Download 2. EPEC Course Whole pt assessment

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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
Module 3
Whole Patient
Assessment
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 suffering
The broad perspective
Symptoms = Suffering
A narrow focus will miss the target
Opioid associated somnolence
Symptom 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
biological
acquisition
chosen
missing
Suffering
Elements include
Unique to the individual
Sense of isolation/loneliness
Often involves self conflict
Loss 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:
Personality and
character
History
Family
Cultural identity
Political identity
Roles and
Activities
Regular behaviors
Relationships with
self and with
others
A private self
An unconscious
self
A body
A perceived future
A transcendent
dimension
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
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Diagnostic tool
Therapeutic tool
Develops the clinician-patient
relationship
The clinician’s role

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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 context
Identifies options for treatment
History as narrative
Allows patient to relate experience
Uncovers the meaning of the illness to
the patient
Relieves sense of isolation
Avoid “interrogation”
Symptoms, suffering ...
Physical symptoms are common
13.5 in cancer inpatients
9.7 in cancer outpatients
Physical symptoms related to
primary illness
adverse effects of medications
therapy
intercurrent illness
… Symptoms, suffering …
Physical symptoms
pain,
nausea / vomiting
constipation
breathlessness
weight loss
weakness / fatigue
loss of function
insomnia
etc...
… Symptoms, suffering
Psychological distress
anxiety
depression
worry
fear
sadness
hopelessness
grief
shame
etc...
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 information
use the information rationally
appreciate 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 directives
patient’s verbal statements
patient’s general values and beliefs
how patient lived his / her life
best 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
Social assessment ...
Culture
Affects 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 isolation
Americans live alone, in couples
working, frail or ill
Other family
live far away
have lives of their own
Friends have other obligations,
priorities
Sense of abandonment
Spiritual assessment
Aspects of spirituality may include
Religious community
Beliefs
Spirituality or religious leaders
Meaning 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 women
ill equipped to provide care
Financial pressures
20% of family members quit work to
provide care
Financial devastation
31% lost family savings
40% of families became impoverished
Coping strategies
Health adjustment and healthy
bereavement is essential
Vary from person to person
May become destructive
suicidal ideation
premature death by PAS or euthanasia
Summary
A comprehensive assessment that
includes the issues that cause patients
suffering guides end-of-life care