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second level
third level
fourth level
fifth level
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le
E
C
Module 3:=
Whole
Patient Assessment
© EPEC Project, 2003
Permission to reproduce for educational purposes granted
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![](3D"master09_background.gif")
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E
P
E
C
P
E
C
Whole Patient Assessment
Module=
3
![](3D"master08_background.gif")
![](3D"master08_image003.gif")
Objectives
<=
span
style=3D'font-weight:normal'>§=
disease
history
§=
physical
symptoms
=
§psychological symptoms
§d=
ecision-making
capacity
<=
span
style=3D'font-weight:normal;visibility:hidden'>§
§information sharing
<=
span
style=3D'font-weight:normal'>§=
social
<=
span
style=3D'font-weight:normal'>§=
spiritual
<=
span
style=3D'font-weight:normal'>§=
practical
§=
anticipatory
planning for death•Know
how to identify, assess
Why skill at assessment
is important
is important
<=
span
style=3D'font-weight:normal'>•Patients expect relief=
of
suffering
The physician’s role
9 dimensions
of assessment
of assessment
l=
1. Illness / treatment summary
2. Physical &#=
13;
3.
Psychological
4. Decision
making
5. Communicati=
on
6. Social
=
7. Spiritual&#=
13;
8. Practical&#=
13;
9. Anticipator=
y planning
for deathIllness /
treatment summary
treatment summary
<=
span
style=3D'font-weight:normal'>•Secondary concurrent
illnesses
Physical assessment
Common symptoms
<=
span
style=3D'font-weight:normal'>•Pain
<=
span
style=3D'font-weight:normal'>•Weakness / fatigue
=
;
<=
span
style=3D'font-weight:normal'>•Breathlessness
<=
span
style=3D'font-weight:normal'>•Insomnia
<=
/div>
<=
span
style=3D'font-weight:normal'>•Weight loss
<=
span
style=3D'font-weight:normal'>•Confusion
=
<=
span
style=3D'font-weight:normal'>•Constipation
<=
span
style=3D'font-weight:normal'>•Anxiety
<=
span
style=3D'font-weight:normal'>•Nausea / vomiting
=
<=
span
style=3D'font-weight:normal'>•Depression
Symptoms – causes
•M=
ultiple
causes
the primary illness
an effect of therapy
psychological, social, spiritual, practical issues
another medical condition
Pain as a model for
symptom assessment
symptom assessment
Pain assessment
•Location (1°, referral
pattern)
Module 3
• Motor function
• Sensory function
<=
/span>
• Effect on activities&#=
13;
• Effect on
relationships
• Patient perspectives <=
/span>
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Module 3
• Avoidance, denial
=
;
• Fear, anger
• Lability,
irritability
• Intellectualization=
3;
• Grief
• Acceptance, spiritual
peace
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Module 3
• Loss of control,
dignity
• Loss of relationships&=
#13;
• Being a burden
• Physical suffering
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Module 3
• Old feuds
<=
/div>
• Last visits
• Lifetime project, piec=
e of
work
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Module 3
• Capacity / competence&=
#13;
• Goals of care
• Advance care planning&=
#13;
• Informed consent
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Module 3
• Global incompetence=
3;
• Decision-specific capa=
city
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Module 3
• Understand authorizati=
on
role
•Rational use of
information, including risk, uncertainty
• Insight into
consequences
• Noncoerced
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Module 3
• Who else to talk to=
3;
• Limits of
confidentiality
• Is language an issue?<=
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Module 3
• Family, family
dynamics
• Community
<=
/div>
• Environment
• Financial
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Module 3
• Culture
• Sources of assistance&=
#13;
• Religious
=
• Disease groups
• Local
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Module 3
• Spending down
• Medical bills
• Family sacrifice
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Module 3
• From community
• From health system
(chaplain)
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Module 3
• Special prayers,
actions
• Last prayers, declarat=
ions
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Module 3
• Questioning of faith&#=
13;
• Desire for
forgiveness
• Sense of abandonment by
God
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Module 3
• Caregivers
=
• Domestic needs
• Dependents
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Module 3
• Who?
• At what sacrifice?
=
;
• Comfortable
relationship?
• Unmet needs?
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Module 3
• Dependents
=
• Children
<=
/div>
• Elders
• Infirm
• Pets
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Module 3
• Current losses
• Anticipated losses
=
;
• Advance care planning&=
#13;
•Advance planning for l=
ast
hours and after death
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<=
span
style=3D'font-weight:normal'>•Quality
• Impact on function
=
;
•Effect of treatments
•Patient perspectives
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<=
span
style=3D'font-weight:normal'>•Timing
<=
span
style=3D'font-weight:normal'>•Severity
<=
/div>
<=
span
style=3D'font-weight:normal'>•Radiation
<=
span
style=3D'font-weight:normal'>•Modifying factors
=
Function
Psychological assessment
. . .
•C=
ognition
delirium, dementia
•A=
ffect
anxiety, depression
•E=
motions
prompted by the life-threatening illness
. .
