The following tools can help health care providers with symptom assessment of palliative and end of life care patients.
The ESAS is a tool that was developed to assist in the assessment of nine symptoms that are common in palliative care patients: pain, tiredness, drowsiness, nausea, lack of appetite, depression, anxiety, shortness of breath, and wellbeing. The ESAS has been revised to improve ease of understanding and completion for patients and is known as the ESAS-r. The ESAS-r is intended to capture the patient’s perspective on symptoms. However, in some situations it may be necessary to obtain a caregiver’s perspective. The ESAS-r provides a profile of symptom severity at a point in time. Repeated assessments may help to track changes in symptom severity over time. The ESAS-r is only one part of a holistic clinical assessment. It is not a complete symptom assessment in itself.
Watanabe SM, Nekolaichuk C, Beaumont C, Johnson L, Myers J, Strasser F. A multi-centre comparison of two numerical versions of the Edmonton Symptom Assessment System in palliative care patients J Pain Symptom Manage 2011; 41:456-468.
Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care 1991; 7:6-9.
The Symptom Assessment Acronym is a tool to aid in a detailed systematic approach to assess palliative or end of life symptoms. This tool guided a consistent and comprehensive symptom assessment in palliative or end of life care.
Algorithms used for specific symptom management available at cancercare.on.ca
Muir J. (2006). Unrelieved Pain. Nursing BC. October; 38(4):22-5.
Peden J, Young, S., Bohn, U. and McDonald, A. (2013). 99 common questions (and more) about hospice palliative care. 4th ed. Edmonton: Alberta Health Services.
The Palliative Performance Scale was developed by Victoria Hospice and used to measure performance status in palliative care. It measures five key areas: ambulation, ability to do activities, self-care, food/fluid intake, and level of consciousness.
The Palliative Performance Scale version 2 (PPSv2) tool is copyright to Victoria Hospice Society. Programs wishing to use the tool should contact Victoria Hospice for reprint and use permissions.
A brief delirium screening instrument that provides continuous cognitive status assessment as well as delirium symptom monitoring.
Gaudreau J-D, Gagnon P, Harel F, Tremblay A, Roy M-A (2005). Fast, systematic, and continuous delirium assessment in hospitalized patients: the nursing delirium screening scale. J Pain Symptom Manage. 29(4):368-75
Radtke FM, Franck M, Schneider M, Luetz A, Seeling M, Heinz A, Wernecke KD, Spies CD (2008). Comparison of three scores to screen for delirium in the recovery room. Brit J Anaesth, 101(3):338-343
CAM was intended to provide a new standardized method to enable clinicians not trained in psychiatry to identify delirium quickly and accurately in both clinical and research settings. Both a long and short version of the CAM are available. The long version is a comprehensive assessment instrument that screens for clinical features of delirium and correlates to DSM IV criteria. The short version includes only those four features that were found to have the greatest ability to distinguish delirium from other types of cognitive impairment. There is also a CAM-ICU version for use with non-verbal mechanically ventilated patients.
Wei LA, Fearing MA, Sternberg E, Inouye SK. (2008). The Confusion Assessment Method (CAM): A systematic review of current usage. J Am Geriatr Soc.; 56:823-830.
Cole, M.G., Ciampi, A., Belzile, E., & Zhong, L. (2009). Persistent delirium in older hospital patients: A systematic review of frequency and prognosis. Age and Ageing, 38(1), 19-26.
A scale designed to quantify the severity of delirium symptoms and to allow for objective measurement of changes in delirium severity in response to medical changes or clinical interventions. Although not designed as a diagnostic tool, the MDAS may also be useful in establishing a delirium diagnosis in medically ill patients
Fadul, N., et al. (2007). "Evaluation of the Memorial Delirium Assessment Scale (Mdas) for the Screening of Delirium by Means of Simulated Cases by Palliative Care Health Professionals." Support Care Cancer 15.11: 1271-6
Constipation is highly common among cancer patients. Malnutrition, poor mobility, decreased oral intake, autonomic failure, and opioid analgesics are all causes of severe constipation. Unfortunately, the problem is often very poorly assessed. Additional methods, other than a history and examination, are occasionally required to assist in adequately assessing the extent of constipation.
