EH Palliative Template RN

ESAS Symptom Assessment 1. Pain Condition - Assessment, including the likely diagnosis and rationale based on subjective and objective findings for pain: Sarah presents with chronic lower back pain, assessed as likely neuropathic pain secondary to spinal stenosis, exacerbated by movement. The pain is described as burning and shooting down her left leg, consistent with nerve root involvement. - Differential diagnosis for pain: Musculoskeletal strain, disc herniation, arthritis. - Investigations planned for pain: MRI of the lumbar spine, nerve conduction study. - Medical treatment planned, including details such as medications, dosage, expected outcomes, potential side effects, considerations for opioid management if applicable, etc.: Initiated gabapentin 300mg orally nightly, titrating up to 900mg as tolerated. Expected outcome is a reduction in neuropathic pain and improved sleep. Potential side effects include dizziness and somnolence. Patient educated on careful monitoring for these effects. - Non-pharmacological interventions, including physical therapy, occupational therapy, speech therapy, outpatient therapy, psychological interventions (e.g., CBT for pain management), acupuncture, etc.: Referral to physical therapy for core strengthening and stretching exercises. Recommended CBT for pain management strategies and coping mechanisms. - Lifestyle modifications, including activity modification, ergonomic adjustments, diet and exercise recommendations related to pain management: Advised activity modification, avoiding prolonged standing and heavy lifting. Suggested ergonomic assessment of her home office. Encouraged gentle daily walks as tolerated. - Mention any referrals for pain: Referral to a pain specialist for further evaluation and management. - Follow-up appointments, including the expected timeline for review, monitoring response to treatment, adjustment of management plans, etc.: Follow-up with palliative care in 2 weeks to assess gabapentin efficacy and side effects. Follow-up with pain specialist in 4 weeks. - Instructions for pain monitoring, including pain diaries, when to seek urgent care for worsening symptoms: Sarah provided with a pain diary to track pain levels and medication effectiveness. Instructed to seek urgent care if experiencing new onset weakness, bowel/bladder dysfunction, or sudden severe pain. 2. Dyspnea Condition - Assessment, including the likely diagnosis and rationale based on subjective and objective findings for dyspnea: Sarah reports occasional shortness of breath with exertion, likely due to deconditioning and mild anxiety related to her underlying lung condition (COPD). Oxygen saturation remains stable at 94% on room air. - Medical treatment planned, including details such as medications, dosage, expected outcomes, potential side effects, considerations for opioid management if applicable, etc.: Discussed PRN albuterol inhaler for acute episodes of breathlessness. Expected outcome is improved comfort during exertion. - Non-pharmacological interventions, including physical therapy, occupational therapy, speech therapy, outpatient therapy, psychological interventions (e.g., CBT for dyspnea management), acupuncture, etc.: Recommended pursed-lip breathing techniques and encouraged regular, short walks to improve endurance. - Lifestyle modifications, including activity modification, ergonomic adjustments, diet and exercise recommendations related to dyspnea management: Advised pacing activities and taking breaks as needed. Encouraged smoking cessation resources. - Follow-up appointments, including the expected timeline for review, monitoring response to treatment, adjustment of management plans, etc.: Review dyspnea management at next palliative care appointment. 3. Nausea Condition - Assessment, including the likely diagnosis and rationale based on subjective and objective findings for nausea: Sarah reports mild, intermittent nausea, primarily in the mornings, possibly due to medication side effects or anxiety. Denies vomiting. - Medical treatment planned, including details such as medications, dosage, expected outcomes, potential side effects, considerations for opioid management if applicable, etc.: Prescribed prochlorperazine 5mg PRN for nausea. Expected outcome is relief of nausea. - Lifestyle modifications, including activity modification, ergonomic adjustments, diet and exercise recommendations related to nausea management: Advised eating small, frequent meals and avoiding strong odours. Suggested ginger tea. - Follow-up appointments, including the expected timeline for review, monitoring response to treatment, adjustment of management plans, etc.: Monitor nausea at next palliative care visit. 4. Appetite Condition - Assessment, including the likely diagnosis and rationale based on subjective and objective findings for appetite: Sarah's appetite has been fair, but she reports feeling full quickly, leading to decreased intake. Attributed to underlying illness and potentially anxiety. - Lifestyle modifications, including activity modification, ergonomic adjustments, diet and exercise recommendations related to appetite management: Encouraged small, calorie-dense meals and nutritional supplements as needed. Discussed importance of adequate hydration. - Follow-up appointments, including the expected timeline for review, monitoring response to treatment, adjustment of management plans, etc.: Review nutritional intake and weight at next appointment. 