EPECEPECEPECEPEC EPECEPECEPECEPEC Whole Patient Assessment Whole Patient Assessment Module 3 The Project to Educate Physicians on End-of-life Care Supported.
Dec 15, 2015
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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
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