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Modules:

  • Introduction
  • 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
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    Back to Module 3: Whole-Patient Assessment
    Nine Dimensions

    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

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    Symptom Assessment

    Common Symptoms

    The following symptoms are common during the last phase of life. Be sure to ask about each one:

    • Pain
    • Weakness/fatigue
    • Breathlessness
    • Insomnia
    • Weight loss
    • Confusion
    • Constipation
    • Anxiety
    • Nausea/vomiting
    • Depression

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    Symptom Causes

    • For every symptom, multiple potential causes should be considered, including:
    • For more information on how to thoroughly assess each symptom and its causes, see:

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    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

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    Overview of Pain Assessment

    • Pain is prevalent
      • 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

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    Aspects of Pain Assessment

    Location

    • 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?

    Quality

    • What words might you use to describe the pain?

    Severity

    • How bad is it on average?
    • At its worst?
    • Is it progressing or remaining stable?

    Modifying Factors

    • 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?

    Patient Perspectives

    • What do you think is causing the pain?
    • What does the pain mean to you?
    • Would you like me to prescribe something?

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    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

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    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
    • Scales for pain:
      • 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
    • Scales in use include:
      • Numerical scales (0–10)
      • Visual analog scales
      • 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

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    Functional Assessment

    Areas of Function to Assess and Questions to Ask:

    • Motor function
      • Can the patient move around?
    • Sensory function
      • Can the patient see or hear well enough?
      • Is he or she safe?
    • Effect on activities
      • Can the patient move around?
    • Effect on relationships
      • How are physical aspects, in particular, sexual function, affected?
    • Patient perspectives
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