Whole Person Assessment: A Physician Isn’t Enough

Kyle P. Edmonds, MD

Assistant Clinical Professor

Doris A Howell Palliative Care Consultation Service

UC San Diego Health Sciences

Adapted from the Palliative Care International Curriculum Series Editor, Frank R. Ferris, MD

Objectives

• Discuss the role of assessment as a means to relieve suffering

• Verbalize your clinical role in assessment

• Use a framework to guide assessment

• Discuss how the assessment fits into the process of providing care

Palliative Care IS…• A team that can help your patients and families manage the pain, symptoms, and stress of serious illness.

• Available at any age and at any stage in a serious illness and can be provided along with curative treatment.

• Expert communication for challenging situations.

• Partnering with you for better outcomes by helping your patients tolerate curative treatment.

Palliative Care…improves the quality of life

…through the prevention and relief of suffering

…early identification and

impeccable assessment and treatment

of pain and other problems,

physical, psychosocial and spiritual WHO

2002

Suffering

Old Man in Sorrow

(On the Threshold

Of Eternity)

Vincent van Gogh, 1890

…impeccable assessment…

• Inquiry

• Active listening

• Reflection statements

Why Skill at Assessment is Important

• Patient/family/caregivers expect relief of suffering

• Develops a therapeutic relationship

• Key diagnostic tool

• Foundation for interdisciplinary care

Scope of practice

• Listen, acknowledge, analyze

• Offer information, practical suggestions

• Introduce sources of support

The Broad Perspective

• A narrow focus on physical pain can miss the patient who is depressed,

• or doesn’t have the money for the pain medicines,

• or is afraid that the pain means that she is going to die

10

Tenants of Assessment

• Find Points of Departure

• Be Severity Aware

• Plan before you pry

• Assume nothing

Tenant: Find Points of Departure

1. Be mentally aware

2. Be at peace with God

3. Not a burden to family

4. Be able to help others

5. Pray

6. Have funeral arrangements planned

7. Not be a burden to society

8. Feel one’s life is completeSteinhauser et al., 2000.

12

Tenant: Be Severity Aware

13

Tenant: Plan Before You Pry…

Tenant: Plan Before You Pry

Jacobson et al., 2013.

• Patients will ask

• Fact clubbing

• Decisional preferences

Tenant: Assume Nothing…

Assessment

Pt/Fam

Disease Mgmt

Physical

Psych

SocialSpiritual

Practical

EOL Worries

Disease Mgmt

• Do patient/family verbalize the dx and px

• Primary dx, Secondary dx & Px

• Co-morbidities

• Adverse events

• Symptoms

• Level of consciousness

• What is the patient’s performance status

• Is he or she safe?

• Fluid and nutrition

• Can the patient see or hear well enough

• Wounds

Physical Issues

• How is the patient responding to being ill

• Personality type / Self Image

• Depression / Anxiety

• Emotions or fears expressed

• Need for Control

• Sense of Dignity

• Conflict tolerance

Psychological & Cognitive

Issues

• Cultural values, beliefs and practices

• Relationship and roles with family, friends, church, community

• Routines and rituals

• Legal- advance directives, will, power of attorney for healthcare and business

• Guardianship issues

• Financial resources

Social Issues

• Intrapersonal, Interpersonal & Transpersonal domains

• Meaning and value of this life

• What comes after this life

• Spiritual advisors

• Rites and rituals

Spiritual Issues

• ADLs / iADLs independent or independent

• Plan for assistance when needed

• Assistive devices available / in use

• Care for pets?

• Transportation?

Practical Issues

• Financial resources

• Legacy creation

• Preparing for expected death

• Last hours expectations

• Legal issues (coroner cases)

• Care of the family

End of Life / Death

Management

• Multiple losses experienced during illness

• Grief-emotional response to loss

• Anticipatory / Acute / Chronic

• Common / Complicated

• Mourning-adaptation to loss

• Bereavement- period after loss

Loss & Grief

25

Pt / Fam

Chaplaincy

Clinical Social Work

Nursing

Pharmacy

Physician

Other

Providing Care

Summary

A comprehensive assessment that includes the issues that cause

patients/families/caregivers suffering guides palliative care