Physical and Psychological Assesment in Palliative Care

PHYSICAL AND PSHYCOLOGICAL
ASSESSMENT IN PALLIATIVE CARE

-Ns. Nur Fithriyanti Imamah, MBA-
Fe Ai Ma
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PAIN

PAIN (PREVALENCE)
 Most pain can be palliated, and patients can be relatively pain
free.
 However, evidence demonstrates that pain is undertreated in the
palliative care setting, contributing significantly to patient
discomfort and suffering at the end of life.
 Studies suggest that as many as 30% of newly diagnosed cancer
patients, 40% of those undergoing treatment, and 75% of those in
the terminal phase of disease have unrelieved pain.2–9
 One study reported that more than 50% of cancer patients have
increased suffering requiring sedation in the last days of life.9

PAIN (DEFINITION)
According to the International Association for the
Study of Pain (IASP), pain is defined as “an
unpleasant sensory or emotional experience
associated with tissue damage.”
Pain has also been clinically defined as “whatever
the experiencing person says it is, existing
whenever the experiencing person says it does.”22

PAIN (ACUTE VS CHRONIC)

 Acute pain is usually chronic or persistent pain worsens and
intensifies with the passage of time, lasts for an
associated with tissue extended period (months, years, or a lifetime),
and adversely affects the patient’s function or
damage, inflammation, a well-being.24
disease process that is  Chronic pain has been further subclassified into
chronic malignant and chronic nonmalignant
relatively brief, or a surgical pain. Chronic pain may accompany a disease
process such as cancer, human
procedure. Regardless of its immunodeficiency virus (HIV) infection and
intensity, acute pain is of acquired immune deficiency syndrome (AIDS),
arthritis or degenerative joint disease,
relatively brief duration: osteoporosis, chronic obstructive pulmonary
disease, neurological disorders (e.g., multiple
hours, days, weeks, or a few sclerosis, cerebrovascular disease),
months.23 fibromyalgia, sickle cell disease, cystic fibrosis,
and diabetes.
PAIN
The Agency for Health Care Policy and Research (AHCPR) Acute and Cancer
Pain Practice Guidelines recommends the following “ABCDE” mnemonic list
as a summary of the clinical approach to pain assessment and management:
 A—Ask about pain regularly. Assess pain systematically.
 B —Believe the patient and family in their reports of pain and what
relieves it.
 C —C hoose pain control options appropriate for the patient, family, and
setting.
 D —Deliver interventions in a timely, logical, and coordi- nated fashion.
 E —Empower patients and their families. Enable them to control their
course to the greatest extent possible.

PAIN

PAIN

PAIN

PAIN

PAIN

PAIN

PAIN

PAIN (TYPES)

Pain in End-of Life (Non Pharmacological Therapies)
cognitive–behavioral
techniques Physical measures
• relaxation, guided • massage,

imagery, music, reflexology, heat,
prayer, and chiropractic and
reframing other techniques

PAIN (Misconceptions)

PAIN (Management in Palliative)

PAIN (OUTCOMES)

Pain in End-of Life (Documentation)
 Initial assessment, including findings from the comprehensive pain
assessment; the current pain management regimen; prior experience with
pain and pain control; patient and caregiver understanding of expectations
and goals of pain management; elaboration of concerns regarding opioids;
and a review of systems pertinent to analgesic use, including bowels,
balance, memory, function, etc.
 Interdisciplinary progress notes, including ongoing findings from recurrent
pain assessment; baseline pain scores; breakthrough pain frequency and
severity with associated causes and timing of episodes; effect of pain and
pain treatment on function, sleep, activity, social interaction, mood, etc.;