. Psychological asses=
sment
•C=
oping
responses
suicidal ideation
•F=
ears
loss of control, burden, abandonment, indignity
•U=
nresolved
issues
Emotional
responses to illness
responses to illness
Fears
Unresolved issues
Decision-making assessment
Decision-making capacity
Decision-specific capacity
Communication assessment
. . .
•Is
there someone to share fears with? talk to? plan with?
•Is
the information clear? understandable?
•W=
hat
the patient wants to know
child’s parents
. .
. Communication asses=
sment
Social assessment
Community
Financial
Spiritual assessment
•M=
eaning,
value – personal, of the illness
burden, control, independence, dignity
•F=
aith
•R=
eligious
life, spiritual life
•P=
astor
Spiritual activities
•Religious
denomination (past or present)
• Activity level
• Prayer / scriptural
resources
Pastors
Rituals
Spiritual crises . . .
•Search
for meaning or purpose in one’s life
• Loss of a sense of
connection
<=
span
style=3D'font-weight:normal'>•Feelings of guilt or
unworthiness
. . .
Spiritual crises
<=
span
style=3D'mso-special-format:lastCR;display:none'>
Practical assessment
Caregiver
Domestic needs
•C=
hores
of day-to-day living
cooking
cleaning
shopping
banking
bill payment
•T=
ransportation
Family
Anticipatory
planning for death
planning for death
End of Mo=
dule
3
Review Fast
Facts
Then Complete
Module 3 Post Q=
uiz
‹header›
‹date/time&=
#8250;
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‹#›
Conducting a comprehensive patie=
nt
assessment of suffering is important for physicians because the relief of
suffering is a fundamental goal of medicine.
Patient assessment in the end of=
life
care differs from other clinical assessments in that its goal is to permit
relief from suffering. Effective implementation of management strategies to
relieve suffering must be based on a comprehensive assessment of the whole
patient. Assessments must recognize that patients’ experiences of
illness is multidimensional; such as disease history, physical symptoms,
psychological/emotion responses, decision-making capacity, information
sharing, social circumstances, spiritual needs, practical needs and
anticipation of death.
The assessment process can be a
therapeutic tool. Besides giving the physician information, the physician =
can
discuss with the patient or proxy the meaning of the information and his or
her assessment of the patient’s situation. This can help convey spec=
ifics
about the prognosis and need for advance planning. Of equal importance, the assessme=
nt
conveys compassion; it initiates the physician’s therapeutic role.
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lide0006.htm",1,-1,1),new hrefList("slide0007.htm",1,-1,1),new hrefList("sl=
ide0039.htm",1,-1,1),new hrefList("slide0009.htm",1,-1,1),new hrefList("sli=
de0010.htm",1,-1,1),new hrefList("slide0040.htm",1,-1,1),new hrefList("slid=
e0012.htm",1,-1,1),new hrefList("slide0013.htm",1,-1,1),new hrefList("slide=
0041.htm",1,-1,1),new hrefList("slide0014.htm",1,-1,1),new hrefList("slide0=
015.htm",1,-1,1),new hrefList("slide0016.htm",1,-1,1),new hrefList("slide00=
17.htm",1,-1,1),new hrefList("slide0018.htm",1,-1,1),new hrefList("slide001=
9.htm",1,-1,1),new hrefList("slide0020.htm",1,-1,1),new hrefList("slide0042=
.htm",1,-1,1),new hrefList("slide0021.htm",1,-1,1),new hrefList("slide0022.=
htm",1,-1,1),new hrefList("slide0023.htm",1,-1,1),new hrefList("slide0024.h=
tm",1,-1,1),new hrefList("slide0026.htm",1,-1,1),new hrefList("slide0027.ht=
m",1,-1,1),new hrefList("slide0028.htm",1,-1,1),new hrefList("slide0029.htm=
",1,-1,1),new hrefList("slide0043.htm",1,-1,1),new hrefList("slide0031.htm"=
,1,-1,1),new hrefList("slide0032.htm",1,-1,1),new hrefList("slide0033.htm",=
1,-1,1),new hrefList("slide0034.htm",1,-1,1),new hrefList("slide0035.htm",1=
,-1,1),new hrefList("slide0046.htm",1,-1,1));
/*********************************************
Frameset functions
These functions control slide navigation
and state of the frameset.