5. Anxiety Condition - Assessment, including the likely diagnosis and rationale based on subjective and objective findings for anxiety: Sarah expresses anxiety regarding her prognosis and ability to manage her symptoms at home. She reports difficulty sleeping due to worries. - Medical treatment planned, including details such as medications, dosage, expected outcomes, potential side effects, considerations for opioid management if applicable, etc.: Discussed starting a low dose anxiolytic if non-pharmacological methods are insufficient, such as lorazepam 0.5mg PRN for severe anxiety. - Non-pharmacological interventions, including physical therapy, occupational therapy, speech therapy, outpatient therapy, psychological interventions (e.g., CBT for anxiety management), acupuncture, etc.: Recommended mindfulness exercises and connection with a support group. Referral to psychological services for CBT. - Mention any referrals for anxiety: Referral to social worker for emotional support and coping strategies. - Follow-up appointments, including the expected timeline for review, monitoring response to treatment, adjustment of management plans, etc.: Ongoing assessment of anxiety levels and coping mechanisms. 6. Constipation Condition - Assessment, including the likely diagnosis and rationale based on subjective and objective findings for constipation: Sarah reports infrequent bowel movements (every 3-4 days), likely due to reduced mobility, pain medications, and decreased fluid intake. - Medical treatment planned, including details such as medications, dosage, expected outcomes, potential side effects, considerations for opioid management if applicable, etc.: Advised regular use of docusate sodium 100mg BID and senna 8.6mg nightly. Expected outcome is daily soft bowel movements. - Lifestyle modifications, including activity modification, ergonomic adjustments, diet and exercise recommendations related to constipation management: Encouraged increased fluid intake and dietary fiber. Advised gentle ambulation as tolerated. - Follow-up appointments, including the expected timeline for review, monitoring response to treatment, adjustment of management plans, etc.: Monitor bowel habits at next visit. 7. Drowsiness Condition - Assessment, including the likely diagnosis and rationale based on subjective and objective findings for drowsiness: Sarah reports mild drowsiness in the afternoons, potentially related to medication side effects (gabapentin) or overall fatigue from her illness. - Lifestyle modifications, including activity modification, ergonomic adjustments, diet and exercise recommendations related to drowsiness management: Advised scheduling rest periods and avoiding driving if feeling drowsy. Encouraged light activity in the mornings. - Follow-up appointments, including the expected timeline for review, monitoring response to treatment, adjustment of management plans, etc.: Continue to monitor drowsiness and adjust medications if necessary at next visit. 8. Tiredness Condition - Assessment, including the likely diagnosis and rationale based on subjective and objective findings for tiredness: Sarah experiences significant fatigue and tiredness, impacting her ability to perform daily activities. This is a common symptom of her advanced illness. - Non-pharmacological interventions, including physical therapy, occupational therapy, speech therapy, outpatient therapy, psychological interventions (e.g., CBT for tiredness management), acupuncture, etc.: Referral to occupational therapy for energy conservation strategies. - Lifestyle modifications, including activity modification, ergonomic adjustments, diet and exercise recommendations related to tiredness management: Recommended prioritising activities and delegating tasks when possible. Encouraged regular, short rest periods. - Follow-up appointments, including the expected timeline for review, monitoring response to treatment, adjustment of management plans, etc.: Reassess fatigue levels and impact on quality of life at each follow-up. 9. Depression Condition - Assessment, including the likely diagnosis and rationale based on subjective and objective findings for depression: Sarah expresses feelings of sadness and loss of interest in hobbies she once enjoyed, consistent with mild depression in the context of serious illness. She denies suicidal ideation. - Non-pharmacological interventions, including physical therapy, occupational therapy, speech therapy, outpatient therapy, psychological interventions (e.g., CBT for depression management), acupuncture, etc.: Encouraged engagement in enjoyable activities as tolerated and connection with support systems. Recommended CBT for depression management. - Mention any referrals for depression: Referral to a psychologist for further assessment and support. - Follow-up appointments, including the expected timeline for review, monitoring response to treatment, adjustment of management plans, etc.: Ongoing monitoring of mood and emotional well-being. 