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EEPPEECC
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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
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?
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
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