**********************************************/
function FullScrInit()
{
g_allowAdvOnClick =3D GetCurSld().mAdvOnClk
document.body.style.backgroundColor=3D"black"
document.oncontextmenu=3Dparent._CM;
document.onkeydown =3D _KDH;
document.ondragstart=3DCancel
document.onselectstart=3DCancel
self.focus()
}
function Redirect( frmId )
{=09
var str=3Ddocument.location.hash,idx=3Dstr.indexOf('#'), sId=3DGetSldId()
if(idx>=3D0) str=3Dstr.substr(1);
if( window.name !=3D frmId && ( sId !=3D str) ) {
obj =3D GetObj("Main-File")
window.location.href=3Dobj.href+"#"+sId
return 1
}
return 0
}
var MHTMLPrefix =3D CalculateMHTMLPrefix();=20
function CalculateMHTMLPrefix()
{
if ( document.location.protocol =3D=3D 'mhtml:') {=20
href=3Dnew String(document.location.href)=20
Start=3Dhref.indexOf('!')+1=20
End=3Dhref.lastIndexOf('/')+1=20
if (End < Start)=20
return href.substring(0, Start)=20
else=20
return href.substring(0, End)=20
}
return '';
}
function GetTags(base,tag)
{
if(g_supportsPPTHTML) return base.all.tags(tag);
else return base.getElementsByTagName(tag);
}
function UpdNtsPane(){ if(frames["PPTNts"]) PPTNts.location.replace( MHTMLP=
refix+GetHrefObj( gCurSld ).mNtsHref ) }
function UpdNavPane( sldIndex ){ if(gNavLoaded) PPTNav.UpdNav() }
function UpdOtNavPane(){ if(gOtlNavLoaded) PPTOtlNav.UpdOtlNav() }
function UpdOtlPane(){ if(gOtlLoaded) PPTOtl.UpdOtl() }
function SetHasNts( fVal )
{
if( gHasNts !=3D fVal ) {
gHasNts=3DfVal
UpdNavPane()
}
}
function ToggleOtlText()
{
gOtlTxtExp=3D!gOtlTxtExp
UpdOtlPane()
}
function ClearMedia()
{
// Clear any sounds playing before launching another browser window. Other=
wise,
// in fullscreen mode, you'll continue to hear the sound in the frames mod=
e.
if (PPTSld.pptSound) PPTSld.pptSound.loop =3D 0;
}
function FullScreen()
{=20
if ( PPTSld.g_animUseRuntime )
PPTSld.document.body.pause();
ClearMedia();
var href =3D ( document.location.protocol =3D=3D 'mhtml:') ? FULLSCR_HREF =
: FULLSCR_HREF+"#"+GetHrefObj(gCurSld).mSldHref;
if(PPTNav.event.ctrlKey) {
var w =3D (window.screen.availWidth * 1.0) / 2.0
var h =3D w * (PPTSld.g_origH * 1.0) / PPTSld.g_origW
win =3D window.open( MHTMLPrefix+href,null,"toolbar=3D0,resizable=3D1,top=
=3D0,left=3D0," + "width=3D"+ w + ",height=3D" + h );
if( win.document.body && PPTSld.g_animUseRuntime )
win.document.body.PPTSldFrameset=3Dwindow;
}
else
{
win =3D window.open( MHTMLPrefix+href,null,"fullscreen=3Dyes" );
if( win.document.body && PPTSld.g_animUseRuntime )
win.document.body.PPTSldFrameset=3Dwindow;
}
}
function ToggleVNarration()
{
rObj=3DPPTSld.document.all("NSPlay")
if( rObj && !PPTSld.g_animUseRuntime ) {
if( (rObj.playState =3D=3D 1)||(rObj.playState =3D=3D 0) )
rObj.Play()
else if( rObj.playState =3D=3D 2 )
rObj.Pause()
else
return;
}
else if( PPTSld.g_animUseRuntime )
{
narObj =3D PPTSld.document.all("narrationID")
if( narObj )
narObj.togglePause()
}
}
function GetCurSldNum()
{ =20
obj=3DGetHrefObj(gCurSld)
if( obj.mOrigVis =3D=3D 1 )
return obj.mSldIdx
else =20
return gCurSld
}
function GetNumSlds()
{ =20
if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 )
return GetSldList().mNumVisSlds;
else
return GetSldList().mList.length
}
function GetSldNum( href )
{
for(ii=3D0; ii 1 )
PopSldList();
else if( !IsFramesMode() ) {
if( gLoopCont )
GoToFirst()
else
EndShow()
}
}
function GoToPrevSld()
{
ii=3DgCurSld-1
if( ii > 0 ) {
obj=3DGetHrefObj(ii)
while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) )
obj=3DGetHrefObj(--ii)
if( ii =3D=3D 0 ) ii=3D1
GoToSldNum(ii)
}
}
function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) }
function GoToLast()
{
ii=3DGetSldList().mList.length
if( ii !=3D gCurSld )
GoToSld( GetHrefObj(ii).mSldHref )
}
function GoToSldNum( num )
{
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
obj =3D GetHrefObj( num )
obj.mVis=3D1
gPrevSld=3DgCurSld
gCurSld =3D num;
PPTSld.location.replace(MHTMLPrefix+obj.mSldHref)
if( IsFramesMode() ) {
UpdNavPane(); UpdOtlPane(); UpdNtsPane()
}
}
function GoToSld( href )
{
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
GetHrefObj( GetSldNum(href) ).mVis=3D1
PPTSld.location.replace(MHTMLPrefix+href)
}
function SldUpdated( id )
{
if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return
