 Well, first of all, I have to apologize. Audrey could not get past the wall and could not get a visa to get here in time. So, but we are gonna try and link her in during the course of this panel. Now, one of the things that Tamara said in the previous panel was that you're the best, you're the brightest, you're the smartest. That's why you're here, and that's absolutely true. So, if anything were to happen to your cognition, whatever your age, you couldn't do the job that you're doing. And that would be devastating. And so, I think that's something we have to take very, very seriously. Last month, I was at one of our neighborhood parties. And one of my neighbors is a landscape architect, a very successful landscape architect. Not that old, I would think probably early 60s. And she came up to me and said, I really want to talk to you. She said, I had a total knee replacement three weeks ago, and I'm having trouble thinking. And she was getting lost on her words. She knew what she wanted to say, but she couldn't come out with it. And she said to me, you know, I'm down to have another knee done next month, this month in fact. What should I do? What should I tell the doctors? So, that's one of the questions we're gonna ask the panel. And see what they can come up with to help me answer her. So, Joe, when he introduced me yesterday, talked about a sedation scale that I came up with. And that was when I was running an ICU. And we used to have this thing called ICU syndrome, where patients were very disorientated when they came through sedation and been on mechanical ventilator. And in those days, we really sedated patients. They were basically in coma if they're on a ventilator. You could walk into an ICU, and the only way you'd know somebody was alive was by looking at the monitors and seeing the heartbeat going across the monitor. And I used to think, you know, surely this isn't good. Why is it when we get them finally well, it takes days to wake them up? And then they're in the hospital for a month. Then they're in rehab for a month. And then I'd telephoned the family a year later. And they would, I'd say, how's dad doing? Oh, he's doing great. In fact, he's sitting looking at the television right now. And then I got smart. And I started thinking, is he looking at the television, or is he actually watching it? Oh, no, no, no. He's no idea what's going on on the television, but he's sitting there looking at it. That was a success. Well, clearly it wasn't a success. We have to do better. And that's why I came in with a sedation score. Many, many things could hurt the brain, but at least one of the things I could look at was why do we have these patients in coma? When it's not disease-induced, it's medically-induced, it's we're giving the drugs that put them into coma. And so I started to titrate drug to level of consciousness. So we just had patients comfortable, not in coma. And that was the idea of it. And so that's where that came from. Now, 30 years later, we have liberated patients in our ICU. We have patients walking down the corridor on ventilators. We're much, much more precise about how we sedate patients, and mentally, they're doing better. So that's a success. And I want to now, just in the interest of time, because we've got an important speaker coming to follow us, we want to introduce our panel to discuss delirium. And first of all, we've got Daniel Arnel. He's chairman of the European Society of Anesthesia, Patient Safety and Quality Committee. He's also the vice president and founder of the Spanish Anesthesia Incident Reporting System. That's a national reporting tool of adverse events so that we can get a handle on how many they're having so they can put improvements into the system. And he's from Madrid in Spain. We have, if all the panelists could come up while we're being introduced here, we have Lee Fleischer, who you've just heard mentioned. And Lee Fleischer is known worldwide by every anesthesiologist, most surgeons and nearly all perioperative physicians, because he saved more lives than probably anybody else in this room by a mile, because he put together cardiac risk factors so that we know the risk of putting somebody under anesthesia and taking them through surgery. He was the author of this text and it's saved many, many patients. So we're very grateful for Lee and the things that he's done. Adrian Gelb is secretary of the World Federation of Societies of Anesthesia. He works closely with the World Health Association and is on the faculty here at UCSF. And Pratik Pandharipanda is a member of the faculty of Vanderbilt University School of Medicine and he's been a leader in the management of ICU sedation and delirium. In fact, he taught us how to spell delirium. He's got two eyes, not two E's. And finally, David Scott, who you've seen on the video, he's here, he was president of the Australian and New Zealand College of Anesthesiologists and he's got a focus on surgery, anesthesia, and cognition and Audrey Curtis was his patient. And so welcome him very much indeed. So thank you, panel. Thank you. Thank you. And so Pratik, I think I'm gonna start with you because