EEPPEECC

EEPPEECC

Whole Patient Assessment

Whole Patient Assessment

Module 3Module 3Module 3Module 3

The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation

The Project to Educate Physicians on End-of-life CareSupported by the American Medical Association andthe Robert Wood Johnson Foundation

ObjectivesObjectives

disease historydisease history

physical physical symptomssymptoms

psychological psychological symptomssymptoms

decision-making decision-making capacitycapacity

disease historydisease history

physical physical symptomssymptoms

psychological psychological symptomssymptoms

decision-making decision-making capacitycapacity

information information sharingsharing

socialsocial

spiritualspiritual

practicalpractical

anticipatory anticipatory planning for deathplanning for death

information information sharingsharing

socialsocial

spiritualspiritual

practicalpractical

anticipatory anticipatory planning for deathplanning for death

Know how to identify, assessKnow how to identify, assess Know how to identify, assessKnow how to identify, assess

Why skill at assessmentis importantWhy skill at assessmentis important Patients expect relief of sufferingPatients expect relief of suffering

Key diagnostic toolKey diagnostic tool

Coordinates team of health Coordinates team of health professionalsprofessionals

Can have therapeutic effectsCan have therapeutic effects

Develops the physician-patient Develops the physician-patient relationshiprelationship

Patients expect relief of sufferingPatients expect relief of suffering

Key diagnostic toolKey diagnostic tool

Coordinates team of health Coordinates team of health professionalsprofessionals

Can have therapeutic effectsCan have therapeutic effects

Develops the physician-patient Develops the physician-patient relationshiprelationship

The physician’s roleThe physician’s role

ListenListen

AcknowledgeAcknowledge

AnalyzeAnalyze

Offer information, practical Offer information, practical suggestionssuggestions

Introduce sources of support Introduce sources of support

ListenListen

AcknowledgeAcknowledge

AnalyzeAnalyze

Offer information, practical Offer information, practical suggestionssuggestions

Introduce sources of support Introduce sources of support

9 dimensionsof assessment9 dimensionsof assessment1.1. Illness / treatment Illness / treatment

summarysummary

2.2. Physical Physical

3.3. Psychological Psychological

4.4. Decision making Decision making

5.5. Communication Communication

1.1. Illness / treatment Illness / treatment summarysummary

2.2. Physical Physical

3.3. Psychological Psychological

4.4. Decision making Decision making

5.5. Communication Communication

6.6. Social Social

7.7. Spiritual Spiritual

8.8. Practical Practical

9.9. Anticipatory Anticipatory planning for deathplanning for death

6.6. Social Social

7.7. Spiritual Spiritual

8.8. Practical Practical

9.9. Anticipatory Anticipatory planning for deathplanning for death

Illness /treatment summaryIllness /treatment summary Primary diagnosisPrimary diagnosis

Secondary concurrent illnessesSecondary concurrent illnesses

Treatment summaryTreatment summary

Primary diagnosisPrimary diagnosis

Secondary concurrent illnessesSecondary concurrent illnesses

Treatment summaryTreatment summary

Physical assessmentPhysical assessment

SymptomsSymptoms

Physical function, impairmentsPhysical function, impairments

Physical examinationPhysical examination

Minimize testsMinimize tests

SymptomsSymptoms

Physical function, impairmentsPhysical function, impairments

Physical examinationPhysical examination

Minimize testsMinimize tests

Common symptomsCommon symptoms

PainPain

Weakness / fatigueWeakness / fatigue

BreathlessnessBreathlessness

InsomniaInsomnia

Weight lossWeight loss

PainPain

Weakness / fatigueWeakness / fatigue

BreathlessnessBreathlessness

InsomniaInsomnia

Weight lossWeight loss

ConfusionConfusion

ConstipationConstipation

AnxietyAnxiety

Nausea / vomiting Nausea / vomiting

DepressionDepression

ConfusionConfusion

ConstipationConstipation

AnxietyAnxiety

Nausea / vomiting Nausea / vomiting

DepressionDepression

Symptoms – causesSymptoms – causes

Multiple causesMultiple causes

the primary illnessthe primary illness

an effect of therapyan effect of therapy

psychological, social, spiritual, practical psychological, social, spiritual, practical issuesissues

another medical conditionanother medical condition

Multiple causesMultiple causes

the primary illnessthe primary illness

an effect of therapyan effect of therapy

psychological, social, spiritual, practical psychological, social, spiritual, practical issuesissues

another medical conditionanother medical condition

Pain as a model forsymptom assessment Pain as a model forsymptom assessment High prevalenceHigh prevalence

Can be well controlledCan be well controlled

Often undertreatedOften undertreated

Adequate treatment requires Adequate treatment requires adequate assessmentadequate assessment

Gateway to other assessmentsGateway to other assessments

High prevalenceHigh prevalence

Can be well controlledCan be well controlled

Often undertreatedOften undertreated

Adequate treatment requires Adequate treatment requires adequate assessmentadequate assessment

Gateway to other assessmentsGateway to other assessments

Pain assessmentPain assessment

Location (1°, Location (1°, referral pattern)referral pattern)

