The EPEC-O Project

1. The EPEC-O Project Education in Palliative and End-of-life Care – Oncology The EPECTM-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation .

2. EPEC - Oncology Education in Palliative and End-of-life Care - Oncology Module 1 Comprehensive Assessment

3. Overall message • A comprehensive assessment that includes the issues that cause patients suffering guides cancer care.

4. 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

5. Video

6. 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

7. The physician’s role • Listen • Acknowledge • Analyze • Offer information, practical suggestions • Introduce sources of support

8. Conceptions of suffering • Fragmentation of personhood – Cassell • Broken stories – Brody • Challenge to meaning – Byock • Total pain – Saunders

9. 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

10. Suffering • Experienced by persons, not bodies • Meaning, Context, Coping • Persons exist in relation to families • Biological, Acquisition, Chosen

11. 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

12. Dimensions of illness, bereavement, and cancer care • Fixed characteristics of the patient • Modifiable dimensions of the patient’s experience • Health care interventions, including their associated outcomes

13. Fixed Patient Characteristics Fixed Patient Characteristics Race, Ethnicity Religion Culture SocioeconomicClass

14. Culture • A group’s learned, repetitive, characteristic way of behaving, feeling, thinking, and being • A strong determinant in attitudes toward health, illness, dying

15. Respect • Err on the side of formality • Ask; don’t assume

16. Language • Use interpreters when language barriers exist • Not family members

17. Modifiable dimensions Spiritual, existential beliefs Loss,grief SymptomsFunction End of life,dying Patient Caregivingneeds Social issues Psychological,cognitivesymptoms Modifiable Characteristics Fixed Characteristics

18. Factors Impacting Patient and Family Characteristics

19. Health system interventions Decision-making Careplanning Informationsharing Caredelivery Patient Health System Interventions Plus Patient Characteristics…

20. Patient Utilization,errors Pain /symptom relief Qualityof life Satisfaction Outcomes …Impact the Outcomes Experienced

21. Process of providing care

22. Efficient assessment • Initial screening • Detailed assessment • Physical examination, tests

23. Initial screening • Validated questionnaires • NEST • RAI-PC

24. NEST: Nine areas to screen • Needs • Physical • Mental • Existential • Personal spirituality • Spiritual distress • Social context • Practical • Personal • Financial • Therapeutic • Culture • Decision-making

25. Detailed assessment • Detailed frameworks in Appendix 1-2 • Assessments throughout EPEC™-O • Additional non-validated questions in Appendix 3

26. Summary A comprehensive assessment that includes the issues that cause patients suffering guides cancer care.