you and Wesley Lee at Vanderbilt put delirium on the map and what we just knew as ICU condition, dysfunction, you itemized it out as delirium and you were able to put in tests in place so that we could actually diagnose it correctly. And so tell us a little bit about how you got there and what's the effect of delirium in the ICU? And the many of this, much of this was post-operative which is the focus of this panel but this is where it started. So tell us a little bit about it. Sure. So I think I'll give Wes a little bit more credit than me. He went down this uncharted territory and he has the experience, the gray hair to show that as compared to me. So he's definitely the one who set this stage but going back to the 80s and 90s, many of us in critical care were looking at techniques and physiological parameters, et cetera, to try and see how we could get people off mechanical ventilation. And we quickly realized that many patients would come into the ICU with sepsis or with ARDS, with pulmonary dysfunction and those admitting diagnosis would get resolved yet we couldn't get people off mechanical ventilation and sort of looking back at Audrey's story and trying to figure out what is it that these patients were manifesting, we would see that they would be having altered mental status, these fluctuating mental status where you'd have inattention, lethargy. On the other hand, you could have hyperactivity, they would have hallucinations, et cetera, and that was preventing us from getting them off mechanical ventilation so that ICU syndrome that you mentioned. And then trying to understand what is this ICU syndrome? So getting along with some neurologists, some psychiatrists, geriatricians, we tried to see what the hallmark of these features were and realized quickly that they seemed to map to the DSM criteria for dillerium. So once we sort of realized that this may be dillerium, the next thing was, well, if this is dillerium and we have to measure dillerium in a standardized manner in the ICU, unfortunately, many of our patients in the ICU are on mechanical ventilation, they are non-verbal so they cannot sit and answer questions for you. So we had to develop tools to try and measure dillerium in the ICU. So we started with a tool called the Confusion Assessment Method in the ICU, which was a modification of the Confusion Assessment Method in floor patients. And then other groups also came up with the intensive care dillerium screening checklist. So with the advent of tools, we now had a standardized way of calling this syndrome at least dillerium. So we had a unified terminology to try and have discussions among healthcare providers. You know, prior to this, we would have terms like ICU syndrome or ICU psychosis or my pet peeve when I have residents still and I've had, I'm probably guilty of this in the past, where you'd say, oh, my patient is pleasantly confused and a poor old grandma pleasantly confused or you listen to Audrey's story where she heard this band playing in her room or she saw gorillas coming in the elevator and you'd find them entertaining. We now know, and Dr. Cole talked about this, dillerium is a manifestation of brain organ dysfunction. There is no other organ dysfunction that you would get away by saying, it's acute renal failure or it is an entertaining cardiac dysfunction. But we sort of underplay the importance of dillerium as a manifestation of brain dysfunction. And we've learned now through evidence-based literature and in high-impact factor journals that dillerium occurs in 60 to 80% of mechanically ventilated patients and it was important to show that this is one of the most prevalent organ dysfunctions that when you look at your post-operative patients or some of the lower severity of ICU patients, it still occurs in 20 to 50% of those patients and it's not something that just occurs in the hospital phase. It has ramifications months to years later, takes away quality of life, impacts cognitive function. Many patients cannot get back to their level of employment and it basically robs many of our patients from dignity basically in the hospital as well as months to years later. So it's a really impactful thing and that's sort of how we went into this. And there is a mortality associated too and that's what we're focused on here obviously is preventing mortality at the moment. But there is a mortality rate associated with dillerium. David, what does that mortality rate? Thanks, Mike. Dillerium, there's a number of large studies now which demonstrate quite clearly that dillerium in the post-operative period is associated with quadrupling of the mortality that would be otherwise expected if you didn't have that dillerium. Quadrupling. Quadrupling, four times the risk of mortality. And that's very serious and you have to ask why but when you start to think about the fact that the brain is our most important organ and if your brain's not functioning well everything else follows. So why would an acute event like dillerium lead to a long-term event like mortality which might be long-term or short-term or cognitive dysfunction? But if you put it into context of well if you're