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Symptom Assessment in Palliative Care
Dr. Dan Malciolu
Assessment
WHEN? HOW OFTEN?
WHY?
WHAT?
WHERE?
BY WHOM?
HOW?
Holistic approach – the Patient: body, soul, mind,
his/her life surrounded by the whole Universe:
social ‐ family/community‐, spiritual, emotional
Team“Delivery of efficient palliative care for advanced cancer patients is driven by
continuous, systematic, multidimensional assessments ideally performed by an
interdisciplinary team”
http://www.npcrc.org
1. General evaluation
a. Actual stage of disease/treatmentb. Signs and symptomsc. Psycho‐social evaluationd. Education, Faith, BeliefsFaith, Importance, Community, Address FICA
e. Expectations and intervention goalsf. Medical emergenciesg. Prognosis
2. Evaluation/monitoring frequencyNeed levels:
Acute – dailyAcute and or multiple needs, uncontrolled symptoms, in‐patient status
Intense – 2‐3/weekNew type of care, any type of crisis, chemotherapy
Moderate – 1‐2/2 weeksOut‐patient status, controlled symptoms, frail social support
Stable – 1/monthStable disease, minor symptoms, good compliance
Inactive – 1/3 monthsMultiple care givers, stable disease
3. Somatometric data, imagistic studies
a. Weightb. Heightc. BMId. other: skin fold, abdominal circumference, waist‐to‐hip ratio, etce. L3/4 CAT fat‐to‐muscle indexf. Body Impedance Analysis BIAg. Dual Energy XRay Absorbtion DEXA
4. Vital signs
Blood Pressure, Heart Rate, Respiratory Rate, Temperature
5th – Pain, GCS, Pulse Oximetry, Blood Glucose
6th – Functional Status, Shortness of Breath
5. Emergencies in Palliative Care
a. Haemorrhage External / Internal / Rythm / Flow / Volume
b. superior vena cava obstructionc. spinal cord compresssiond. hypercalcemiae. any symptom with a VAS > 7other emergencies
seizures ‐ intracranial lesions/pressuresepsisintestinal occlusiondeliriumcavity fluid accumulation: pleural/pericardial
effusion, ascites
6. Consciousness
Comatose patient Glasgow Coma Scale GCSDelirium, confusion, agitation
Hyperactive, Hypoactive, Mixed‐type deliriumDiff with dementia – onset!!!Evaluate and treat cause [metabolic, hipoxia, infection, organ failure (kidney, liver – portal enceph), anemia, pain, fever, acute urine retention, severe constipation, medication(opioids, benzodiazepines, TCA, corticosteroids, anti‐seizure meds), withdrawal (alcohol, benzodiazepines, barbiturates)]
Memorial Delirium Assessment Scale MDAS (based on DSM IV)Delirium Rating Scale DRSBedside Confusion Scale BCSRichmond Sedation and Agitation Scale RASSConfusion Assessment Method CAMMini Mental State Examination MMSE
7. Performance (Functional) Status
Eastern Oncology Cooperative Group ECOGEdmonton Functional Assessment Tool EFATKarnofsky Performance ScaleKatz Index of Independence in Activities of Daily LivingPalliative Performance Scale PPSFunctional Assessment Staging FASTNew York Heart Association Classification NYHAActivities of Daily Living ADL
8. Pain – the fifth vital signAlways multidimensional
Physical – Psychosocial ‐ SpiritualAssess:
Site and Number of different painsIntensityIrradiation/distributionTimingQualityAggravating/alleviating factorsSensory DisturbancesImpact on ADLCause(s) Type (nociceptive, neuropathic, referred, mixed, acute, predictable…)Analgesic historyClinically significant psychological distressInterferences (psychosocial/spiritual)Patient’s understanding/beliefs
Watson M, Lucas C., Hoy A, Back I, Armstrong P ‐ Palliative Adult Network Guidelines, Third Ed 2001
Verbal Descriptor Scale VDSVisual Analogue Scale VASWong‐Baker FACES Pain Rating ScaleNon‐verbal Pain IndicatorsPain Assessment for Dementing Elderly PADEMemorial Pain Assessment CardDiscomfort Scale for Dementia of Alzheimer Type DS_DATAbbey Pain Scale Late DementiaEdmonton Symptom Assessment Scale ESASIntegrated Palliative Care Outcome Scale IPOSBrief Pain Inventory BPI, short or long versionMcGill Pain Questionnaire MPQ
9. Digestive system
Apetite
a. oral cavityxerostomia
Challacombe Dry Mouth Rating Scalecandidosisstomatitis/mucositis
grade 1 erythemagrade 2 erythema, oedema, can eatgrade 3 erythema, oedema, false membranes, cannot eat solidsgrade 4 all plus spontaneous bleeding, cannot eat at
all
9. Digestive System (cont)
b. NauseaIncidence 48%Onset, progression, associated elements (cough, constipation, mouth and throat status, ascitis, hypercalcemia, medication), aggravating or alleviating factors
