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The EPEC-O TM Education in Palliative and End-of-life Care - Oncology Project The EPEC-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.
EPEC - Oncology Education in Palliative and End-of-life Care - Oncology Module 1 Comprehensive Assessment
Main message • A comprehensive assessment that includes the issues that cause patients suffering guides cancer care
Objectives • Describe conceptions of suffering • Use a framework to guide assessment • Use a validated screening tool, NEST, to facilitate an initial screening assessment • Carry out a detailed assessment of active issues
Why skill at assessmentis important • Patients expect relief of suffering • Key diagnostic tool • Coordinates team of health professionals • Can have therapeutic effects • Develops the physician-patient relationship
The physician’s role • Listen • Acknowledge • Analyze • Offer information, practical suggestions • Introduce sources of support
Conceptions of suffering • Fragmentation of personhood – Cassell • Broken stories – Brody • Challenge to meaning – Byock • Total pain – Saunders
The Nature of Suffering The relief of suffering and the cure of disease must be seen as twin obligations. Failure to understand the nature of suffering can result in medical intervention that (though technically adequate) not only fails to relieve suffering but becomes a source of suffering itself. Eric Cassell, MD
Suffering • Experienced by persons, not bodies • Meaning, Context, Coping • Persons exist in relation to families • Biological, Acquisition, Chosen
The Broad perspective • A narrow focus will miss the target • depression affects experience of pain • medication useless if can’t get it • spiritual strength may enhance tolerance • feeling abandoned may be expressed as physical suffering
Dimensions of illness, bereavement and cancer care • Fixed characteristics of the patient • Modifiable dimensions of the patient’s experience • Healthcare interventions including their associated outcomes
Fixed Patient Characteristics Race, Ethnicity Religion Culture SocioeconomicClass
Culture • A group’s learned, repetitive, characteristic way of behaving, feeling, thinking and being • A strong determinant in attitudes toward health, illness, dying
Respect • Err on the side of formality • Ask, don’t assume
Language • Use interpreters when language barriers exist • Not family members
Modifiable dimensions Spiritual, existential beliefs Loss,grief SymptomsFunction End of life,dying Fixed Characteristics Patient Caregivingneeds Social, issues Psychological,cognitivesymptoms
Health system interventions Decision-making Careplanning Informationsharing Caredelivery Patient
Patient Utilization,errors Pain /symptom relief Qualityof life Satisfaction Outcomes
Efficient assessment • Initial screening • Detailed assessment • Physical examination, tests
Initial screening • Validated questionnaires • NEST • RAI-PC
NEST: 9 areas to screen • Social context Practical Personal Financial • Therapeutic Culture Decision-making • Needs Physical Mental • Existential Personal spirituality Spiritual distress
Detailed assessment • Detailed frameworks in Appendix 1-2 • Assessments throughout EPEC-O • Additional not-validated questions in Appendix 3
Summary A comprehensive assessment that includes the issues that cause patients suffering guides cancer care