Case Study
Paul is an 88-year-old man with prostate cancer metastatic to the bone
that is unresponsive to hormonal manipulation, chemotherapy, and
radiation therapy. Paul has new left hip and low back pain; a recent bone
scan shows widespread metastatic disease. Paul’s past medical history
includes arthritis and stroke with residual left-sided weakness. Paul has
had difficulty walking due to increased pain and disuse syndrome due to
his previous stroke. He recently fell and is now bedridden. It is extremely
uncomfortable for him to be moved from side to side because of the
pain. He also has a stage II pressure ulcer on his coccyx that seems to be
worsening.
Case Study
Paul describes his pain as achy, throbbing, and gnawing as he points to his left hip
and lower back. He rates his persistent pain as a 4 (on a scale of 0 to 10), worsening
to an 8 with movement and activity. His pain has interfered with his ability to sleep
throughout the night and with his movement; his appetite has decreased
significantly over the past month, and he has had some constipation. Paul’s family is
concerned about his taking pain medication because of fears of dependence and
side effects (constipation, sedation). Paul is a stoic man who does not openly
complain about pain to his wife, daughters, nurses, or doctor. He does not want to
be a burden on his family, and realizes his prostate cancer is incurable. He has
accepted hospice care.

Case Study
1. What type of pain is Paul experiencing?
2. How do you know he is having pain?
3. What pharmacological approaches would you suggest?
4. What nonpharmacological strategies would you
incorporate into the pain management plan?
5. What other symptoms or side effects would you be
concerned about?
FATIGUE

FATIGUE (DEFINITION)
Fatigue is a devastating symptom that deserves the same attention that pain and
other well recognized symptoms of chronic illness receive. Fatigue is the symptom
that has the greatest potential for hindering the optimism of patients that they
will one day be well again.1
The National Comprehensive Cancer Network (NCCN) Fatigue Practice Guidelines
Panel defines fatigue as “an unusual, persistent, subjective sense of tiredness
related to cancer or cancer treatment that interferes with usual functioning.”3
The multiple sclerosis panel defined fatigue as a subjective lack of physical and/or
mental energy perceived by individuals that interferes with usual and desired
activities.4

“a complex, changing state of exhaustion that at times
seems to be a physical condition, at other times a mental
state, and still other times to be a combination of physical
and mental tiredness.”9
Fatigue was expressed by the children as being tired, not
sleeping well, and not being able to do the things they
wanted to do.

1. typical tiredness (normal ebb and flow of energy)
2. treatment fatigue (energy loss greater than
replenishment)
3. shutdown fatigue (profound, sustained loss of
energy).10

FATIGUE (PREVALENCE)
1. Of note, 11% to 25% of patients present with chronic fatigue as
their chief complaint in primary care settings.15 Of these, 20%
to 45% will have a primary organic cause and 40% to 45% will
have a primary psychiatric disorder diagnosed.
2. The prevalence of fatigue in children is difficult to gauge from
the general lack of research, but one study in 75 school-aged
children receiving cancer treatments reported a prevalence rate
of 50%.18

Factors Influencing Fatigue
Personal Factors Disease-Related Factors
 Age (youth vs. aged)  Anemia
 Marital status (home demands)
Menopausal status
 Stage of disease/presence of
metastases Pain
 Psychosocial factors (depression,
fear, anxiety, unfinished business,  Sleep patterns/interruptions
unresolved family/friend conflicts,  Permanent changes in energy
unmet goals)
“new normal” Continency
 Culture/ethnicity Income/insurance
Physical living situation Spiritual  Cachexia Dyspnea
factors

Factors Influencing Fatigue
Treatment-Related Factors Care Factors
 Radiation related side effects (skin  Number/cohesiveness of
reaction, urinary or bowel changes,
caregivers
temporary altered energy level,
temporary increase in physical  Commitment of doctor/nurse
demands) (involvement and availability
 Medication side effects (nausea,
vomiting, diarrhea, weight loss or
gain, taste changes)
 Permanent physiologic
consequences (altered energy or
sleep pattern)
Case Study
Mrs. Patterson is a 65-year-old retired postal inspector. She attends
night school, taking economics and international business classes,
plays golf a couple of times a week, and has a rigorous walking
routine for exercise. She was recently diagnosed with stage III breast
cancer, and had surgery and radio- therapy. She participated in a
fatigue study to help identify physiological indicators of fatigue. At
baseline and mid-radiation treatment, her fatigue intensity was “0”
or no fatigue.

