EEPPEECC

EEPPEECC

Whole Patient Assessment

Module 3

The Education in Palliative and End-of-life Care program at Northwestern University Feinberg School of Medicine, created with the support of the American Medical Association and the Robert Wood Johnson Foundation

Overall goal of whole patient assessment A comprehensive assessment

that allows the provider to address all the issues that contribute to a patient’s suffering at the end of life

Objectives Describe concepts of suffering Recognize importance of

comprehensive assessment Identify and assess 9 key areas

affecting patients.

Symptoms and sufferingThe broad perspective Symptoms = Suffering A narrow focus will miss the target

Opioid associated somnolenceSymptom intensity vs symptom distress

The meaning of the symptom is more important than its’ intensity

Recognizing suffering

Concepts of suffering

Fragmentation of personhood – Cassell

Broken stories – Brody Challenge to meaning – Byock Total pain – Saunders Relational distress- Ferrell and

Coyle

Suffering

Persons exist in relation to families

biologicalacquisitionchosenmissing

Suffering

Elements includeUnique to the individualSense of isolation/lonelinessOften involves self conflictLoss of meaning

Threat to “personhood”

Suffering

Experienced by persons, not bodies

Suffering is a threat to the person To understand the suffering one

must understand the person But what is a person?

Aspects of personhood:

The nature of suffering

“Failure to understand the nature of suffering can result in medical intervention that not only fails to relieve suffering but becomes a source of suffering itself.”

The relief of suffering and the cure of disease must be seen as twin obligations.

- Eric Cassell, MD

Role of assessment

Diagnostic tool Therapeutic tool Develops the clinician-patient

relationship

The clinician’s role

Listen & Acknowledge Analyze & Interpret Provide information & solutions But above all

communicate interest and caring

Assessment overview …

Illness/treatment summary Physical assessment Psychological assessment Decision-making capacity

… Assessment overview Communication assessment Social assessment Spiritual assessment Practical assessment Anticipatory planning

Illness/treatment summary History as medical evaluation

Defines the medical contextIdentifies options for treatment

History as narrativeAllows patient to relate experienceUncovers the meaning of the illness to the patient

Relieves sense of isolation Avoid “interrogation”

Symptoms, suffering ...

Physical symptoms are common13.5 in cancer inpatients 9.7 in cancer outpatients

Physical symptoms related toprimary illnessadverse effects of medicationstherapyintercurrent illness

… Symptoms, suffering … Physical symptoms

pain, nausea / vomiting constipationbreathlessnessweight loss weakness / fatigue loss of functioninsomniaetc...

… Symptoms, suffering

Psychological distressanxietydepressionworryfearsadnesshopelessnessgriefshameetc...

Psychological assessment Symptoms are common and

unrecognized Normalize emotional responses Discuss patient fears, unresolved

issues, and goals of care Determine patient capacity

Decision-making capacity ... Implies the ability to understand

and make own decision Patient must

understand informationuse the information rationallyappreciate the consequences come to reasonable decision for him/her

... Decision-making capacity Any physician can determine Capacity varies by decision Other cognitive abilities do not

need to be intact

When a patient lacks capacity Proxy decision-maker Sources of information

written advance directivespatient’s verbal statementspatient’s general values and beliefshow patient lived his / her lifebest interest determinations

Communication assessment There are many different

communication styles Determine who is close to the

patient Ask how much information the

patient wants to know Ask who else should receive

information and how much

CultureAffects ways of behaving, feeling, thinking and being

A strong determinant in attitudes toward health, illness, dying

Look for care networks in a patient’s community

Explore financial concerns Allow patient to express the

meaning of their illness

Social assessment ...Social assessment ...

Social isolation

Americans live alone, in couplesworking, frail or ill

Other familylive far awayhave lives of their own

Friends have other obligations, priorities

Sense of abandonment

Spiritual assessment

Aspects of spirituality may includeReligious communityBeliefsSpirituality or religious leadersMeaning of existence

May be distinct from religion Ask

Any desired spiritual activities or rituals?Any spiritual concerns?What gives you strength and hope?

Be aware of and discuss spiritual crises

Practical assessment

Ask about practical concerns and abilities, including functional status

Learn about family or informal caregivers

Make sure basic needs are being met

Caregiving

90% of Americans believe it is a family responsibility

Frequently falls to a small number of people

often womenill equipped to provide care

Financial pressures

20% of family members quit work to provide care

Financial devastation31% lost family savings40% of families became impoverished

Coping strategies

Health adjustment and healthy bereavement is essential

Vary from person to person May become destructive

suicidal ideationpremature death by PAS or euthanasia

A comprehensive assessment that includes the issues that cause patients suffering guides end-of-life care

Summary