confused whether you're quiet and with hypoactive dillerium this three quarters of cases post-operatively are this quiet form where you think you've got the perfect patient. They're sitting in the ward they're not doing anything harmful they're not calling the nurse but they're not remembering their instructions they're not remembering the physiotherapy to deep breathe or respiratory therapy they're not remembering to call the nurse to go up to the bathroom so they get up and they have a fall. Or they may be discharged still from the hospital with dillerium and so they won't remember their discharge instructions when to come back for instance instructions to care for themselves at home. They get an increased incidence of other complications such as pneumonia as Dan Colt pointed out. So there's a lot of links below the fact that dillerium is about your brain and about thinking. Okay I would think Daniel that many physicians still don't look at dillerium as being a problem post-operatively my patients don't get dillerious in recovery room. What was the finding from your Spanish audit tool that reviewed the outcomes? Thank you, yes that is true. Dillerium is kind of the perfect example of how patient safety will ever be changing so that my grandmother had this hip replacement 15 years ago and she got the dillerium and afterwards post-operative cognitive dysfunction and it went off into her dementia and so but at that time even myself I just thought that that was usually people with her age and her fragility and that is what is happening in most of our colleagues I'm afraid because we see the dillerium as usual in our Spanish incidence reporting system for patient safety. We've been working 10 years into this anesthesia and reporting system for more than and in more than 9,500 incidents reported throughout the 10 years we've only been able to find six dillerium related incident reports which talks about the lack of awareness between physicians and nurses. This is an incident report system for anesthetists intensive care providers and nurses related to and it means that we are still not aware of the importance not only of the important we can be aware of the importance but not that this is preventable and we can work on it. Maybe we know that it is there we've always been we've obviously seen our patients even our relatives as myself or part of a dillerium but we believe that it's normal and we can't do anything and it's not we have to do them something. And I think what we picked up in the past was we'd see the hyperactive dillerium that because you have to intervene they're gonna hurt themselves unless you do something but the hyperactive that you just mentioned is more prevalent and it's more difficult to detect. I know just from my perspective I look at patients and pose them a question if I don't get eye contact then I really start to think this patient may be a hyperactive dillerium patient. So we do have Audrey on the phone so we can have her picture I think on the screen and Audrey are you there? I think she can use. Yes, sorry. Okay, sorry you couldn't join us. I think one of the things that impressed me about your commentary on what happened was that you have good memory of it and I don't know whether you can hear us maybe it's been transmitted through the phone but most patients who have psychotic incidences don't have memory of what went on and if they have a drug induced problem they don't have memory they can't recall what happened other than they have a memory blank but Audrey recounted this procedure in this episode very accurately. So Audrey do you remember? I'm sorry reception isn't too good. I can't, could you repeat the question please? Sure, so is that Liz? Okay. Yes. So Audrey do you recall clearly what happened to you after your surgery? Just recall the story. Just recall the story. Yes, it's very vivid. I think I was saying this when they actually did the video is that it's nearly two years now and just for it to be so vivid it has just stayed and when we started to do the video there was a bit of preamble that I'd only written down those a while before and we had to have three takes to do that but as soon as we got onto recording the actual delirium and the nightmare as I call it I was fine because it was so vivid still in my mind I didn't have to think about it. Thank you, thank you so much. Well Lee what can you tell us now about where the brain initiative is going and what have we accomplished so far? Thank you and I wanna thank Joe and the patient safety movement for joining with us and taking on this incredibly important problem. And Mike Scotton, a team with Rod Eckenhof and Liz helped sort of develop this new nomenclature of delayed cognitive recovery and one of our patients that we've partnered with describes it as the brain fog which I think really nicely discusses it. So we've actually taken a lesson very similar to here and from the National Quality Forum where I'm on the board of a multi-stakeholder approach and working with the AARP, our surgical colleagues, our nursing colleagues, working with funders, the National Institutes of Health and the Patient-Centered