1. . The EPEC-O Project Education in Palliative and End-of-life Care – Oncology The EPEC TM -O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation

2. EPEC  - Oncology Education in Palliative and End-of-life Care - Oncology Module 1 Comprehensive Assessment Module 1 Comprehensive Assessment

3. Overall message l A comprehensive assessment that includes the issues that cause patients suffering guides cancer care.

4. Objectives l Describe conceptions of suffering l Use a framework to guide assessment l Use a validated screening tool, NEST, to facilitate an initial screening assessment l Carry out a detailed assessment of active issues l Describe conceptions of suffering l Use a framework to guide assessment l Use a validated screening tool, NEST, to facilitate an initial screening assessment l Carry out a detailed assessment of active issues

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6. 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

7. 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

8. Conceptions of suffering l Fragmentation of personhood – Cassell l Broken stories – Brody l Challenge to meaning – Byock l Total pain – Saunders l Fragmentation of personhood – Cassell l Broken stories – Brody l Challenge to meaning – Byock l Total pain – Saunders

9. The nature of suffering The relief of suffering and the cure of disease must be seen as twin obligations. Failure to understand the nature of suffering can result in medical intervention that (though technically adequate) not only fails to relieve suffering but becomes a source of suffering itself. Eric Cassell, MD The relief of suffering and the cure of disease must be seen as twin obligations. Failure to understand the nature of suffering can result in medical intervention that (though technically adequate) not only fails to relieve suffering but becomes a source of suffering itself. Eric Cassell, MD

10. Suffering l Experienced by persons, not bodies Meaning, Context, Coping l Persons exist in relation to families Biological, Acquisition, Chosen l Experienced by persons, not bodies Meaning, Context, Coping l Persons exist in relation to families Biological, Acquisition, Chosen

11. The broad perspective l A narrow focus will miss the target depression affects experience of pain medication useless if can’t get it spiritual strength may enhance tolerance feeling abandoned may be expressed as physical suffering l A narrow focus will miss the target depression affects experience of pain medication useless if can’t get it spiritual strength may enhance tolerance feeling abandoned may be expressed as physical suffering

12. Dimensions of illness, bereavement, and cancer care l Fixed characteristics of the patient l Modifiable dimensions of the patient’s experience l Health care interventions, including their associated outcomes l Fixed characteristics of the patient l Modifiable dimensions of the patient’s experience l Health care interventions, including their associated outcomes

13. Fixed Patient Characteristics Religion Culture Socioeconomic Class Race, Ethnicity Fixed Patient Characteristics

14. Culture l A group’s learned, repetitive, characteristic way of behaving, feeling, thinking, and being l A strong determinant in attitudes toward health, illness, dying l A group’s learned, repetitive, characteristic way of behaving, feeling, thinking, and being l A strong determinant in attitudes toward health, illness, dying

15. Respect l Err on the side of formality l Ask; don’t assume l Err on the side of formality l Ask; don’t assume

16. Language l Use interpreters when language barriers exist l Not family members l Use interpreters when language barriers exist l Not family members

17. Fixed Characteristics Modifiable dimensions Patient Psychological, cognitive symptoms Symptoms Function Caregiving needs End of life, dying Loss, grief Social issues Spiritual, existential beliefs Modifiable Characteristics

18. Factors Impacting Patient and Family Characteristics

19. Health system interventions Information sharing Decision- making Care delivery Care planning Patient Health System Interventions Plus Patient Characteristics…

20. Outcomes Quality of life Utilization, errors Satisfaction Pain / symptom relief Patient …Impact the Outcomes Experienced

21. Process of providing care

22. Efficient assessment l Initial screening l Detailed assessment l Physical examination, tests l Initial screening l Detailed assessment l Physical examination, tests

23. Initial screening l Validated questionnaires NESTRAI-PC NESTRAI-PC

24. NEST: Nine areas to screen  Needs PhysicalMental  Existential Personal spirituality Spiritual distress  Needs PhysicalMental  Existential Personal spirituality Spiritual distress  Social context PracticalPersonalFinancial  Therapeutic CultureDecision-making

25. Detailed assessment l Detailed frameworks in Appendix 1-2 l Assessments throughout EPEC™-O l Additional non-validated questions in Appendix 3 l Detailed frameworks in Appendix 1-2 l Assessments throughout EPEC™-O l Additional non-validated questions in Appendix 3

26. SummarySummary A comprehensive assessment that includes the issues that cause patients suffering guides cancer care.