Case Study
At the end of treatment, Mrs. Patterson rated her fatigue as an “8,”
severe fatigue. She had been able to play golf 2 weeks before and
had to cut her walking time from 45 minutes to 15 minutes. She was
studying for a test and could not comprehend what she had read.
When she sat and read, she would fall asleep. She used to watch her
husband fall asleep while reading shortly before he died. He had
non–small-cell lung cancer and died 2 years ago. His tendency to fall
asleep like that was incomprehensible to her until now.

Case Study
At 2 months’ post-radiation therapy, Mrs. Patterson rated her
fatigue as a “9.” She was forcing herself to attend night classes, two
evenings a week from 7 to 10 pm. When not in school, she would go
to bed between 8 and 9 pm and wake up in the morning between 5
and 6 am. She was also taking 2 1⁄2-hour naps every day. She started
to play golf again once a week, but was exhausted after only nine
holes. She continued to walk but not as far or as long as before. She
received a B on her exam (previously a straight-A student), but felt
her concentration was improving.
Case Study
One month later, Mrs. Patterson was contacted by phone at home.
She was obviously short of breath, but remarked that she had just
crawled up the side of a hill where she had been installing a
sprinkler system for her flowers. On further discussion, she reported
that her family and friends had been commenting on her shortness
of breath for weeks. She never really gave it much thought, except
that she was still quite fatigued.

FATIGUE (ASSESSMENT)

FATIGUE (ASSESSMENT)

FATIGUE
(ASSESSMENT)

FATIGUE (MANAGEMENT)



Anorexia and Cachexia
DEFINITION
Anorexia, the “lack or loss of appetite, resulting in the
inability to eat,” and resulting weight loss are common in
many illnesses.1
Unchecked, anorexia (or decreased nutritional intake from
other causes such as lack of available food) leads to
protein calorie malnutrition (PCM) and weight loss,
primarily of fat tissue but also of lean muscle mass.

DEFINITION
The word “cachexia” is derived from the Greek kakos, meaning bad,
and hexis, meaning condition. Cachexia is defined as a state of
“general ill health and malnutrition, marked by weakness and
emaciation”.
In contradistinction to anorexia or starvation, in cachexia, there is
approximately equal loss of fat and muscle, significant loss of bone
mineral content, and no response to nutritional supplements or
increased intake.

PREVALENCE
1. Anorexia common among patients with advanced
cancer and acquired immune deficiency syndrome
(AIDS).3,5
2. Cachexia occurs in more than 80% of patients with
cancer before death and is the main cause of death in
more than 20% of such patients

MECHANISM &
EFFECTS

ASSESSMENT

ASSESSMENT
The following laboratory values are of significance in ACS15:
 Serum albumin is influenced by a number of stressors, such as infection,
hydration, and kidney or liver disease, and hence is not an accurate measure
of nutritional status. Decreased serum albumin is prognostic of increased
morbidity and/or mortality.
 Serum thyroxin-binding prealbumin (transtyretin) levels are indicative of
visceral protein stores and nutritional status. Decreased levels indicate
undernutrition.
 Changes in other laboratory values, such as electrolyte and mineral levels, may
also show changes in nutritional status.

INTERVENTION
 (Exogenous) Symptom Management
The presence or absence of symptoms that may cause or contribute to anorexia and weight loss
should be evaluated.
 Nutritional Support
Nutritional support, especially oral, to increase intake overall or to maximize nutritional content may
be helpful to some extent, especially early in the disease process.4,15. In some cases, certain
traditional foods may be thought especially nutritious and some foods with good nutritional content,
harmful. Small meals, on the patient’s schedule and according to the taste and whims of the patient,
are helpful, at least emotion- ally, and should be instituted early in the illness so that eating does not
become burdensome. Foods with different tastes, textures, temperatures, seasonings, degrees of
spiciness, degrees of moisture, and colors. Oral care may be considered an integral part of nutritional
support. Hygiene and management of any oral pain are essential in nutritional support.

