EPECEPECEPECEPEC EPECEPECEPECEPEC Whole Patient Assessment Whole Patient Assessment Module 3 The Project to Educate Physicians on End-of-life Care Supported by the American Medical Association and the Robert Wood Johnson Foundation

Objectives n disease history n physical symptoms n psychological symptoms n decision-making capacity n disease history n physical symptoms n psychological symptoms n decision-making capacity n information sharing n social n spiritual n practical n anticipatory planning for death l Know how to identify, assess

Why skill at assessment is important l Patients expect relief of suffering l Key diagnostic tool l Coordinates team of health professionals l Can have therapeutic effects l Develops the physician-patient relationship l Patients expect relief of suffering l Key diagnostic tool l Coordinates team of health professionals l Can have therapeutic effects l Develops the physician-patient relationship

The physician’s role l Listen l Acknowledge l Analyze l Offer information, practical suggestions l Introduce sources of support l Listen l Acknowledge l Analyze l Offer information, practical suggestions l Introduce sources of support

9 dimensions of assessment 1. Illness / treatment summary 2. Physical 3. Psychological 4. Decision making 5. Communication 1. Illness / treatment summary 2. Physical 3. Psychological 4. Decision making 5. Communication 6. Social 7. Spiritual 8. Practical 9. Anticipatory planning for death

Illness / treatment summary l Primary diagnosis l Secondary concurrent illnesses l Treatment summary l Primary diagnosis l Secondary concurrent illnesses l Treatment summary

Physical assessment l Symptoms l Physical function, impairments l Physical examination l Minimize tests l Symptoms l Physical function, impairments l Physical examination l Minimize tests

Common symptoms l Pain l Weakness / fatigue l Breathlessness l Insomnia l Weight loss l Pain l Weakness / fatigue l Breathlessness l Insomnia l Weight loss l Confusion l Constipation l Anxiety l Nausea / vomiting l Depression

Symptoms – causes l Multiple causes the primary illness an effect of therapy psychological, social, spiritual, practical issues another medical condition l Multiple causes the primary illness an effect of therapy psychological, social, spiritual, practical issues another medical condition

Pain as a model for symptom assessment l High prevalence l Can be well controlled l Often undertreated l Adequate treatment requires adequate assessment l Gateway to other assessments l High prevalence l Can be well controlled l Often undertreated l Adequate treatment requires adequate assessment l Gateway to other assessments

Pain assessment l Location (1°, referral pattern) l Quality l Timing l Severity l Radiation l Location (1°, referral pattern) l Quality l Timing l Severity l Radiation l Modifying factors l Impact on function l Effect of treatments l Patient perspectives

Function l Motor function l Sensory function l Effect on activities l Effect on relationships l Patient perspectives l Motor function l Sensory function l Effect on activities l Effect on relationships l Patient perspectives

Psychological assessment... l Cognition delirium, dementia l Affect anxiety, depression l Emotions prompted by the life- threatening illness l Cognition delirium, dementia l Affect anxiety, depression l Emotions prompted by the life- threatening illness

... Psychological assessment l Coping responses suicidal ideation l Fears loss of control, burden, abandonment, indignity l Unresolved issues l Coping responses suicidal ideation l Fears loss of control, burden, abandonment, indignity l Unresolved issues

Emotional responses to illness l Avoidance, denial l Fear, anger l Lability, irritability l Intellectualization l Grief l Acceptance, spiritual peace l Avoidance, denial l Fear, anger l Lability, irritability l Intellectualization l Grief l Acceptance, spiritual peace

Fears l Loss of control, dignity l Loss of relationships l Being a burden l Physical suffering l Loss of control, dignity l Loss of relationships l Being a burden l Physical suffering

Unresolved issues l Old feuds l Last visits l Lifetime project, piece of work l Old feuds l Last visits l Lifetime project, piece of work

Decision-making assessment l Capacity / competence l Goals of care l Advance care planning l Informed consent l Capacity / competence l Goals of care l Advance care planning l Informed consent

Decision-making capacity l Global incompetence l Decision-specific capacity l Global incompetence l Decision-specific capacity

Decision-specific capacity l Understand authorization role l Rational use of information, including risk, uncertainty l Insight into consequences l Noncoerced l Understand authorization role l Rational use of information, including risk, uncertainty l Insight into consequences l Noncoerced

Communication assessment... l Is there someone to share fears with? talk to? plan with? l Is the information clear? understandable? l What the patient wants to know child’s parents l Is there someone to share fears with? talk to? plan with? l Is the information clear? understandable? l What the patient wants to know child’s parents

... Communication assessment l Who else to talk to l Limits of confidentiality l Is language an issue? l Who else to talk to l Limits of confidentiality l Is language an issue?

Social assessment l Family, family dynamics l Community l Environment l Financial l Family, family dynamics l Community l Environment l Financial

Community l Culture l Sources of assistance l Religious l Disease groups l Local l Culture l Sources of assistance l Religious l Disease groups l Local

Financial l Spending down l Medical bills l Family sacrifice l Spending down l Medical bills l Family sacrifice

Spiritual assessment l Meaning, value – personal, of the illness burden, control, independence, dignity l Faith l Religious life, spiritual life l Pastor l Meaning, value – personal, of the illness burden, control, independence, dignity l Faith l Religious life, spiritual life l Pastor

Meaning of illness l Fears & concerns l Illness l Death & dying l Changes and losses l Family / self / role l Control l Fears & concerns l Illness l Death & dying l Changes and losses l Family / self / role l Control

Spiritual activities l Religious denomination (past or present) l Activity level l Prayer / scriptural resources l Religious denomination (past or present) l Activity level l Prayer / scriptural resources

Pastors l From community l From health system (chaplain) l From community l From health system (chaplain)

Rituals l Special prayers, actions l Last prayers, declarations l Special prayers, actions l Last prayers, declarations

Spiritual crises... l Search for meaning or purpose in one’s life l Loss of a sense of connection l Feelings of guilt or unworthiness l Search for meaning or purpose in one’s life l Loss of a sense of connection l Feelings of guilt or unworthiness

... Spiritual crises l Questioning of faith l Desire for forgiveness l Sense of abandonment by God l Questioning of faith l Desire for forgiveness l Sense of abandonment by God

Approach to spiritual assessment l Suspect spiritual pain l Establish a conducive atmosphere l Express interest, ask specific questions l Listen for broader meanings l Be aware of own beliefs, biases l Suspect spiritual pain l Establish a conducive atmosphere l Express interest, ask specific questions l Listen for broader meanings l Be aware of own beliefs, biases

Practical assessment l Caregivers l Domestic needs l Dependents l Caregivers l Domestic needs l Dependents

Caregiver l Who? l At what sacrifice? l Comfortable relationship? l Unmet needs? l Who? l At what sacrifice? l Comfortable relationship? l Unmet needs?

Domestic needs l Chores of day-to-day living cookingcleaningshoppingbanking bill payment l Transportation l Chores of day-to-day living cookingcleaningshoppingbanking bill payment l Transportation

Family l Dependents l Children l Elders l Infirm l Pets l Dependents l Children l Elders l Infirm l Pets

Anticipatory planning for death l Current losses l Anticipated losses l Advance care planning l Advance planning for last hours and after death l Current losses l Anticipated losses l Advance care planning l Advance planning for last hours and after death

EPECEPECEPECEPEC EPECEPECEPECEPEC Whole Patient Assessment Summary Summary