QualityQuality

TimingTiming

SeveritySeverity

RadiationRadiation

Location (1°, Location (1°, referral pattern)referral pattern)

QualityQuality

TimingTiming

SeveritySeverity

RadiationRadiation

Modifying factorsModifying factors

Impact on functionImpact on function

Effect of Effect of treatmentstreatments

Patient Patient perspectives perspectives

Modifying factorsModifying factors

Impact on functionImpact on function

Effect of Effect of treatmentstreatments

Patient Patient perspectives perspectives

FunctionFunction

Motor functionMotor function

Sensory functionSensory function

Effect on activitiesEffect on activities

Effect on relationshipsEffect on relationships

Patient perspectives Patient perspectives

Motor functionMotor function

Sensory functionSensory function

Effect on activitiesEffect on activities

Effect on relationshipsEffect on relationships

Patient perspectives Patient perspectives

Psychological assessment . . .Psychological assessment . . . CognitionCognition

delirium, dementiadelirium, dementia

AffectAffect

anxiety, depressionanxiety, depression

Emotions prompted by the life-Emotions prompted by the life-threatening illnessthreatening illness

CognitionCognition

delirium, dementiadelirium, dementia

AffectAffect

anxiety, depressionanxiety, depression

Emotions prompted by the life-Emotions prompted by the life-threatening illnessthreatening illness

. . . Psychological assessment. . . Psychological assessment Coping responsesCoping responses

suicidal ideationsuicidal ideation

FearsFears

loss of control, burden, abandonment, loss of control, burden, abandonment, indignityindignity

Unresolved issuesUnresolved issues

Coping responsesCoping responses

suicidal ideationsuicidal ideation

FearsFears

loss of control, burden, abandonment, loss of control, burden, abandonment, indignityindignity

Unresolved issuesUnresolved issues

Emotionalresponses to illnessEmotionalresponses to illness Avoidance, denial Avoidance, denial

Fear, anger Fear, anger

Lability, irritabilityLability, irritability

IntellectualizationIntellectualization

GriefGrief

Acceptance, spiritual peaceAcceptance, spiritual peace

Avoidance, denial Avoidance, denial

Fear, anger Fear, anger

Lability, irritabilityLability, irritability

IntellectualizationIntellectualization

GriefGrief

Acceptance, spiritual peaceAcceptance, spiritual peace

FearsFears

Loss of control, dignityLoss of control, dignity

Loss of relationshipsLoss of relationships

Being a burdenBeing a burden

Physical sufferingPhysical suffering

Loss of control, dignityLoss of control, dignity

Loss of relationshipsLoss of relationships

Being a burdenBeing a burden

Physical sufferingPhysical suffering

Unresolved issuesUnresolved issues

Old feudsOld feuds

Last visitsLast visits

Lifetime project, piece of workLifetime project, piece of work

Old feudsOld feuds

Last visitsLast visits

Lifetime project, piece of workLifetime project, piece of work

Decision-making assessmentDecision-making assessment Capacity / competenceCapacity / competence

Goals of careGoals of care

Advance care planningAdvance care planning

Informed consentInformed consent

Capacity / competenceCapacity / competence

Goals of careGoals of care

Advance care planningAdvance care planning

Informed consentInformed consent

Decision-making capacityDecision-making capacity

Global incompetenceGlobal incompetence

Decision-specific capacityDecision-specific capacity

Global incompetenceGlobal incompetence

Decision-specific capacityDecision-specific capacity

Decision-specific capacityDecision-specific capacity Understand authorization roleUnderstand authorization role

Rational use of information, Rational use of information, including risk, uncertaintyincluding risk, uncertainty

Insight into consequencesInsight into consequences

NoncoercedNoncoerced

Understand authorization roleUnderstand authorization role

Rational use of information, Rational use of information, including risk, uncertaintyincluding risk, uncertainty

Insight into consequencesInsight into consequences

NoncoercedNoncoerced

Communication assessment . . .Communication assessment . . . Is there someone to share fears Is there someone to share fears

with? talk to? plan with?with? talk to? plan with?

Is the information clear? Is the information clear? understandable?understandable?

What the patient wants to knowWhat the patient wants to know

child’s parentschild’s parents

Is there someone to share fears Is there someone to share fears with? talk to? plan with?with? talk to? plan with?

Is the information clear? Is the information clear? understandable?understandable?

What the patient wants to knowWhat the patient wants to know

child’s parentschild’s parents

. . . Communication assessment. . . Communication assessment Who else to talk toWho else to talk to

Limits of confidentialityLimits of confidentiality

Is language an issue?Is language an issue?

Who else to talk toWho else to talk to

Limits of confidentialityLimits of confidentiality

Is language an issue?Is language an issue?

