speaker 1: So absolutely do you need to scale back.
• 32:19
  Speaker 1: Anything that is not going to improve their quality of life needs to go.
• 32:23
  Speaker 1: So definitely yes.
• 32:26
  Speaker 1: The other part of your question is is have I ever had to have discussions around patients feeling like it's not a benefit?
• 32:33
  Speaker 1: Never, because generally it's more the other way, that it is such a um, under assessed, undervalued part of what we do that, to be honest with you, I'd say, 90 of naturopaths, nutritionists, don't take an active role in palliative care.
• 32:50
  Speaker 1: So, and that's purely because they didn't know that they could, and that's probably because the practitioner didn't let them know that they could.
• 32:59
  Speaker 1: So, to be honest with you, I've never had anyone go.
• 33:01
  Speaker 1: What's the point of seeing you in palliative care?
• 33:03
  Speaker 1: They're all like, yeah, what can I, what can I do?
• 33:06
  Speaker 1: To, to, to help help this person through this last stage okay, so is this then?
• 33:14
  Speaker 2: uh, do I, do I be brazen and say the word failing?
• 33:17
  Speaker 2: Is this a failing of naturopathic teaching institutions in that they're not teaching it as an important part of naturopathic care and therefore?
• 33:28
  Speaker 2: People don't know da-da-da.
• 33:30
  Speaker 1: Yeah, I do.
• 33:31
  Speaker 2: That's why you're an academic mentor.
• 33:35
  Speaker 1: I do so, you know, as a palliative oncology nurse and a nurse that's done palliative care and worked in palliative units.
• 33:44
  Speaker 1: Being a part of someone's death is like being a part of a pregnancy or birth.
• 33:49
  Speaker 1: It can be a really beautiful thing that you can make really beautiful and everyone can be supported and valued.
• 33:56
  Speaker 1: But often that's not the case and I think that is a failing on our education and awareness in that people don't know when to recognise it, they don't know how to have the hard discussions and to have that communication.
• 34:09
  Speaker 1: And I think at the end of the day you have to be comfortable with your own immortality and belief systems around that to be comfortable to work with this.
• 34:18
  Speaker 1: So I think you need to be, you know, you really need to be comfortable.
• 34:22
  Speaker 1: Where you are, you know what do you think about your own immortality.
• 34:26
  Speaker 1: Where you are, you know what do you think about your own immortality, and I know that.
• 34:34
  Speaker 1: You know.
• 34:35
  Speaker 1: I know for me I struggled with it initially working in palliative care as a nurse.
• 34:36
  Speaker 1: It took me a long time to be comfortable with death and fortunately I had colleagues that were able to.
• 34:43
  Speaker 1: You know, I guess I had that support structure around me to help me process that.
• 34:46
  Speaker 1: And I guess when I became a naturopath and I had kids, I had a lot of anxiety around working with people dying again, because you're like, oh my god, everyone I see is dying and you get a distorted perception on reality.
• 34:58
  Speaker 1: And then for me I had to really sit there and go.
• 35:02
  Speaker 1: What was that about for me?
• 35:03
  Speaker 1: Where was that anxiety coming from?
• 35:05
  Speaker 1: For me and for me it was purely ego that I thought that if I died, my children wouldn't be okay, which was not true.
• 35:12
  Speaker 1: So for me that's once I was able to nail it down and go actually my kids would be okay.
• 35:17
  Speaker 1: That's my own ego, that I think I'm so self-important that they wouldn't thrive.
• 35:21
  Speaker 1: Um, when, yes, of course I know that ups that I would, they would be upset and of course that would have an impact on them.
• 35:29
  Speaker 1: But I also know that they would have been okay.
• 35:31
  Speaker 1: And there's lots of kids that have lost a parent, that thrive and they grow from it and it's not the end of the world.
• 35:37
  Speaker 1: So once I was sort of able to move through that and acknowledge that, then I was and you know again to be comfortable with my own immortality, that once you surrender to that you can be quite comfortable and have open discussions around all those fears that those patients have, which is, what's going to happen when I die?
• 35:55
  Speaker 1: Is it going to be painful and what's going to happen?
• 35:58
  Speaker 1: And a part of that is understanding the dying process and these different diseases.