Outcome Research Institute as well as some of the regulatory bodies like CMS have asked how can we push out something very similar to apps and we hope to really coordinate this of infographics that we can give to our providers and give them best practices and teach them through collaboratives and that we've started to push that out, we're working on that now further, working with AARP for putting stories out there because others have said that transparency and I've had this occur several times since where patients have said, I've thought I've gone demented, I've thought I've had a stroke and just tell me that there is this delirium and then cognitive delay that most of the time returns to function. So we want that transparency as well as for the families to understand that when they go home, maybe they shouldn't get their keys back. Maybe they shouldn't be driving. So those sort of messaging. So again, it's really pushing out best practices and now on Tuesday, CMS has actually invited us to lecture to CMS and lecture to all of their medical officers to say, how do we actually get our hospitals engaged nationally through the American Hospital Association, CMS and the Joint Commission to care for older patients and have protocols in place to remember to give them back their glasses, bring their hearing aids, orient them after surgery. The last piece that was actually the email that I got and the discussion from yesterday is there's increasing evidence that delirium may in effect have a downstream effect of increased dementia. There's work by Sharon Inouye and others, including work from your group to say that their cognitive decline increases greatly. So that's the illuminating delirium message that may be sent. I'm a little nervous about that in mid-March, but if we can get and galvanize the public that not only is it the quadrupling of mortality, but delirium, not the cognitive fog, but the delirium may lead to higher dementia and if we block that, we don't know if that's true, would that actually reduce the risk of Alzheimer's in the future? It's a key question everybody's starting to ask. Adrian, from the sort of World Health approach, what are your thoughts? Big numbers would be the initial thought. There is no global inventory, but we could do some back-of-the-envelope calculations here. We know there's about 320 million operative procedures a year. We also know there are 140 million patients every year who don't get curative surgery. We'll exclude them from the calculation. And then if we apply some fairly simple, conservative numbers to that, 20% are geriatric, 20% develop delirium. We're looking at something like 12 million patients per year as the global burden of disease. If we included patients who don't come through an operating room to the ICU, add that in, we're talking in excess of 20 million people every year. I haven't tried to calculate out the economic burden and the post-discharge burden on families. Among the challenges is how do we try and make this a global agenda? We're sitting here all from high-income countries, but a sizable part of the burden is in middle and low-income countries who are not aware of the challenge and don't have the resources. Among the ideas that Lee and I have had as an ASA, WFSA partnership is to create a caring, wisely-type approach. FIC five approaches that could be implemented. WFSA will circulate it to our membership group, 135 national societies, and we'll create a global challenge over what have you implemented. And at the World Congress of Anesthesia and Prague in September 2020, we'll be asking national societies to report and discuss which they've implemented, what their success has been, what have they learned from the implementation strategies that would be relevant to other countries with similar economic and patient care problems, and perhaps a water prize for those who've been most innovative in putting it together. And just one other comment, seeing that you mentioned the WHO, the World Health Organization, where we do officially represent anesthesia. Delirium is not a single entity within their portfolio. There's the psychiatry group who see delirium as their issue. There's the patient safety group that the Patient Safety Movement Foundation, ourselves, interact with regularly, see it as part of their problem. And then there's a surgery anesthesia portfolio who don't yet see it as their problem. So one of our challenges at the World Health Assembly, that's the annual meeting of the Ministers of Health in Geneva in May, is to try and get some kind of consensus that brings these groups together at the Palastres Nation in the Serpent Cafeteria lounge, get a conversation going on how we bring these parts together so that the WHO endorses this as a huge patient safety economic and patient outcome initiative. Now let's just open this to all of you. Is this really just an elderly patient's problem? Or do young people also at risk for delirium after surgery? And they're just able to get over it faster? You know, we've actually seen this brain fogged. So both the delirium and the cognitive dysfunction in 50-year-olds. It could