1. Advance Care Planning
2. Communicating Bad News
3. Whole Patient Assessment
4. Pain Management
5. Assisted Suicide Debate
6. Anxiety, Delirium
7. Goals of Care
8. Sudden Illness
9. Medical Futility
10. Common Symptoms
11. Withholding Treatment
12. Last Hours of Living
13. Cultural Issues
14. Religion, Spirituality
15. Legal Issues
16. Social and Psychological
Clergy and Faith Communities
Step 2. Physical
Step 3. Psychological
Step 2. Physical Assessment
General Guidelines for Physical Assessment in End-of-Life Care
Physical assessment at end of life differs from a standard patient assessment
Organized by symptoms and functional activities rather than by organ system or anatomy
After assessing symptoms and physical impairments, a physical examination can be conducted to:
- Confirm findings from the history and provides baseline clinical information
- Establish a relationship that includes therapeutic touch
Minimize diagnostic tests
- Conduct only if the results will clearly affect or help determine the therapeutic plan
- Remember that burden associated with diagnostic tests may conflict with a goal of maximizing comfort
The following symptoms are common during the last phase of life. Be sure to ask about each one:
- Weight loss
For every symptom, multiple potential causes should be considered, including:
- Another medical condition
For more information on how to thoroughly assess each symptom and its causes, see:
Pain as a Model for Symptom Assessment
Why Use Pain as a Model?
- High prevalence
- Usually can be well controlled
- Often undertreated
- Adequate treatment requires adequate assessment
- Gateway to assessment of other symptoms
Overview of Pain Assessment
- Present in up to 90% of patients with advanced cancer or AIDS
- Similar prevalence rates reported in pediatric and geriatric patients
Pain assessment relies on patient self-report
- Symptoms are inherently subjective
- No reliable way to assess what the patient is experiencing other than by asking the patient
- Patient self-report is the "gold standard" for assessment
Pain assessment conducted using the methods outlined below will:
- Help the physician gain a clearer understanding of diagnosis
- Convey to the patient that the symptom is important to the physician
Aspects of Pain Assessment
- Where does it hurt most? Does it go anywhere?
- How does your pain change over time?
- How long have you had this pain?
- Did it begin gradually or all of a sudden?
- Does it come and go, or do you have it all the time?
What words might you use to describe the pain?
- How bad is it on average?
- At its worst?
- Is it progressing or remaining stable?
- Does it feel better when you’re in a certain position?
- Do you notice any change with [various activities]?
Impact on Function
- To what extent does the pain interfere with your normal activities?
- What about your sleep?
- Your ability to walk?
- Your relationship with others?
Effect of Treatments
- What have you been doing for the pain?
- Have you taken any medications?
- How much relief does that provide?
- What do you think is causing the pain?
- What does the pain mean to you?
- Would you like me to prescribe something?
Assessing Pain when the Patient Cannot Communicate Verbally
Pain assessment in the non-cognitively intact person, such as an elderly patient with dementia, is challenging
Similar challenges are present in pre-verbal children
Behaviors such as grimacing, moaning, or crying may the only way to assess pain
Rely on experienced colleagues to help with assessment
Tools for Pain Assessment
Symptom severity is an important aspect of assessment
Despite being subjective, patients can accurately and reproducibly indicate the severity of their symptom using a scale
- Have been well validated as tools
- Help to assure that pain is adequately assessed
- Enhance the ability of the patient to communicate severity to health care professionals
- Enhance communication of severity between professionals
- Faces scales (showing a sequence of faces in a row from happy to intermediate to sad)
The specific scale used is less important than using one in a consistent way over time
- Some patients have trouble with the concept of rating pain on a numerical or visual analog scale
- Using a more concrete scale such as the Borg Faces Scale may be helpful, particularly with children
The Brief Pain Inventory (Short Form) of the Pain Research Group, University of Wisconsin, Madison is one example of a pain assessment tool
- A copy is included in the Resources section of this module
A similar approach to that described for the systematic assessment of pain should be applied to the assessment of all other symptoms
- When assessing a patient with multiple symptoms, it is extremely helpful to use a standardized form that can be used to track the symptoms over time
- The Memorial Symptom Assessment Scale is an example that is included in the Resources section of this module
Areas of Function to Assess and Questions to Ask:
- Can the patient move around?
- Can the patient see or hear well enough?
Effect on activities
- Can the patient move around?
Effect on relationships
- How are physical aspects, in particular, sexual function, affected?