END-OF-LIFE BEDSIDE ASSESSMENT

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END-OF-LIFE BEDSIDE ASSESSMENT

• By Michael Marschke, MD
• Medical Director of Horizon Hospice in Chicago

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DIMENSIONS OF ASSESSMENT

• Illness History
• Physical exam
• Psychologic exam
• Decision-making
• Communication
• Social concerns
• Spiritual concerns
• Planning

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ILLNESS HISTORY

• Understanding disease
• Complication from treatment
• Active symptoms
• Quality of life
• Determining prognosis

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PROGNOSIS DETERMINATION

• Functional decline need for help, unable to get
  around
• Weight loss of over 10 in recent months (low
  albumin lt 2.8)
• Complicating morbidities decubiti, frequent
  hospitalizations, recurrent infections

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PALLIATIVE PERFORMANCE SCALE
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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

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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 lt 2.8,
  PT/INRgt 2, encephalopathy, hepatorenal failure
• HIV CD4 lt 50, refractory viral load,
  complicating diseases (dementia, PML, malignancy,
  refractory infections)

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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

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ACTIVITIES OF DAILY LIVING ASSESSMENT

• Bathing
• Dressing
• Toileting
• Transfer
• Continence
• Feeding
• Higher levels shopping, finances, cooking,
  housework

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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

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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