The constipation score is one such tool. It consists of a plain, supine x-ray of the abdomen which is then divided into four quadrants. The four quadrants being representative of the ascending, transverse, descending and rectosigmoid colon segments respectively. Each quadrant is assessed for the amount of stool present and is scored from 0 to 3; 0 being the absence of stool and 3 being complete impaction of stool. The scores for each quadrant are totaled. The maximum score being 12 out of 12. A score of 7 or more indicates more aggressive constipation management is necessary.
Nagaviroj K, Yong WC, Fassbender K, Zhu G, Oneschuk D (2011) “Comparison of the Constipation Assessment Scale and plain abdominal radiography in the assessment of constipation in advanced cancer patients” Journal of Pain & Symptom Management. 42(2):222-8.
There are seven types of stools (feces) according to the Bristol Stool Chart. The Bristol Stool Chart or Bristol Stool Scale is a medical aid designed to classify feces into seven groups.
Heaton, K W & Lewis, S J. (1997). Stool form scale as a useful guide to intestinal transit time. Scandinavian Journal of Gastroenterology, 32(9): 920-924.
Dyspnea is one of the most common symptoms at the end of life, yet it is common to find patients who are unable to quantify their respiratory distress. The RDOS is a practical tool to quantify the level of respiratory distress in a population with severe cognitive impairment.
Campbell ML (2008) Psychometric testing of a respiratory distress observation scale. J Palliat Med; 11:44–50.
Campbell, M. L., T. Templin, et al. (2010). A Respiratory Distress Observation Scale for patients unable to self-report dyspnea. Journal of Palliative Medicine, 13(3): 285-290
The Edmonton Classification System for Cancer Pain is a validated assessment instrument for pain classification in cancer patients. It consists of five pain features: mechanism of pain, incident pain, psychological distress, addictive behavior, and cognitive function. It is a clinician-rated assessment, based on an integration of clinical findings including but not limited to the patient history, patient reports, physical examination, medical record, objective assessments, available diagnostic imaging and collateral history. The ECS-CP helps to predict which cancer pain patients will be more difficult or time consuming to manage, enables physicians and the inter-disciplinary team to better manage patients’ cancer pain, and better allocate resources. It also provides useful information for training palliative medicine and pain specialists in the assessment of pain staging/classification in cancer patients.
Fainsinger, R., Nekolaichuk, C., Lawlor, P., Hagen, N., Bercovitch, M., Fisch, M., Galloway, L., Kaye, G., Landman, W., Spruyt, O., Zhukovsky, D., Bruera, E., Hanson, J. (2010). An international multicentre validation study of a pain classification system for cancer patients. European Journal of Cancer, 46, 2896-- 2904.
Nekolaichuk CL, Fainsinger RL, Aass N, et al. (2013). The Edmonton Classification System for Cancer Pain: Comparison of pain classification features and pain intensity across diverse palliative care settings in eight countries. J of Palliative Medicine; 16(5):516-523.
Nekolaichuk CL, Fainsinger RL, Lawlor P. (2013). Challenges of conducting research on cancer pain classification: How do we make sense of the outcomes? J of Palliative Medicine; 16(11): 1323-1325.
This pain behavior tool is used to assess pain in older adults who have dementia or other cognitive impairment and are unable to reliably communicate their pain. It can be used by a nurse or assistant to screen for pain related behaviors.
Leong, I., Chong, M., & Gibson, S. (2006). The use of self-reported pain measure, a nurse-reported pain measure, and the PAINAD in nursing home residents with moderate and severe dementia: a validation study. Age and aging, 35, 252-256.
Warden, V., Hurley, a., Volicer, L. (2003). Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) scale. American Medical Directors Association, 4, 9-15..
