Transcript bedside symptom assessment common challenges and pitfalls

Dr. Pablo H. Amigo, MD, MCFP
Attending Physician, Tertiary Palliative Care Unit
Grey Nuns Hospital, Covenant Health.
Associate Clinical Professor, Division of Palliative Medicine,
Department of Oncology, University of Alberta
Objectives:
At the end of the presentation, participants will
be able to:
 List factors impacting their ability to assess symptoms
at the bedside .
 Provide strategies for appropriate assessment of
symptoms in their clinical practice.
 Take home strategies that will result in adequate
symptom management.
PAIN ASSESSMENT
Pain assessment:
 Pain is a subjective, complex and multidimensional
experience.
 Gold standard in symptom assessment is patients’ self-
report.
 Health care providers attempt to make a subjective
experience objective using assessment tools, balancing
between burden and clinical information obtained.
 Patients reliability can be compromised in some
circumstances.
Clinical Scenario:
 Mr. Glenn Morangie, 70 year old gentleman with
diagnosis of Prostate Cancer for 8 years.
 Known extensive metastatic deposits to bone in axial
and appendicular skeleton and skull.
 Treated initially with radiotherapy and hormonal
treatment, followed by 8 cycles of chemotherapy.
 Cancer has become hormone-refractory.
 No further oncological treatment options available,
discharged from cancer treatment center recently.
Clinical Scenario (cont’d):
 PMH: Significant for hypertension, Type II Diabetes,
Hypercholesterolemia, Coronary Artery Disease with
AMI in 2009.
 Social history: Widower, lives independently. Has 2
children, one son age 45 living in the U.S and one
daughter age 42 living in Ontario. Has some friends in
town, who are supportive. No religious affiliation,
believes in High Power. No PD or POA.
 Habits: Ex smoker 40 pack/ year, drinker of 6-8 glasses
of alcoholic beverages/ day/ 30 years.
Clinical Scenario (cont’d):
 Assessed at home, with main concern of pain.
 Pain is localized in the back, severity 5/10 at rest and
10/10 with movement, radiates to the buttock and right
leg with “shooting “episodes, tingling and numbness in
the right leg.
 Has developed difficulties with walking in the last
couple of days as his leg “gives up”, and has fallen twice.
 Other symptoms: he also reports tiredness, feeling
sleepy, sadness and “not knowing what to do with
himself”.
Clinical Scenario (cont’d):
 Other assessments: declined assessment of alcohol
abuse and cognition, jokingly talks about having “old
timer`s”, rambles for 15 minutes and is difficult to
redirect.
 On exam: appears thin, skin pallor. BP: 100/ 60, HR:
100 x min, afebrile. Dry mucous membranes. SEM 2/6,
pedal edema with pitting. Liver not palpable, diffuse
pain in abdomen. Weakness in hip flexion right side,
decreased sensation L4-5 dermatome and decreased
patellar reflex on the right side. Pain on palpation of
lumbar spine.
Clinical Scenario (cont’d):
What is the advantage of a
systematic approach to symptom
assessment with validated tools?
•Edmonton Symptom Assessment System-revised
(ESAS-r).
•CAGE questionnaire.
•Folstein’s Mini Mental Status Exam (MMSE).
•Edmonton Classification System-Cancer Pain
(ECS-CP).
•Palliative Performance Status (PPS).
ESAS-r
 Revised version of the original tool.
 Different order for symptoms, with expanded
definitions.
 Easier to understand for patients, preferred by tool
administrators.
 Same 10 items: pain, tiredness, drowsiness, nausea,
lack of appetite, shortness of breath, depression,
anxiety, wellbeing, and other (constipation, etc.)
 Allows the discussions/ better appreciation of
multidimensional aspects of suffering.
Clinical scenario:
 Other ESAS-r scores: tiredness 9/10, drowsiness 8/10,
nausea 5/10, lack of appetite 8/10, shortness of breath
4/10, depression 9/10, anxiety 8/10, wellbeing 9/10,
other: constipation 9/10.