gPrevSld=3DgCurSld
gCurSld=3DGetSldNum(id)
if( IsFramesMode() ) {
UpdNavPane(); UpdOtlPane(); UpdNtsPane()
}
}
function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) }
function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO=
bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) }
function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) }
function CloseWindow() {
if( HideMenu() ) return;
=09
var event =3D PPTSld.event;
if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D=
=3D32 || event.type=3D=3D"click" ) )
window.close( self );
CatchNumKeys( self, event );
}
function Unload() { gIsEndShow=3D0; }
function SetupEndShow() {
gIsEndShow=3D1;
PPTSld.document.body.scroll=3D"no";
PPTSld.document.onkeypress=3DCloseWindow;
PPTSld.document.onclick=3DCloseWindow;
PPTSld.document.oncontextmenu=3D_CM;
}
function EndShow()
{
if( IsFramesMode() ) return
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
doc=3DPPTSld.document
var dir =3D doc.body.dir
if( dir !=3D "rtl" ) dir =3D "ltr";
doc.open()
doc.writeln(' 0) {
PushSldList(sldList,fEnd);
gCurSld =3D 1;
}
else
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
}
function PushSldList(arr,fEnd) {
var ii =3D gSldStack.length;
gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd);
GoToSld( gSldStack[ii].mList[0].mSldHref );
}
function PopSldList() {
if (gSldStack[gSldStack.length-1].fEndShow)
EndShow()
else {
gCurSld =3D gSldStack[gSldStack.length-1].mCurSld;
gSldStack[gSldStack.length-1] =3D null;
gSldStack.length--;
var sldList =3D gSldStack[gSldStack.length-1];
GoToSld( sldList.mList[gCurSld - 1].mSldHref );
}
}
var custShowList=3Dnew Array();
/*********************************************
Navigation button implementation
There are 2 types of buttons: ImgBtn, TxtBtn
implemented as function objects. They share
a similiar interface so the event handlers
can call SetActive, for example, on a button=20
object without needing to know exactly=20
what type of button it is.
**********************************************/
//----------------------------------
function ImgBtn( oId,bId,w,action )
//----------------------------------
{
var t=3Dthis
t.Perform =3D _IBP
t.SetActive =3D _IBSetA
t.SetInactive=3D _IBSetI
t.SetPressed =3D _IBSetP
t.SetDisabled=3D _IBSetD
t.Enabled =3D _IBSetE
t.ChangeIcon =3D null
t.UserAction =3D action
t.ChgState =3D _IBUI
t.mObjId =3D oId
t.mBorderId=3D bId
t.mWidth =3D w
t.mIsOn =3D t.mCurState =3D 0
}
function _IBSetA()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 )
obj.style.posTop=3D0
}
}
function _IBSetI()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 )
obj.style.posTop=3D0=20
}
}
function _IBSetP()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 )
obj.style.posLeft+=3D1; obj.style.posTop+=3D1
}
}
function _IBSetD()
{ =20
obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 )
obj.style.posTop=3D0=20
}
function _IBSetE( state )
{
var t=3Dthis
GetObj( t.mBorderId ).style.visibility=3D"visible"
if( state !=3D t.mIsOn ) {
t.mIsOn=3Dstate
if( state )
t.SetInactive()
else
t.SetDisabled()
}
}
function _IBP()
{
var t=3Dthis
if( t.mIsOn ) {
if( t.UserAction !=3D null )
t.UserAction()
if( t.ChangeIcon ) {
obj=3DGetObj(t.mObjId)
if( t.ChangeIcon() )
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth
else
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth
}
t.SetActive()
} =20
}
function _IBUI( clr1,clr2,nextState )
{
var t=3Dthis
SetBorder( GetObj( t.mBorderId ),clr1,clr2 )
obj=3DGetObj( t.mObjId )
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj=
.style.posTop
t.mCurState=3DnextState
return obj
}
//-----------------------------------------
function TxtBtn( oId,oeId,action,chkState )
//-----------------------------------------
{
var t=3Dthis
t.Perform =3D _TBP
t.SetActive =3D _TBSetA
t.SetInactive=3D _TBSetI
t.SetPressed =3D _TBSetP
t.SetDisabled=3D _TBSetD
t.SetEnabled =3D _TBSetE
t.GetState =3D chkState
t.UserAction =3D action
t.ChgState =3D _TBUI
t.mObjId =3D oId
t.m_elementsId=3D oeId
t.mIsOn =3D 1
}
function _TBSetA()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gHiliteClr,gShadowClr,0,0 )
}
function _TBSetI()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
}
function _TBSetP()