be 40-year-olds. There's a lot of work, and David may be able to comment more, that this may be an inflammatory response that actually enters the brain in causing neural inflammation. But if we were to attack it, and we had lots of debates about this, that's why we think a screen to see if people are at risk by having some form of cognitive dysfunction at baseline. And that can occur at any age. It's just, who do we pick first? But I think it can start from people certainly younger than me. So I think I'd be at risk if I go in. But it's more likely a brain age thing than simply the years. Yeah. David, what do we know about the etiology of delirium? So delirium is part of what we're now describing as perioperative neurocognitive disorders. But it's an acute event. And I think the idea of brain failure, acute brain failure, is a useful term. The brain fog description really can occur at any age and probably is more associated with a delayed neurocognitive recovery. It is age-related. But in some of our studies now, we've looked at comparing with accurate preoperative testing for cognitive impairment. If you identify those patients who have got some form of mild cognitive impairment or formally assessed preoperative impairment, it almost takes age out of the equation. So the healthy brain at whatever age is much less vulnerable. Patients with higher education are less vulnerable, probably just because they've got more cognitive reserve, they're more likely to live in a more stimulating environment. And then there are all the other trigger factors, which we've already discussed and can go on at length about. So it is part of that constellation. But I think delirium is measurable. It has a DSM-5 criteria for diagnosis. It spans the professional areas that we work in. I have the privilege of working along with Liz Everett with the Alzheimer's Association International with a perioperative cognition special interest group or a professional interest area, which is a collaboration across disciplines and trying to bring the geriatricians or psychogeriatricians, the researchers into Alzheimer's disease, into the space of perioperative cognitive disorders. But I think you need to target your energies. And at the moment, delirium is high on the list of things we should be focusing on whilst we continue to work on these other areas. So in the ICU, what can you do to prevent delirium? So I think we have been looking at the idrogenic risk factors, so mostly the modifiable risk factors. There are older patients who come in. You can't change the age of your patients. There are patients who come in with preexisting cognitive impairment, can't refuse admission to them, or say that if you don't have adequate education, can't come into the ICU. But what we've been seeing is perhaps some of the medications we give, such as benzodiazepines, might be associated with a higher probability of delirium and adjusting sedation regimens either by changing the drug class or even reducing the amount of sedation, like you were mentioning earlier, makes a big impact. Now mobilizing our patients, so we used to chemically restrain them, keeping them in a coma with the benzodiazepine drip, changing that paradigm to have more interactive patients so they can get up, they can walk. And so there's a push for this ABCDEF bundle where you're trying to, and F being family, where you're looking for pain medication and adjusting for pain meds so that you have them free of pain, waking them up, doing spontaneous breathing trial, assessing them for delirium, choosing the right sedative, the C part, coordinating all the scare, assessing them for delirium and mobilizing them. So I think those are some of the things that we can incorporate in getting family involved so that you can orient them, put things into perspective for them because many of these patients remember things like Audrey talks about these nightmares, et cetera. At least when you consider nightmares, there's an escape hatch, right? You wake up and that's the end of the nightmare. It doesn't happen for patients. The other thing is support groups and so we've been adding support groups for our patients and many patients talk about delirium and the experiences to being like an alien abductee. Surprisingly, the alien abductees have a support group but our delirium patients don't. So. No. Lee, well, it's interesting what you mentioned and in that we give a lot of drugs after surgery and on the ward and there's something called beer's criteria which are drugs that actually increase the probability of delirium. And when we looked at our own hospital, first of all, they were on the post-operative orders, the worst one being Benadryl and everyone sort of gets Benadryl, they think it's more gentle but it increases delirium. And we've looked in about 20 to 30% of our post-operative older individuals get these drugs that they shouldn't be getting. So I think the first thing we can stop doing that's preventable is stop giving drugs unless we really think twice that it's safe in that patient population which I'm sure is part of the apps that you're doing. Daniel, what are the European