INTERVENTION
Enteral feeding (via nasoenteral tube, gastrostomy, jejunostomy) is
indicated in a few terminally ill patients, including those with weight
loss due to, or exacerbated by, fistulas, mechanical bowel
obstruction, dysphagia, odynophagia, vomiting, or malabsorption
due to tumor or treatment. For short-term feeding (< 4 weeks),
naso-enteral feeding is commonly used, while for long-term enteral
feeding (> 4 weeks), gastrostomy or jejunostomy is the preferred
means.20

INTERVENTION
The primary sources of nutrients are usually as follows:
Calories from carbohydrates
Protein from casein or whey
Fat from triglycerides or vegetable oils
Various nutrients (fish oil, glutamine, arginine, and RNA
are sometimes added)

Case Study
A 58-year-old woman with a diagnosis of advanced cervical
carcinoma was cared for at home by family and the services of a
home care agency. Despite careful symptom management and
nutritional support, she continued to lose weight and suffer from
increasing weakness and fatigue. She had refused several
opportunities for inpatient treatment, but when she developed
fever, diarrhea, and dehydration, she agreed to go to the hospital.

Case Study
 Within several hours of admission, she became agitated and disoriented. Her
condition deteriorated rapidly; she developed chest pain and became
extremely fearful and paranoid, and she began hallucinating. She was started
on intravenous haloperidol with little effect. A consulting psychiatrist, called
from the emergency department, determined that she was experiencing acute
alcohol withdrawal.
 Although the patient and family had previously denied alcohol use, when
confronted with her deteriorating condition, the family admitted that the
patient was a heavy drinker.

Case Study
She was switched to intravenous diazepam and within several days
was lucid. She also was septic, requiring hospitalization for 6 weeks
for treatment of her sepsis and nutritional status. In the 3rd week,
she began to gain weight. She continued to gain weight throughout
the hospitalization and experienced a slight increase in strength.
Within a few weeks of discharge, she, unfortunately, began losing
weight, and it was clear that she was again drinking. She died in an
emaciated state at home several months later.

What’s Different?
ANOREXIA CACHEXIA

ANSWER
 Anorexia is characterized by decreased appetite that may result
from a variety of causes (including unmanaged symptoms such as
nausea and pain), it results primarily in loss of fat tissue, and
resultant weight loss is reversible.
 Cachexia is a complex metabolic syndrome thought to result from
the production of pro-inflamatory cytokines such as TNF and IL-1.
In cachexia, there is approximately equal loss of fat and muscle
and significant loss of bone mineral content. Weight loss from
cachexia does not respond to nutritional interventions.
ANXIETY & DEPRESSION
PREVALENCE
 Acute stress is a common response to the diagnosis of a life-threatening
chronic illness that occurs at transitional points in the disease process
(beginning treatment, recurrence, treatment failure, disease progression).7
The response is characterized by shock, disbelief, anxiety, depression, sleep
and appetite disturbance, and difficulty performing activities of daily living.
 Patients who are diagnosed with late- stage disease or have aggressive
illnesses with no hope for cure are often most vulnerable to psychological
distress, particularly anxiety, depression, family problems, and physical
discomfort

DEVELOPMENT
 During the diagnostic period, patient concerns focus on existential issues of life and death more
than on concerns related to health, work, finances, religion, self, or relationships with family and
friends.
 Development of a recurrence after a disease is a difficult one, during which patients may also
experience pessimism, renewed preoccupation with death and dying, and feelings of helplessness
and disenchantment with the medical system. Patients tend to be more guarded and cautious at
this time and feel as if they are in limbo. The point of recurrence was found to be the most
distressing time, with an increase in depression, anxiety, and suicidal ideation.
 Once the terminal period has begun, it is usually not the fact of dying but the quality of dying that
seems to be the over- whelming issue confronting the patient and family.21,22 Patients living in
the final phase of any advanced chronic illness experience fears and anxiety related to uncertain
future events, such as unrelieved pain, separation from loved ones, burden on family, and loss of
control.