 Multiple elements suggestion “total pain” syndrome.
 Depressed since wife died, anxious about future and
lack of treatment options, fear of loss of independency
and social isolation, does not want to be a burden to
his children.
Steps in the pain experience:
Production (Nociception)
Psychological
Social
Perception
Spiritual
Cultural
Expression
Treatment
Clinical scenario:
 Patient felt that he had to “cut down” alcohol use.
 “Annoyed” by his children’s criticism of his
drinking.
 Has felt “guilty” lately.
 No “eye opener” in the morning.
 CAGE score: 3/4.
Clinical scenario:
 Upon formal assessment of cognition, patient
scores 21/30 on MMSE with expected for age and
education of 26/30.
 Lost points in orientation, recall, drawing.
 Likely multi-factorial (aging process, multiple co-
morbid conditions, smoking, alcohol abuse,
chemotherapy, disease progression?).
 Acute superimposed delirium on dementia?
Clinical scenario:
 Helps identify poor predictors to achieve good pain
control rapidly.
 Presence of neuropathic pain, incident pain,
psychological distress (affecting pain perception and
expression), addictive behavior and cognitive
impairment are poor predictors.
 Patients has them all!! (perfect storm scenario).
PPS:
Clinical scenario:
 Patient’s PPS is 40%.
 Mainly in bed, unable to do most activities, requires
considerable assistance / mainly assistance, reduced
intake, drowsy conscious level.
 Home Care assistance maximized, concerns about
patient’s safety.
 Staying home no longer an option, patient aware and
distressed by this.
Clinical scenario:
 Complex pain syndrome : neuropathic and
incident components.
 Complex patient: older, frail, poor coping skills,
alcohol addiction, psychological distress affecting
patient’s pain perception and expression, cognitive
impairment (?chronic vs. acute or both), declining
functional status.
 Complex social circumstances: socially isolated,
supports maximized, unsafe situation.
Clinical scenario:
 Patient will likely require admission to Tertiary
Center (likely PCU) for symptom control and multidisciplinary support for his “total pain” syndrome.
 Unlikely to return home in view of functional
limitations and little social supports.
 May be appropriate for hospice if physical and
psychosocial symptoms controlled.
Clinical scenario: lessons learned
Tools can help assessing:
 Multidimensional aspects of the pain experience.
 Alcohol addiction/ poor coping skills.
 Cognitive impairment complicating symptom
evaluation.
 Patients who require intensive resources to adequately
control symptoms.
 Poor functional status making patient’s unsafe to
remain at home.
CONSTIPATION
ASSESSMENT
Scope of the problem:
 Common gastrointestinal motility disorder
 12% - 19% of adult population in North America
 23% – 70% of terminally ill patients
1
2,3
 87% of palliative care patients receive laxatives
4
 adds significantly to suffering & burden of care
1. Higgins PD, Johanson JF. Am J Gastroenterol 2004; 99:750
2. Curtis EB, Krech R, et al. J Palliative Care 1991; 7:25
3. Solano JP, Gomes B, et al. J Pain Symptom Manage 2006; 31:58
4. Sykes NP. Palliative Medicine 1998; 12:375
Constipation definitions
 Unsatisfactory defecation
 Infrequent stools
 Difficult stool passage
 Straining
 Sense of difficulty passing stool
 Incomplete evacuation
 Hard/lumpy stools
 Prolonged time to pass stool
 Need for manual maneuvers to pass stool
Thompson W. Gut 1999;45 (Suppl II):II43
Etiologies
 Pre-existing constipation (elderly, poor bowel habits)
 Neurological abnormalities (spinal cord lesions,
autonomic dysfunction )
 Metabolic disorders (Hypothyroidism, uremia,
hypercalcemia, dehydration)
 Structural obstruction (Adhesions, strictures, tumor)
 Decreased food, fiber & fluid intake
 Uncontrolled pain (Increased with straining, inability
to toilet because of pain) .