society guidelines now on delirium and trying to prevent delirium? Yeah, thank you. The European society of anesthesiology started working in 2013 through its guidelines committee to put together all the information that is there, all the evidence and build up these evidence-based guidelines. And I believe there are four kind of main ideas from those guidelines that one was the importance of having a pre-surgery screening for the cognitive status as it was said in the video. The second would be that although delirium is more prevalent in elderly patients, we have to think on delirium also in young patients with risk factors and even in the pediatric with our child population as well when they also can have this kind of agitation and delirium as well. The third would be to monitor an electron and cephalogram during surgery so that we can avoid too deep anesthesia. We know that there are some patterns in this ECG ECG that we can avoid and reduce the presence of delirium and finally keep screening for delirium until the five days after surgery because we could find a delayed onset of delirium. These four points kind of were kind of new when in 2017, not new but at least they could, the committee agreed of them for this guidance. Okay, David, so how long does delirium last in general? Well, we don't know. We know that we used to think that it was most common in certainly very common in intensive care and then it was much less common as the days went by. We've been examining patients for up to five days post-surgery of a different range of types twice daily and it still occurs even out to five days after surgery as a new episode. But there are many patients who have a number of episodes and Audrey actually experienced by a diagnostic criteria and we were applying formal diagnostic criteria because she was in a research project. Four episodes of delirium, three of those episodes were hypoactive. So she was not agitated but she nonetheless met all the criteria for delirium which included inattention, decreased conscious state, acute onset, et cetera. And so it is important to realize that it can carry out and what we don't want happening is patients being discharged home on delirium. So one of the things that and apps would be useful and the other groups which are working on this including the Brain Health Initiative is to have that as part of the high-risk patients if they've had an episode diagnosed during hospital or if they're in that high-risk category to have a screening test before they're discharged home to make sure that's one of the criteria for being discharged home. Certainly we've had delirium screening in our ICU for years now but we've only just instituted it in our recovery rooms from patients recovering from surgery so we're now screening them before they leave recovery. We're not screening beforehand so you're putting together our app right now for the patient safety movement. Is preoperative screening part of that app that we're putting together? So it is. At the moment, preoperative screening would be to assess preoperative cognitive screening to assess some form of cognitive impairment prior to anesthesia and surgery as it should be for any admission to hospital in an elderly patient or an at-risk patient because that's one of the high-risk factors, the significant risk factors and within that you should be able to, you can screen for delirium as well. Postoperatively, really in the acute phase it's screening for delirium. Yes. I'm just gonna jump into the conversation on the preoperative screening because we have put in place a screening. So all of our surgical patients this is at UCSF? At UCSF. Yeah. And there are some simple, reasonably accurate assessment tools spelling words backwards. If a patient can't take words, keep it in their head and then do the SD, L-O-R, whatever it is. You've got it wrong. Exactly. And the other one that we've used is the animal naming from the alphabet. So within 60 seconds, one should be able to name at least 20 animals as you go through the alphabet, you know? A, B, C, D, E, F, G. And those are the sort of things you can actually do on a telephone interview. And they do flag patients and they come up on our anesthetic electronic health record, little red box that says delirium risk flagging the patient. And then we have a PACU order set where one can select the delirium bundle or the standard PACU set. And implementing it initially was put together by a multidisciplinary group led by anesthesia but anesthesia surgery, hospital administration nursing of the scoring. And implementation, I would say was a dismal failure initially partly because the faculty not interested. So the patients would be graded, we'd ignore it. And we made it a resident incentive project put a little money in front of them. If they can get an 80% or 50%, I think is what we compromised on buy into using the pathway for faculty to offer them $200 to achieve that. That's it's not worth the effort but residents was worth the effort and they are tremendous force for change within an organization. You know, we talk about grassroots being the patients or perhaps ourselves as