{
if( this.mIsOn )
this.ChgState( gShadowClr,gHiliteClr,1,1 )
}
function _TBSetD()
{ =20
this.ChgState( gFaceClr,gFaceClr,0,0 )
this.mIsOn =3D 0
}
function _TBSetE()
{
var t=3Dthis
if( !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
else
t.ChgState( gShadowClr,gHiliteClr,1,1 )
t.mIsOn =3D 1
}
function _TBP()
{
var t=3Dthis
if( t.mIsOn ) {=20
if( t.UserAction !=3D null )
t.UserAction()
if( !t.GetState )
return
if( t.GetState() )
t.SetPressed()
else
t.SetActive()
} =20
}
function _TBUI( clr1,clr2,lOffset,tOffset )
{
SetBorder( GetObj( this.mObjId ),clr1,clr2 )
Offset( GetObj( this.m_elementsId ),lOffset,tOffset )
}
function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle=
ft }
function SetBorder( obj, upperLeft, lowerRight )
{
s=3Dobj.style;
s.borderStyle =3D "solid"
s.borderWidth =3D 1=20
s.borderLeftColor =3D s.borderTopColor =3D upperLeft
s.borderBottomColor=3D s.borderRightColor =3D lowerRight
}
function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] }
function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() }
function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() }
function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() }
function BtnOnUp()
{
b=3DGetBtnObj()
if( b !=3D null )
b.Perform()
else
Upd()
}
function GetNtsState(){ return parent.gNtsOpen }
function GetOtlState(){ return parent.gOtlOpen }
function GetOtlTxtState(){ return parent.gOtlTxtExp }
function NtsBtnSetFlag( fVal )
{
s=3Ddocument.all.item( this.m_flagId ).style
s.display=3D"none"
if( fVal )
s.display=3D""
else
s.display=3D"none"
}
function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etActive() }
function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etInactive() }
function _BSetP_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etPressed() }
function _BSetA_BorderImg()
{=20
b =3D gBtnArr[this.mBorderId]=20
if( b !=3D null && this.mIsOn && !b.GetState() ) {
obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 )
obj.style.posTop=3D0
}
}
function _BSetI_BorderImg()
{=20
b =3D gBtnArr[this.mBorderId]
if( b !=3D null && this.mIsOn && !b.GetState() ) {
obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 )
obj.style.posTop=3D0
}
}
var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"=
THREEDFACE"
var gBtnArr =3D new Array()
gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan=
e,GetOtlState )
gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt=
lPane,GetOtlState )
gBtnArr["nb_nts"] =3D new ImgBtn( "nb_nts","nb_ntsBorder",10,parent.ToggleN=
tsPane )
gBtnArr["nb_nts"].SetActive =3D _BSetA_BorderImg;
gBtnArr["nb_nts"].SetInactive =3D _BSetI_BorderImg;
gBtnArr["nb_ntsBorder"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.=
ToggleNtsPane,GetNtsState )
gBtnArr["nb_ntsElem"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.To=
ggleNtsPane,GetNtsState )
gBtnArr["nb_prevBorder"] =3D gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","n=
b_prevBorder",30,parent.GoToPrevSld )
gBtnArr["nb_nextBorder"] =3D gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","n=
b_nextBorder",30,parent.GoToNextSld )
gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent=
.FullScreen )
gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa=
rent.FullScreen,null )
gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent=
.FullScreen,null )
gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_voice"] =3D gBtnArr["nb_voiceBorder"] =3D new ImgBtn( "nb_voice=
","nb_voiceBorder",18,parent.ToggleVNarration )
gBtnArr["nb_otlTxtBorder"] =3D gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlT=
xt","nb_otlTxtBorder",23,parent.ToggleOtlText )
gBtnArr["nb_ntsBorder"].m_flagId=3D "nb_nts"
gBtnArr["nb_ntsBorder"].SetFlag =3D NtsBtnSetFlag
gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState
/*********************************************
Context menu implementation
_CM() is the function that's hooked up to
the oncontextmenu event. Once we're asked to
show the menu, we first build it by creating
DIVs on-the-fly. Then we position it=20
within the screen area so it doesn't get
clipped.
Creating the DIVs using createElement() means
we don't have to write out any extra HTML
into the slide HTML files.
