299 An Unusual Nasal Lump

A 70-year-old man received a few courses of various antibiotics for left dacrocystitis under the care of ophthalmologists. Despite the treatment, the lump was not improving. The patient, in the meantime, presented to his GP with recurrent left-sided epistaxis and it became apparent that he was also experiencing ipsilateral nasal blockage. He reported a 3-year history of left-sided tinnitus but no other red flag symptoms. He was subsequently referred as 2-Week-Wait to ENT and nasoendoscopy revealed complete blockage of the left nostril with the postnasal space fully obstructed by enlarged mucosal tissue and no palpable lymph nodes. CT showed an aggressive locally invasive sinonasal tumour and a necrotic posterior mediastinal lesion. MRI further defined the extent of invasion and revealed a significant level 2 lymph node. A gastroscopy and EUA nose were arranged to obtain histology to confirm the differential diagnosis of sinonasal SCC. This case highlights the importance of lateral thinking when presented with a refractory symptom, as a more sinister diagnosis can be detected earlier. It also reinforces the need for examination of surrounding anatomy that may influence the condition.

302 - The Effectiveness and Safety of Electroconvulsive Therapy for Treatment Refractory Agitation or Aggression in Major Neurocognitive Disorder

Introduction:Fifty to ninety percent of individuals with Major Neurocognitive Disorder (MNCD) have Neuropsychiatric Symptoms (NPS)1. Agitation and aggression are amongst the most persistent and treatment-refractory symptom clusters. Patients with these NPS are associated with increased risk of institutionalization, psychotropic medication use, caregiver burden, and mortality2.Safe and effective treatments for NPS are lacking. Consensus guidelines emphasize the initial use of non-pharmacologic approaches though supportive evidence is limited3.Extensive research has established the safety and efficacy of ECT in elderly patients with depression and other psychiatric conditions6. Clinical experience suggests that ECT is a valuable treatment option in MNCD-related treatment refractory NPS cases7-10. However, data supporting the efficacy and safety of this practice is scant.Materials and Method:Patients admitted to the geriatric psychiatry inpatient units who meet the inclusion criteria, were recruited from 2 Vancouver sites and 3 unit at Ontario Shores. These patients had an anesthesia consultation to evaluate their safety of going through ECT. Consent was obtained from their substitute decision makers. All patients enrolled are already on psychotropic medications.

Refractory psycho-existential distress and continuous deep sedation until death in palliative care: The French perspective

ObjectiveSince February 2016, French Claeys-Leonetti law has recognized patients' right to confront incurable diseases with short-term prognosis and refractory physical or psychological or existential symptoms by requesting continuous deep sedation until death (CDSUD). Determining when psychological or existential distress is refractory and unbearable remains complex and controversial.This review provides a comprehensive thought on CDSUD for advanced incurable patients with refractory psychological and/or existential distress in palliative care settings. It offers guidance on psychiatric or psychological diagnosis for explaining patients' requests for CDSUD.MethodA narrative literature review (2000–2019) was conducted on the MedLine search about the use of palliative sedation in cases of refractory psychological and/or existential distress.Results(1) Definitions of “refractory symptom,” “refractory psychological distress,” and “refractory existential distress” are inconsistent; (2) alternative diagnoses might obscure or be obscured by psycho-existential distress; and (3) criteria on meanings, reasons for requests, decision-making processes, and functions are evolving in practice.Significance of resultsBefore implementing CDSUD, palliative healthcare professionals should seek input from psycho-oncologists in palliative care. Mental health professionals should analyze and assess the reasons for psychological and/or existential distress, consider the intentionality processes of requests, and explore alternative diagnoses, such as depressive or adjustment disorders, demoralization syndrome, desire to hasten death, and desire for euthanasia. Therapeutic responses (e.g., pharmacological and psychotherapeutic) should be implemented before deciding that psycho-existential distress is refractory.

Propofol for palliative sedation

Palliative sedation is the intentional use of sedatives to manage refractory symptom(s), such as pain and/or terminal restlessness. This case report describes the successful use of propofol, an ultra-fast-acting anaesthetic agent commonly used for anaesthesia induction and maintenance to manage refractory agitated delirium in an acute inpatient palliative medicine setting.

Palliative Sedation

The goal of palliative sedation is to relieve suffering due to refractory symptoms by inducing a state of decreased or absence in awareness—a reduction in consciousness—by administering sedating medications. It is a legally and ethically acceptable treatment and is distinct from euthanasia. However, prior to consideration of palliative sedation, necessary steps are required after a thorough interdisciplinary assessment. One of the most important step is that the patient must be suffering from a refractory symptom, defined as a symptom that “cannot be adequately controlled despite aggressive efforts to identify a tolerable therapy that does not compromise consciousness.” The intention of palliation sedation is to palliate the refractory symptom(s) and not to shorten the duration of life. This chapter reviews the common reasons for and various important aspects involved in palliative sedation.