sort of leaders within the institution. But I think we should never overlook the role that everybody can play, including residents. They have huge influence on the faculty on how they want to provide care. And as long as they can justify it, a lot of us go along with it. So should we be sitting down with families before surgery, particularly on elderly patients or patients with maybe a little bit of cognitive decline? Should we be discussing with them the potential of what might happen after surgery? Absolutely, yes. We've been doing work with AARP and so forth. That's a strong message, isn't it, Lee? I mean, I started as part of Inform Consent saying it. And I've had found, you know, there was this great fear. People would say, I don't want surgery and we don't see them till the day of surgery. And in fact, the family said, thank you for telling us. We'll be watching for it. So I don't know about the others, but I think the transparency that's been such a tremendous message here for the last two days is actually accepted and people will, they won't cancel. They'll actually feel better. At least that's my finding. I've certainly found that patients coming in to have surgery up to maybe two, three years ago would often voice, I won't wake up during the operation. Will I dock? And you have to sort of tell them, no, we're gonna be watching you closely. The anesthesia is gonna be precise. Now it's changed. I don't get asked that anymore. Now I get asked, will my brain be the same when I wake up? You know, dad had surgery and he's not quite the same again. And so it's out there now. And I think the population certainly in the United States are now getting very much aware that we need to be much more precise about what we're doing. So we've talked a little bit about depth of anesthesia. What other things can we do to try and prevent somebody developing this mental dysfunction? Or how can we treat it? Could I suggest while we're running it on time a question you might want to pose to Audrey? Sure. She, I believe, is considering having future surgery. I wonder if you could ask her, or we could ask her, how has her experience of delirium affecting her feelings about her potentially upcoming surgery? Certainly. Liz, did you hear that? Yeah, your experience. How was your feelings about the experience of delirium? Well, at the time it was extremely frightening. And in fact, one of the points I was gonna bring up unless you've actually experienced delirium after operation. Well, after operation. And mine was just so intense and so real that it has left it. I mean, I don't have nightmares about it, but if anybody was to ask me, I can relate exactly what happened. There's nothing about it that I forget. And do you think having that information pre-operatively would have helped? No, that was another point I was gonna bring up. When we discussed this before and we've talked about, well, perhaps if we spoke to patients before, the first thing I thought of was it might, well, I was quite keen on the fact that that would probably help. But then I started to think, well, some people are probably nervous anyway about going into an operation. And if you start speaking to them about the possibilities of them having a nightmare or if we found a different way to put it over to them, it could cause more distress than, sorry. No, that's right. So what would help? So I think just before I go on to that, the other thing that I've had about this sort of speaking to patients before, there is no way even if you've been told a hundred times not to worry if you get a nightmare, when you get that sort of delirium, you wouldn't even remember. It just would not come to your mind, oh, well, I shouldn't worry about this because this happens because the nightmare, the delirium is so vivid, there is no way. So I'm not sure that any of that pre-advice before the operation would really have any effect at all. Audrey, thank you so much. And what do you think would help for you? What I think the major thing that I think would have helped for me was the fact of it, the difficulty of getting hold of someone when I was really stressed. That sort of feeling that I felt guilty because I'd pulled all my tubes out and the nurse actually said, don't worry about if it happens. But I think afterwards there was never any discussion on it. So I don't know whether the intonation was passed on but it was never brought up or the problem wasn't raised at all. No one spoke to me about it. Education post-operative league would have helped. Liz, we're out of time. I'm gonna have to ask you to stop. Not actually for the actual nightmare. Okay. Can you pass that on, Liz? Thank Audrey very much indeed but the clock's down to zero. So I'm gonna thank everybody very much for being here and talking about something that's obviously been there for years but we really haven't grappled with certainly not in the operating room post-operative period but now it looks like we are and it is associated with increased mortality which is what this organization's about trying to prevent. So thank you all very much indeed. Thank you and Audrey, thank you so much. Thank you.