**********************************************/
var sNext=3D"Next",sPrev=3D"Previous",sEnd=3D"End Show",sFont=3D"Arial",sAr=
row=3D"Arrow",sFreeform=3D"Freeform",sRect=3D"Rectangle",sOval=3D"Oval"
function ShowMenu()
{
BuildMenu();
var doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y=
=3DPPTSld.event.clientY+doc.scrollTop
m =3D PPTSld.document.all.item("ctxtmenu")
m.style.pixelLeft=3Dx
if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) )
m.style.pixelLeft=3Dx-m.scrollWidth
m.style.pixelTop=3Dy
if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) )
m.style.pixelTop=3Dy-m.scrollHeight
m.style.display=3D""
}
function _CM()
{
if( !parent.IsFullScrMode() ) return;
if(!PPTSld.event.ctrlKey) {
ShowMenu()
return false
} else
HideMenu()
}
function BuildMenu()
{
if( PPTSld.document.all.item("ctxtmenu") ) return
var mObj=3DCreateItem( PPTSld.document.body )
mObj.id=3D"ctxtmenu"
mObj.style.visibility=3D"hidden"
var s=3DmObj.style
s.position=3D"absolute"
s.cursor=3D"default"
s.width=3D"120px"
SetCMBorder(mObj,"menu","black")
var iObj=3DCreateItem( mObj )
SetCMBorder( iObj, "threedhighlight","threedshadow" )
iObj.style.padding=3D2
CreateMenuItem( iObj,sNext,M_GoNextSld,M_True )
CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld )
=09
CreateSeparator( iObj )
CreateMenuItem( iObj,sEnd,M_End,M_True )
mObj.style.visibility=3D"visible"
}
function Cancel() { window.event.cancelBubble=3Dtrue; window.event.returnVa=
lue=3Dfalse }
function Highlight() { ChangeClr("activecaption","threedhighlight") }
function Deselect() { ChangeClr("threedface","menutext") }
function Perform()
{
e=3DPPTSld.event.srcElement
if( e.type=3D=3D"menuitem" && e.IsActive() )
e.Action()
else
PPTSld.event.cancelBubble=3Dtrue
}
function ChangeClr( bg,clr )
{
e=3DPPTSld.event.srcElement
if( e.type=3D=3D"menuitem" && e.IsActive() ) {
e.style.backgroundColor=3Dbg
e.style.color=3Dclr
}
}
function M_HasPrevSld() { return( parent.HasPrevSld() ) }
function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() }
function M_GoPrevSld() { if( gIsEndShow ) { gIsEndShow=3D0; history.back();=
PPTSld.event.cancelBubble=3Dtrue; } else GoToPrevSld() }
function M_True() { return true }
function M_End() { window.close( self ) }
function CreateMenuItem( node,text,action,eval )
{
var e=3DCreateItem( node )
e.type=3D"menuitem"
e.Action=3Daction
e.IsActive=3Deval
e.innerHTML=3Dtext
if( !e.IsActive() )
e.style.color=3D"threedshadow"
e.onclick=3DPerform
e.onmouseover=3DHighlight
e.onmouseout=3DDeselect
s=3De.style;
s.fontFamily=3DsFont
s.fontSize=3D"9pt"
s.paddingLeft=3D2
}
function CreateSeparator( node )
{
var sObj=3DCreateItem( node )
SetCMBorder(sObj,"menu","menu")
var s=3DsObj.style
s.borderTopColor=3D"threedshadow"
s.borderBottomColor=3D"threedhighlight"
s.height=3D1
s.fontSize=3D"0px"
}
function CreateItem( node )
{
var elem=3DPPTSld.document.createElement("DIV")
node.insertBefore( elem )
return elem
}
function SetCMBorder( o,ltClr,rbClr )
{
var s=3Do.style
s.backgroundColor=3D"menu"
s.borderStyle=3D"solid"
s.borderWidth=3D1
s.borderColor=3DltClr+" "+rbClr+" "+rbClr+" "+ltClr
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Module 3
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The role of the physician is to =
care for
the whole patient, not just the disease. In listening to the history,
acknowledging the patient’s experiences and analyzing the causes of =
the
suffering, the physician establishes this role in the eyes of the patient =
and family.
By offering information and practical advice, teaching and friendship aspe=
cts of
the role are conveyed. By introducing sources of support, the physician
promotes the role of patient advocate.
The patient near the end of life=
will
likely have a long list of medical problems with multiple interventions. T=
he
illness’ effects and treatment’s adverse effects often combine=
to
create complex histories. In addition, there are often secondary concurren=
t illnesses.
It may be that efforts to control the underling disease are appropriate ev=
en
in advanced stages of illness. This especially true with pediatric patient=
s.
Their parents may desire curative or life-prolonging therapy even in the f=
ace
of poor prognosis.
Physical assessments for a patie=
nt
facing the end of life differs from a standard patient assessment in that =
it
is best organized by symptoms and functional activities rather than by org=
an
system or anatomy. After symptoms and physical impairments are assessed, a
physical examination can be conducted. A physical examination confirms fin=
dings
from the history and provides a baseline of clinical information. It also =
establishes
a relationship that includes therapeutic touch. Occasionally it is helpful to con=
duct
diagnostic testing. However, the results should clearly affect or help det=
ermine
the therapeutic plan. Before ordering a test (whether relatively noninvasi=
ve, such
as a hemoglobin or more invasive, such as a biopsy), consider with the pat=
ient
and family, how you will intervene or not based on the test results. At ti=
mes
the value of the test may be in the acknowledgment of disease progression =
(or
stability) that it gives, even when no other therapeutic intervention is
planned.
It is common for patients to exp=
erience
multiple symptoms during the last phase of life. These represent the most
common complaints. Many of these will be reported spontaneously by the patient. Some
symptoms will not be reported and so it is important to inquire specifical=
ly
about each one.
For every symptom, multiple pote=
ntial
causes should be considered. The symptom may be related to the primary
illness. Alternatively, it may be related to the medical therapy for that
condition, or it may be related to another evolving condition. Each symptom
should be thoroughly assessed and a specific treatment planned.
The assessment of pain may serve=
as a
model of the full spectrum of other physical symptoms that patients may
experience. In practice it often serves as a natural point of entry into o=
ther
aspects of the whole patient assessment. Pain is highly prevalent and often
under treated. Frequently, it may not be assessed at all. However, once
assessed, most physical pain can be controlled. The assessment of pain may
well be the gateway to the assessment of physical symptoms as well as the
psychological, social, spiritual dimensions of illness.