c. VomitingDiff with regurgitation/expectoration
Quantify: frequency, number of episodes, volume per episode
VASMorrow Assessment of Nausea and Emesis MANE
9. Digestive System (cont)
d. tranzit: constipation, diarrhoeawhen last BM, frequency, quantity, content, aspect, consistency, pathological elements (blood, pus, mucus), associated symptoms (abdominal distension, gas, cramping, pain, nausea, vomiting, palpitations, dyspneea, cold sweats, fainting or near‐fainting, lypotimia), passage of gas, accompanying effort/straining, recent/sudden change with moment of onset
constipationcauses: malignancy itself, medication, co‐morbidities, lifestyle: old or new
diarrhoeadehydration?true or false diarrhoeafever for infectious cause, absent for C. difficile
10. Respiratory System
a. DyspneaOnset, progression, associated factors (pain, cough, wheesing, secretions, dizziness, tremor), worsening or alleviating elements, duration
b. CoughOnset, progression, character, associated factors (pain, dyspnoea, wheesing, secretions, dizziness, tremor), worsening or alleviating elements, duration
Borg Scale BSVAS ScaleAmerican Thoracic Society Scale ATS Medical Research Council Dyspnea Scale
11. Skin
Signs: Color, texture, hydration, sweatingBilicam phone‐basedColorimetric strips
Symptoms: Pruritus, paresthesias, dysesthesiasLesions: Pressure ulcers, infection, tumors, oedema, fistula, stomae
Bates Jansen wound assessment toolBraden ScaleWaterlow Score
12. Urinary System
hydration level: intake, output ‐ urinary volume
dehydrationmild: weakness, darker urinemedium: tachycardia, delayed
capillary refill >2s, decresed uri outputsevere: pale, blue extremities, weak / shallow peripheral pulse, low BP, anuria, tachipnoea
Assess:Urine: color, clarity, compositionUrinationGiordano
13. Neurological, neuropsychic and emotional status
Reflexes, mioclonus, seizures, spasticitySeizures
Incomplete or complete, partial or generalizedDiff with tremor
Hx. seizures, cerebral disease, ICH, prophylactic treatment and compliance, metabolic changes, infections and hyperpirexia, medication (opioids, TCA, tramadol, decrease or stop of steroids), abstinence (alcool, benzodiazepines, barbiturates, opioids)
Opistotonus and extrapiramidal manifestationsMedication: Metoclopramide, haloperidol
13. Neurological, neuropsychic and emotional status (cont)
DeliriumConfusionDepresionAnxiety
Only 13% presents pure anxietyBe aware of psycho‐somatic aspectsIs it anxiety or is it something else: pain, pulmonary embolism, coronary artey disease?Interacts wih pain, dyspnoaea, diarrhea, sleep
SleepSuicide
Beck Depression Inventory BDI, Hamilton Anxiety Scale HAM, Hospital Anxiety and Depression Scale HAD, Sheehan Anxiety Scale SAS, Patient Health Questionnaire 9 PHQHerth Hope Index, Snyder Hope Scale
14. Metabolic evaluation, cachexia
always related to somatometric values (weight, height, BMI)a. Nutritional Intake (energy, nutrients), fluid intakeb. Calorimetryc. Electrical Impedance Measurement
d. other: skin fold, abdominal circumference, waist‐to‐hip ratio, etce. L3/4 CAT fat‐to‐muscle indexf. Body Impedance Analysis BIAg. Dual Energy XRay Absorbtion DEXA
15. Quality of Life QOL
EORTC QOL ScaleMcGill Quality of Life IndexNeeds at the End‐of‐Life Screening Tool (NEST)Quality of Life at the End of Life (QUAL‐E)
Scales and Instruments
evaluation/assessmentdiagnosticmonitoring
focusedmultidimensional
numericalvisual/symbol‐based
validated or not (yet)
"In physical science the first essential step in the direction of learning any subject is to find principles of numerical
reckoning and practicable methods for measuring some quality connected with it. I often say that when you can measure what you are speaking about, and express it in
numbers, you know something about it” Sir William Thomson Kelvin
„Everything that can be counted does not necessarily count; everything that counts cannot necessarily be counted.”
Albert Einstein
“The Broken Column,” by Frida Kahlo (Banco de México Diego Rivera and Frida Kahlo Museums Trust)
Accessed on 11 April 2015 at: http://well.blogs.nytimes.com/2008/04/22/pain‐as‐an‐art‐form
“Medicine is not only a science; it is also an art. It does not consist of compounding pills and plasters; it deals with the very processes of life, which must
be understood before they may be guided.”
Paracelsus 1493 –1541
