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END-OF-LIFE BEDSIDE ASSESSMENT

END-OF-LIFE BEDSIDE ASSESSMENT . By Michael Marschke, MD Medical Director of Horizon Hospice in Chicago. DIMENSIONS OF ASSESSMENT. Illness History Physical exam Psychologic exam Decision-making Communication Social concerns Spiritual concerns Planning. ILLNESS HISTORY.

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END-OF-LIFE BEDSIDE ASSESSMENT

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  1. END-OF-LIFE BEDSIDE ASSESSMENT By Michael Marschke, MD Medical Director of Horizon Hospice in Chicago

  2. DIMENSIONS OF ASSESSMENT • Illness History • Physical exam • Psychologic exam • Decision-making • Communication • Social concerns • Spiritual concerns • Planning

  3. ILLNESS HISTORY • Understanding disease • Complication from treatment • Active symptoms • Quality of life • Determining prognosis

  4. PROGNOSIS DETERMINATION • Functional decline – need for help, unable to get around • Weight loss of over 10% in recent months (low albumin < 2.8) • Complicating morbidities – decubiti, frequent hospitalizations, recurrent infections

  5. PALLIATIVE PERFORMANCE SCALE

  6. PROGNOSIS DETERMINATION DISEASE SPECIFIC: • Cancer: stage 4, mets, refractory to therapeutic agents • Heart disease: stage 4 – dyspnea at rest, multiple hospitalizations/infarcts/ severe arrhythmias recently • Lung disease – stage 4,dyspnea/hypoxia at rest, refractory to max therapy

  7. PROGNOSIS DETERMINATION DISEASE SPECIFIC: • Neurologic disease – progressed to affect all ADLs, ability to eat • Renal disease – needing dialysis but not getting it • Liver disease – severe cirrhosis, albumin < 2.8, PT/INR> 2, encephalopathy, hepatorenal failure • HIV – CD4 < 50, refractory viral load, complicating diseases (dementia, PML, malignancy, refractory infections)

  8. FUNCTIONAL ASSESSMENT STAGING (FAST SCORE) 1.No difficulty 2. Complains of forgetting location of objects 3. Decreased job functioning; difficulty traveling; decreased organization 4. Decreased ability to perform complex tasks (finances, planning a dinner) 5. Needs assist in choosing proper clothes 6a. Improperly putting on clothes 6b. Unable to bathe properly 6c. Unable to toilet self 6d. Urinary incontinence 6e. Fecal incontinence 7a. Can speak only 6 intelligible words or less 7b. Speech limited to only one word in a day 7c. Cannot walk by self 7d. Cannot sit-up without help 7e. Cannot smile 7f. Cannot hold up head by self

  9. ACTIVITIES OF DAILY LIVING ASSESSMENT • Bathing • Dressing • Toileting • Transfer • Continence • Feeding • Higher levels – shopping, finances, cooking, housework…

  10. PHYSICAL EXAM • Focus on active symptoms • Functional activity/risks • Fall risk • Risk for decubiti/skin exam • Risk for impaction • Mental functioning/competency • Psychosocial assessment • Spiritual assessment

  11. MEDICATION ASSESSMENT • How are they taking their meds? • Can meds be stopped? i.e. when declining pts can get in more trouble continuing HTN/DM meds • Focus on comfort, ease of taking meds • Interactions • Fears, side effects

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