The Checklist of Nonverbal Pain Indicators (CNPI) was designed to observe and measure pain behaviors in cognitively impaired elders. The tool includes six pain behavioral items commonly observed in older adults including nonverbal vocalizations, facial grimacing or wincing, bracing, rubbing, restlessness, vocal complaints.
Nygaard, H. A., & Jarland, M. (2006). The checklist of nonverbal pain indicators (CNPI): Testing of reliability and validity in Norwegian nursing homes. Age and Ageing, 35(1), 79-81.Morphine Equivalent Daily Dose (MEDD)
The Morphine Equivalent Daily Dose (MEDD) is used to translate the dose and route of each of the opioids the patient has received over the last 24 hours to a parenteral morphine equivalent using a standard conversion table.
Bruera E, Lawlor P, Watanabe S, Turner K, Hanson J. (1997). The effects of opioid rotation (OR), dose ratio (DR) on pain control and cognition in patients (P) with cancer pain. Presented at the A.S.C.O. meeting in Denver, CO May 20, 1997. Proceedings of ASCO.; 16(212):62a
Charrois T, Lindsay MA, Bruera E. (1998). Utilizing a morphine equivalent daily dose for comparison of opioid use in two palliative care units in Canada. Presented at the 12th International Congress on Care of the Terminally Ill, Montreal, PQ September 1317, J Palliat Care; 14(3):117
Copyright is held by Dr. Charles S. Cleeland (1991)
The Brief Pain Inventory is a medical questionnaire used to measure pain, developed by the Pain Research Group of the WHO Collaborating Centre for Symptom Evaluation in Cancer Care.
The purpose of the BPI is to assess the severity of pain and the impact of pain on daily functions. Originally developed to assess cancer pain, the BPI has been validated for use in the chronic nonmalignant pain population. It provides an important and widely used diagnostic tool for the clinician treating chronic pain.
Cleeland CS, Ryan KM. (1994). Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Singapore 23(2): 129-138.
Kalyadina SA, Ionova TI, Ivanova MO, Uspenskaya OS, Kishtovich AV, Mendoza TR, Guo H, Novik A, Cleeland CS, Wang XS. (2008). Russian Brief Pain Inventory: validation and application in cancer pain. J Pain Symptom Manage 35(1): 95-102.
The CAGE Questionnaire is a reliable, easily administered acronym screening tool that can aide in assessment and management of problem alcohol use. The CAGE Questionnaire was developed in 1970 by Dr. John A. Ewing as a tool for identifying individuals with undisclosed alcohol misuse.
Ewing, JA, Rouse, BA. (1970). Identifying the hidden alcoholic. In: Proceedings of the 29 the International Congress on Alcohol and Drug Dependence, February 3, Sydney, Australia.
Ewing, JA. (1984). Detecting Alcoholism: the CAGE Questionnaire. Journal of the American Medical Association; 252 (14): 1905-1907.
The Opioid Risk Tool (ORT) is an office-based, 5-question assessment designed to predict which patients may develop aberrant, drug-related behaviors based on known risk factors associated with abuse or addiction. The ORT can either be self-administered by the patient (patient form) at the initial clinic visit or completed by the physician as part of the patient interview (clinician form).
Webster LR. (2005). Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the opioid risk tool. Pain Medicine; 6(6):432-442.
The FICA Spiritual History Tool was an acronym developed by Dr. Puchalski and a group of primary care physicians to equip physicians and other healthcare professionals with a tool to address spiritual issues with patients. Spiritual histories are taken as part of the regular history during an annual exam or new patient visit, but can also be taken as part of follow-up visits, as appropriate. The acronym follows as a guide for conversations in the clinical setting by addressing: F - Faith and Belief; I – Importance; C – Community; A – how can the clinician Address this in the patient’s care.
Puchalski C (2006), Spiritual Assessment in Clinical Practice Psychiatric annals; Psychology Module 36 (3): 150.
Puchalski C, Romer AL, (2000) Taking Spiritual History Allows Clinicians to Understand Patients More Fully; Journal of Palliative Medicine 3(1): 129–137.