ASSESSMENT OF DEPRESSION
 In addition to medical comorbidity, risk factors that favor the development of
a depressive disorder include prior episodes of depression, family history of
depression, prior suicide attempts, female gender, age under 40 years,
postpartum period, lack of social support, stressful life events, personal history
of sexual abuse, and current substance abuse.55
 Patients may see themselves as worth- less and burdensome to family and
friends. Family members may find themselves immobilized, impatient, or
angry with the patient’s lack of communication, cooperation, or motivation.55

FACTORS RELATED

FACTORS RELATED

FACTORS RELATED

SYMPTOMS

SYMPTOMS

SYMPTOMS

MANAGEMENT of ANXIETY and DEPRESSION
Psychosocial interventions can exert an important effect on the overall

adjustment of patients and their families to chronic illness and treatment.78
Several studies document the beneficial effect of counseling on anxiety, feelings

of personal control,79 depression, and generalized psychological distress.80
Increased length of survival from time of diagnosis has highlighted the need for
psychopharmacological, psychotherapeutic, and behaviorally oriented
interventions to reduce anxiety and depression and to improve quality of life for
patients diagnosed with a chronic illness.

INTERVENTIONS

ASSESSMENT OF SUICIDE RISK
 An assessment of depression should always include direct
questions about suicidal thinking, plans or attempts, despair or
hopelessness, distress from poorly managed symptoms, and
personal or family history of suicidal ideation, plans, or
attempts.76
 When any indicator of suicide risk is recognized, risk factors,
clues, suicidal ideation, level of depression, hopelessness and
despair, and symptom distress should be thoroughly evaluated to
estimate individual lethality.
Recognition of Clues
 Suicidal persons usually give verbal and/or behavioral clues, such as isolated or withdrawn
behavior or death wishes or death themes in art, writing, play, or conversation. Clues may be
subtle or obvious, for example, joking about suicide, asking questions concerning death (e.g.,
“How many of these pills would it take to kill someone?”), comments with a theme of giving up, or
statements that indicate hopelessness or helplessness.
 Resistance or refusal of treatments, food, or fluids may indicate suicidal ideation or intent and
require further assessment.74,76 Keys to determining lethality are suicide plan, method, intended
out- come (e.g., death or rescue), and availability of resources and ability to communicate.74,76
 Lethal means include guns, knives, jumping from heights, drowning, or carbon monoxide poison-
ing. Other potentially lethal means include hanging or strangulation (using strong pieces of twine,
rope, electric cords, sheets), taking high doses of aspirin or Tylenol, being in a car crash, or
undergoing exposure to extreme cold. Low to moderately lethal methods are wrist cutting and
mild aspirin overdose.

MANAGEMENT of SUICIDE
 A patient with an immediate, lethal, and precise suicide plan needs strict safety
precautions such as hospitalization and continuous or close supervision. The low-risk
patient should not be underestimated.
 The motivation for suicide can be reduced through palliative care interventions such as
improved pain and symptom management; referral and treatment for depression or
other psychiatric disorders; discussion of alternative interventions to improve quality of
life; referral to spiritual, social, and psychiatric resources; and education and accurate
facts about options for terminal care or end-of-life decision-making.
 Openness to talking about suffering, distress, death prefer- ences, and decision-making
in a sensitive and understanding manner and advocacy to aid communication with
others is helpful for patients and their families.76,77

REFERENCES
American Nurses Association and Hospice and palliative nurses Association.
Palliative nursing: scope and standards of practice-An Essential
Resources for hospice and palliative Nurses. 5th ed. Silver spring, MD:
American Nurses Association and Hospice and palliative Association
2014.
Betty R, Nessa C., Judith A., 2015, oxford Textbook of Palliative Nursing” fourth
Edition, Oxford.
Ferrell, B. R., et al. (2014). Oxford textbook of palliative nursing, Oxford University
Press.


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PHYSICAL AND PSHYCOLOGICAL

ASSESSMENT IN PALLIATIVE CARE

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• relaxation, guided • massage,

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Psychosocial interventions can exert an important effect on the overall

Several studies document the beneﬁcial effect of counseling on anxiety, feelings

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