Pain is present in up to 90% of =
patients
with cancer and AIDS in advanced stages. Similar prevalence rates are repo=
rted
in pediatric and geriatric patients. Because symptoms are inherently
subjective, patient self-report is the gold standard for assessment. There=
is
no reliable way to assess what the patient is experiencing other than by
asking. Pain assessment in t=
he
non-cognitively intact persons is challenging. Similar challenges are pres=
ent
in preverbal children. Behaviors such as grimacing, moaning or crying may =
be
the only way to assess pain.
Standardized pain assessment tools may he=
lp
to assure that pain is being assessed adequately.
Be sure to assess both motor and sensory
functions. To what degree are the activities of daily living diminished or
compromise. How do these impediments affect interpersonal relations?
Ask screening questions about co=
gnition
– are there times of confusion, hallucination? Ask about mood –
anxiety, sadness. Depression and anxiety are among the most pervasive and =
most
under diagnosed symptoms in patients facing the end of life.
Among the most important psychol=
ogical
issues are the meaning of the illness, emotional state and communication a=
nd
support. Do not hesitate to =
ask
screening questions about suicide. As a routine question among others, or
indeed as an explicit and
exploratory discussion, there is no evidence that it fosters though=
ts
of self-harm. Rather, it sets the groundwork for later discussions if they=
are
needed, and allows for self-expression, which can be therapeutic.
There is always an emotional res=
ponse to
serious illness; it challenges a person’s sense of themselves and th=
eir
role in life. Some people may move through “stages”; struggle =
and
then eventually reach resolution. Other may move between a range of emotio=
ns and
not always in a predictable order. Emotions come in surprising waves and c=
a be
persistent.
In the case of a dying child, the emotional responses of t=
he
parents and the siblings are particularly relevant, since they directly af=
fect
the child.
Almost all patients have fears f=
or the
future as they face the end of life. Fears over loss of control, loss of
dignity, loss of relationships, and physical suffering may present. Fears
among family members may be as important for the patient as fears of physi=
cal
symptoms. In formulating a therapeutic relationship and a plan of care, it=
is critical
to know what it is that the patient tends to fear.
Unresolved issues in personal ma=
tters
and especially in relationships are prominent in the end of life. You may discover that what stands
between the patient and a comfortable frame of mind is an unresolved issue.
Whether those issues have to do with settling old issues, or making or
receiving last visits, or completing a lifetime project or piece of work,
creating a plan that allows for these tasks is important. Clearly, some ta=
sks
will be physically possible while others will be difficult to achieve.
=
;These
issues are rarely apparent to the physician unless questions directed to t=
his
area are asked.
For example:
1. is there something that you would like to do before you get too
sick?
2. many people have old differences they would like to settle before that =
die.
Is there anyone you want to be able to communicate with before you die?=
3;
3. many people have places or people they would like to visit. Do
you?
4. in what way has you illness affected you emotionally?
5. how has your mood be since the lat time we spoke?
6. how have you been coping with all of the things going on in your l=
ife?
An aspect of assessment that fol=
lows
naturally from a psychological assessment is that of decision-making
capacity. It is fundamental =
for
planning care. In order that decisions
can be made with the patient’s or parent’s (if the patient is a
child) understanding and agreement, it is important not only to follow the
necessary steps for information giving, but also to be sure that the patie=
nt
has the capacity to give meaningful consent.
Capacity may be though of in two=
ways:
global and decision-specific. Some patients are globally incompetent, ie, =
not
competent in any area of functioning. They cannot handle their own affairs=
and
must rely on others. Nor can the give meaningful consent to any particular
health care decision. Under such circumstance, prior preferences, perhaps =
as
expressed in an advanced directive document or conversation must be consid=
ered.
In patients with advanced illness, it is quite common that the patient has=
compromised
mental function without being globally incompetent. Capacity may only be
limited with respect to questions whose answers rely on careful analysis.
Decisions based on firmly held beliefs may still be authentic. Consequentl=
y,
it is generally helpful to include the patient as much as possible even wh=
en
there is some mental compromise.
To afford that patients have the=
full
role in the informed consent process, the physician needs to determine whe=
ther
the patient can these three areas and that their decision is free of coercive
influence.
Communication between patients a=
nd
families members will occur in a variety of ways and physicians need to
respect different styles of communication. Whether a person is a talker or=
a
silent type, communication happens and it matters. Most people do better if
there is someone to share difficulties with. It is useful to identify who =
this
person is for the patient. I=
t may
be a family member , or it may not. One of the challenging aspects of
end-of-life is when the patient is all alone. Then, the physician and memb=
ers
of the health care team become critical components of support.
There are different personal and=
family
styles of information sharing. Ask the patient whether he or she wants a l=
ot
of information or not so much information. Ask how the patient wnats to
involve family and friends in information about the illness.
Clear
communication between the health care team and the patient is critical. Ac=
curate
information generally leads to the best outcomes. Misunderstandings over i=
nformation
become problematic.