Social assessmentSocial assessment

Family, family dynamicsFamily, family dynamics

CommunityCommunity

EnvironmentEnvironment

FinancialFinancial

Family, family dynamicsFamily, family dynamics

CommunityCommunity

EnvironmentEnvironment

FinancialFinancial

CommunityCommunity

CultureCulture

Sources of assistanceSources of assistance

Religious Religious

Disease groups Disease groups

LocalLocal

CultureCulture

Sources of assistanceSources of assistance

Religious Religious

Disease groups Disease groups

LocalLocal

FinancialFinancial

Spending downSpending down

Medical billsMedical bills

Family sacrificeFamily sacrifice

Spending downSpending down

Medical billsMedical bills

Family sacrificeFamily sacrifice

Spiritual assessmentSpiritual assessment

Meaning, value – personal, of the Meaning, value – personal, of the illnessillness

burden, control, independence, dignityburden, control, independence, dignity

FaithFaith

Religious life, spiritual lifeReligious life, spiritual life

PastorPastor

Meaning, value – personal, of the Meaning, value – personal, of the illnessillness

burden, control, independence, dignityburden, control, independence, dignity

FaithFaith

Religious life, spiritual lifeReligious life, spiritual life

PastorPastor

Meaning of illnessMeaning of illness

Fears & concernsFears & concerns

IllnessIllness

Death & dyingDeath & dying

Changes and lossesChanges and losses

Family / self / roleFamily / self / role

ControlControl

Fears & concernsFears & concerns

IllnessIllness

Death & dyingDeath & dying

Changes and lossesChanges and losses

Family / self / roleFamily / self / role

ControlControl

Spiritual activitiesSpiritual activities

Religious denomination (past or Religious denomination (past or present)present)

Activity levelActivity level

Prayer / scriptural resourcesPrayer / scriptural resources

Religious denomination (past or Religious denomination (past or present)present)

Activity levelActivity level

Prayer / scriptural resourcesPrayer / scriptural resources

PastorsPastors

From communityFrom community

From health system (chaplain)From health system (chaplain)

From communityFrom community

From health system (chaplain)From health system (chaplain)

RitualsRituals

Special prayers, actionsSpecial prayers, actions

Last prayers, declarationsLast prayers, declarations

Special prayers, actionsSpecial prayers, actions

Last prayers, declarationsLast prayers, declarations

Spiritual crises . . .Spiritual crises . . .

Search for meaning or purpose in Search for meaning or purpose in one’s lifeone’s life

Loss of a sense of connectionLoss of a sense of connection

Feelings of guilt or unworthinessFeelings of guilt or unworthiness

Search for meaning or purpose in Search for meaning or purpose in one’s lifeone’s life

Loss of a sense of connectionLoss of a sense of connection

Feelings of guilt or unworthinessFeelings of guilt or unworthiness

. . . Spiritual crises. . . Spiritual crises

Questioning of faithQuestioning of faith

Desire for forgivenessDesire for forgiveness

Sense of abandonment by GodSense of abandonment by God

Questioning of faithQuestioning of faith

Desire for forgivenessDesire for forgiveness

Sense of abandonment by GodSense of abandonment by God

Approach tospiritual assessmentApproach tospiritual assessment Suspect spiritual painSuspect spiritual pain

Establish a conducive atmosphereEstablish a conducive atmosphere

Express interest, ask specific Express interest, ask specific questionsquestions

Listen for broader meaningsListen for broader meanings

Be aware of own beliefs, biasesBe aware of own beliefs, biases

Suspect spiritual painSuspect spiritual pain

Establish a conducive atmosphereEstablish a conducive atmosphere

Express interest, ask specific Express interest, ask specific questionsquestions

Listen for broader meaningsListen for broader meanings

Be aware of own beliefs, biasesBe aware of own beliefs, biases

Practical assessmentPractical assessment

CaregiversCaregivers

Domestic needsDomestic needs

Dependents Dependents

CaregiversCaregivers

Domestic needsDomestic needs

Dependents Dependents

CaregiverCaregiver

Who?Who?

At what sacrifice?At what sacrifice?

Comfortable relationship?Comfortable relationship?

Unmet needs?Unmet needs?

Who?Who?

At what sacrifice?At what sacrifice?

Comfortable relationship?Comfortable relationship?

Unmet needs?Unmet needs?

Domestic needsDomestic needs

Chores of day-to-day livingChores of day-to-day living

cookingcooking

cleaningcleaning

shoppingshopping

bankingbanking

bill paymentbill payment

Transportation Transportation

Chores of day-to-day livingChores of day-to-day living

cookingcooking

cleaningcleaning

shoppingshopping

bankingbanking

bill paymentbill payment

Transportation Transportation

FamilyFamily

DependentsDependents

Children Children

EldersElders

InfirmInfirm

PetsPets

DependentsDependents

Children Children

EldersElders

InfirmInfirm

PetsPets

Anticipatoryplanning for deathAnticipatoryplanning for death Current losses Current losses

Anticipated lossesAnticipated losses

Advance care planningAdvance care planning

Advance planning for last hours and Advance planning for last hours and after deathafter death

Current losses Current losses

Anticipated lossesAnticipated losses

Advance care planningAdvance care planning

Advance planning for last hours and Advance planning for last hours and after deathafter death

EEPPEECC

EEPPEECC Whole Patient Whole Patient

AssessmentAssessment

SummarySummary

Whole Patient Whole Patient AssessmentAssessment

SummarySummary