• 36:01
  Speaker 1: So if a liver patient said to me what's going to happen, I'd say, well, you're probably going to get ascites and you'll get a build-up of fluid in your tummy and you know they'll try to keep that down as much as they can, but then it will press on the lungs and you'll you'll get shortness of breath and you might get, you know, more confusion.
• 36:17
  Speaker 1: So if you and they all have a different process, they're not all the same.
• 36:19
  Speaker 1: So, um, the way that a liver patient dies is different to a way, a person with chronic kidney disease dies where they, you know, loss of appetite, um, increased confusion, drowsiness, um, you know they're all.
• 36:33
  Speaker 1: They're all different because their pathology, their pathology is different.
• 36:37
  Speaker 1: So I think that's again understanding.
• 36:39
  Speaker 1: If you have a palliative patient, do some research on what the what the pathology is like at the end, because how you would treat them and and and preparing the patient and the family for when these things come on.
• 36:49
  Speaker 1: I remember reading a.
• 36:50
  Speaker 1: They did a coroner study and they were talking about just that preparation of when people were identifying um, deceased people for coroner, for coroner's reasonings, and they had one study where they really explained to them what's going to happen.
• 37:08
  Speaker 1: So you're going to come in the room, this is what it's going to feel like, it's going to be cold, this is what's.
• 37:13
  Speaker 1: This is what's going to happen.
• 37:14
  Speaker 1: We're going to come in.
• 37:15
  Speaker 1: The person will be.
• 37:16
  Speaker 1: You know, I mean they talk through the whole process before the patient, the person, the family member went in the room to identify the body and then they had a group where they didn't so much and it was huge.
• 37:27
  Speaker 1: It was huge the difference when people are prepared for something and they know what's coming and what that experience is going to be like, it's not so scary and it's not so they're ready for it, versus going.
• 37:40
  Speaker 1: Oh my God, what's happening?
• 37:41
  Speaker 1: This is all out of control and the family become distressed and is that normal?
• 37:45
  Speaker 1: And you know they're just not prepared for it.
• 37:46
  Speaker 1: And and you know they're just they're not prepared for it.
• 37:48
  Speaker 1: And you know it's not just.
• 37:50
  Speaker 1: It's not just a failing on our industry, it's a failing on the healthcare sector.
• 37:54
  Speaker 1: How many palliative patients are not managed well and then they end up at home and then it ends up becoming a disaster and it ends up being a really out of their control.
• 38:04
  Speaker 1: Yeah, rather than pre-empting it and going, okay, we need to put these things in place so that we're we're ready for this sarah um I'm going to put up, sorry, you know, yeah, but you know what it shows your care.
• 38:21
  Speaker 2: Um, you had me teary there for a tick, but I'll get over it.
• 38:25
  Speaker 2: Um, one of the interesting things I'm going to put up in the show notes is it was a podcast that was on ABC Conversations.
• 38:35
  Speaker 2: This one was done by a woman, led by a woman, but she was speaking with an oncologist who openly discusses death very early and talks about that very early in the meetings with her patient to say what would you like to happen if and when this should eventuate, and it's a beautiful podcast.
• 38:55
  Speaker 2: Um, so we'll put that up in the show notes and I'm blinking.
• 38:58
  Speaker 2: So, sarah, I can't thank you enough for taking us through what you do every day, but when I I see you doing it, I am just inspired.
• 39:10
  Speaker 2: I am awe-inspired by your care Ah, damn it of your human Sorry, not just your patients.
• 39:17
  Speaker 1: If I could give you a baseball hug, I would.
• 39:20
  Speaker 2: Well, you're only three Ks away, but I am truly honoured to know you, because you are a caring individual who really is there for your patients, and I thank you so much for sharing your expertise, and that care indeed, with us today.
• 39:38
  Speaker 1: You're welcome.
• 39:40
  Speaker 2: And thank you everyone for joining us.
• 39:42
  Speaker 2: Sorry, teary moment, I'm a bit of a sook, but we'll put up as much information as we can in the show notes.
• 39:47
  Speaker 2: Obviously, you can find all the other podcasts on the Designs for Health website.
• 39:52
  Speaker 2: I'm Andrew Whitfield-Cook.
• 39:54
  Speaker 2: This is Wellness by Designs.
• 39:55
  Speaker 2: No-transcript.