Be particularly attuned for difficulties if the
patient is keeping his or her diagnosis a secret, or if the family is doing
the same in reverse. In such cases, it can be helpful to ask the informed
party if you can check with the uninformed to see how much information he =
or
she would like for them to have. Each side may be surprised at how much the
other knows or wants to know. Sometimes it is helpful to organize a family=
meeting
where the physician can tell=
the
information and ensure that all hear the same information at the same time=
.
Illness impacts the social aspec=
ts of
life. Conversely, social circumstances impact illness. The discipline of
social work should be appropriately integrated into the treatment team to
assist families, the patient and the physician. While the physician cannot
perform the work of a social worker, the physician should be able to make =
an initial
assessment of the patient’s social needs.
Some cultures have a more positi=
ve
attitude toward care of the dying than others, but in general in the US, t=
here
is little care offered routinely to the dying. A small percentage of
life-threatening ill patients get practical assistance from their communit=
y.
However services may be available and all efforts should be sought wherever
possible. As an example, the Family Medical Leave Act ( see http://www.dol.gov/esa/whd/=
fmla/
) can help support family caregivers facing an increased need for care. &#=
13;
About 30% of families with a
life-threateningly ill member spend a considerable portion of their life
savings for the care of the patient. A similar percentage loses a major so=
urce
of family income because of illness. The results may be create significant
economic hardships. A major source of shame and even desire to hasten death
stems from financial burden on family members.
Each person creates their own di=
mension
of life based on spiritual beliefs or transcendental dimensions or just
functional finality. Physicians often hesitate to inquire into these
dimensions of human experience, yet studies suggest patients welcome the
inquiry. Spiritual life is understood by some in terms of religious feelin=
gs,
and by others in terms of personal meaning in a larger context.
Individuals who report a strong
spiritual life sometimes report a greater sense of purpose and a greater s=
ense
of having come to terms with dying that others, as well as better
communication and relationships. The physician should bear in mind the pos=
sibility
that patients can experience
significant spiritual growth and gain meaningful fulfillment during the la=
st
stages of life. The physician should know how spiritual a patient has tend=
ed
to be in the past, how inclined toward spiritual life he or she is now,
whether or not he or she has a pastor and whether or not if there are reli=
gious
rituals that are important
Some patients may do better with=
their
own pastor from their existing community. However, chaplains, pastors, Rabi
from the institution may be able to assist also.
Ask if the patient wants special
prayers, declarations, rituals or last actions and who is person most able=
to
assist in these wishes.
Many aspects of advanced illness=
are not
commonly appreciated to be fundamentally spiritual. Yet, the search for
meaning and purpose in life is a spiritual quest. Likewise, the perceived loss of connection to a
community or a way of life may challenge the sense of meaning and purpose.
Sometimes feelings of guilt or unworthiness may be manifested as suffering=
. If
they remain unrecognized, an appropriate&=
nbsp;
plan for relief can not be instituted.
Other aspects may be more conven=
tionally
noted to be spiritual. Patients may question their core faith or express a
desire for forgiveness and reconciliation. For those who believe in a high=
er
power, they may feel a sense of abandonment.
There are some general
guidelines for spiritual assessment – remember it is a universal
component of illness and affects the quality of life in profound ways. The=
physician
will frequently want assistance in managing spiritual suffering, but may p=
lay
a role in identifying it.
The relationship between the pat=
ient and
the caregiver is very important. Some patients, and some caregivers, find =
the
relationship difficult and it can leave a lasting negative impact on them.=
It
is hard to overestimate the importance of practical help. Ask about who is
available to help and how they are dividing work caring for the patient am=
ong
each other. Ask about domestic needs, including how to manage with the
activities of daily living.
Studies indicate that most careg=
ivers in
home are wives or daughters. In the case of dying children, caregivers are
usually the parents. Consequently, widows and single people may be more
isolated and may have to rely on paid or volunteer help.
The relationship between the pat=
ient and
the caregiver is important. Some patients, and some caregivers, find the
relationship difficult and it can leave a lasting negative impact on the
caregiver. Others do not want to have their families caring for them, no m=
atter
how willing they may be.
The process of looking outside the family and
hiring caregivers can be difficult and complicated both financially and
emotionally.
As illness progress, difficulties getting between the hea=
lth
care provider site and the home is common.
Families and their composition v=
ary. One
way to broadly understand family is to consider family to be any one whom =
the
patient considers family, whether by blood or marriage or neither. Ask the patient to describe their
family. Pets may be as important family members as anyone.
Patients and family members grie=
ve over
loss of function, and they grieve in anticipation of loss. Figuring out wh=
at
grief is normal and what is complex or exaggerated and in need of interven=
tion
is an important part of the whole person assessment.
Planning ahead can be a very helpful coping mechanism for present and
future losses.
Patient’s experiences of illness is multidimensional, and effective
management strategies in end-of-life care require a comprehensive assessme=
nt
of the whole person. Essential elements of assessment include disease hist=
ory,
physical symptoms, psychological symptoms, decision-making capacity,
information sharing, social, spiritual and practical and anticipatory plan=
ning
for death.
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