13
Etiologies
 Limited mobility (exercise has been shown to increase
bowel movements)
 Medications (opioids, tricyclic antidepressants,
anticholinergic drugs, NSAIDs)
 Hypomotility of the bowel (diabetes? postoperative or
paraneoplastic?)
 Generalized weakness/ cachexia/ sarcopenia (limited
ability to empty bowel and/or get to the toilet )
 Environmental issues (lack of privacy)
15
Constipation: challenges
 Patients/ caregivers may not remember last BM.
 Self-perception of constipation may differ from clinical
reality.
 Patient may decrease/ discontinue laxatives due to
“diarrhea” (overflow diarrhea).
 Little correlation between constipation questionnaires
and objective findings.
Constipation score:
 Developed by the Edmonton Palliative Care Program.
 Assessment of fecal loading in the ascending, transverse,
descending and recto-sigmoid bowel.
 Score in each section ranging from 0 to 3 (maximum
12/12).
 0/3: no stool, 1/3: <50% of lumen, 2/3: >50% of lumen,
3/3: full of stool.
 7/12 or less is acceptable.
Bruera et al, JPSM 1994,9:515-519.
37
Constipation: lesson learned
 Clinical assessment can be challenging.
 Patients’ perception may not correspond with clinical
reality.
 No correlation between constipation questionnaires
and objective assessment.
 Abdominal flat plate, if indicated and feasible, can
ascertain clinical situation.
 Bowel routine critical to maintain BM q2 or 3 days
maximum.
The next best thing for our patients?
DYSPNEA
ASSESSMENT
Definition:
“Subjective experience of breathing
discomfort consisting of qualitative distinct
sensations, derived from the interactions
among multiple physiological, psychological,
social, and environmental factors”
American Thoracic Society, 1998
Multidimensional aspects:
1. Production
Mechano-receptors
Chemo-receptors
Respiratory centers
2. Perception
Modulators: Anxiety-depression
Somatization
Opioids
3. Expression
Intrapsychic
Beliefs
Cultural
4. Assessment and Treatment
Ripamonti et al, JPSM 1997;13:220-232
Prevalence:
 National Hospice Study: 70% of the patients in
their last six weeks of life.
 Fainsinger et al: 49.1% of 100 patients admitted
to a Tertiary PC Unit.
 Dudgeon et al: 46% of the general cancer
population in a regional cancer center.
Assessment Tools:
 Most used in non cancer patients with chronic
dyspnea.
 No single tool takes into account all the different
components of dyspnea.
 Choice of tool according to the purpose of the
assessment.
 Should not worsen patient’s QOL (burdensome,
complicated tools).
 VAS, NRS, VRS-D: useful in daily assessment and
assessment of therapies.
Mancini et al, Supp Care Cancer (1999) 7:229-232
Dyspnea:
 No correlation with respiratory effort (use of accessory
muscles, respiratory rate, laboured breathing,
presence of respiratory secretions, tachypnea, etc)
 No correlation between dyspnea and objective
measurements (PFT, oxygen saturation, Chest X-Ray).
 Patients under Midazolam sedation or comatose can
not experience dyspnea, as per the definition!
Opioids:
 Mainstay of the treatment of dyspnea since
the late nineteenth century.
 Respiratory depression potential recognized in
1950.
 Physicians reluctant to prescribe opioids ever
since.
 Respiratory depression from opioids: depends
on the rate of change of the dose, previous
opioid exposure and route of administration.
Sometimes it’s not our fault.......
Dyspnea assessment: lessons
 Subjective and multidimensional experience!
 No correlation with anything we can measure or
objectively assess.
 Ignore what you see, listen to what the patient
says!
 If a patient is sedated pharmacologically or in a
comatose state, can’t experience dyspnea.
Summary:
 Self-report is the gold standard of symptom
assessment in Palliative Care, however in some
situations patient’s perception may be unreliable.
 Validated tools can help assess the multidimensional
elements of patients’ suffering.
 Investigations , when indicated, can yield relevant
information in symptom assessment.
 Objective findings sometimes are not helpful to assess
patients’ discomfort.
QUESTIONS?
THANK YOU