10. Additional Issues or Conditions - Follow the same structure as above for each additional issue or condition identified: Sarah also reports occasional dry mouth, likely due to medications. Advised regular sips of water and use of artificial saliva products. Sources of Hope: - Focus on discussion about life meaning, strengths, challenges, peace, connection, future events looking forward to, hope for the future, who is important in life and why, etc.: Sarah finds hope in spending quality time with her grandchildren and completing her family photo albums. She expressed a desire for peace and comfort in her remaining time, and the strong support of her daughter is very important to her. Organized Religion: - Spiritual history, focusing on religion, faith, spirituality, importance of spirituality in decision making, church attended, denomination, etc.: Sarah identifies as Anglican and finds comfort in prayer and attending church services when her health permits. Her faith is a significant source of strength and informs her acceptance of her illness. Cultural Aspects of Care: - Any discussion or information regarding cultural differences, rituals of culture, background beliefs, values that impact healthcare experiences, how they want their care provided, language barriers, traditional healers, gender roles, non-verbal communication, tribal leaders, introducing hospice, hospice at home, GIP hospice inpatient, GIP hospice house, routine-level hospice care at home or in a facility, etc.: Sarah expressed a preference for open and honest communication about her prognosis. She values her family's involvement in decision-making and wishes for her daughter to be present at all significant discussions. No specific language barriers or traditional healers were mentioned. Discussion around routine-level hospice care at home was initiated. **Other Concerns: ** - Any specific patient or family concerns or worries addressed during the consultation: Sarah's primary concern is maintaining her independence for as long as possible and not becoming a burden to her family. Her daughter is worried about managing Sarah's pain at home. - Any specific information about discharge plan including rehab, home with community palliative care follow up, home with hospice, home with oncology or clinic follow up, long term care, short term rehab, assisted living, etc.: Discharge plan is home with community palliative care follow-up and initiation of routine-level hospice care at home. Symptom Management Teaching - Patient education on the diagnosed condition(s), symptom management strategies, importance of adherence to treatment plans, and lifestyle modifications, wound care, medication compliance, or other medical interventions to be carried out at home or in an office or clinic setting: Sarah was educated on the nature of neuropathic pain and the expected effects and side effects of gabapentin. Detailed instructions on administering PRN albuterol and prochlorperazine were provided. Emphasised the importance of adherence to bowel regimen. Teaching included energy conservation techniques and the benefits of gentle exercise. Wound care instructions for a minor skin tear on her arm were also provided. Illness Trajectory, Prognosis, Treatment: 1. Present at consultation: “With express permission, the palliative care team met to review goals of care and advance care planning today with” Sarah and her daughter, Jane Smith. Hospital Course: “Palliative care is consulted in the setting of chronic obstructive pulmonary disease (COPD) with spinal stenosis causing severe neuropathic pain, progressive dyspnea, and significant fatigue as well as assistance with symptom management, advance care planning needs, and goals of care discussions in the context of serious illness.” 1. Psychosocial Screen: - Social history, focusing on lifestyle factors, support systems, coping mechanisms, history of substance use or abuse, hobbies, housing, living situation, occupation, military service or history, number of children, grandchildren, great-grandchildren, marital status, etc.: Sarah is a 78-year-old widow living alone in her own home, with her daughter living nearby and providing daily support. She enjoys gardening and knitting but has found it difficult to engage in these hobbies recently due to pain and fatigue. No history of substance abuse. She has two children and five grandchildren. She worked as a librarian before retirement. - Dietary history, assessing intake related to pain management or conditions influencing pain: Patient reports reduced appetite and early satiety. Struggles to maintain consistent meal times. Advised on high-calorie, small-portion meals and fluid intake to aid medication absorption and overall well-being. - Environmental and occupational history, including any factors that may exacerbate or relieve pain, ergonomic considerations: Her home has stairs which exacerbate her lower back pain. Plans are underway to arrange for a temporary downstairs living arrangement. No specific occupational factors are currently relevant as she is retired. - Detailed history of patient or family understanding of disease, illness trajectory or prognosis based on information shared by providers, clinicians, specialists, primary care, etc.: Sarah and her daughter have a good understanding of her COPD and spinal stenosis. They understand the progressive nature of her illness and the palliative focus of care. They are aware of previous discussions with her pulmonologist regarding her declining lung function. 2. Interval History: - Detailed history of the presenting complaint(s), including onset, duration, intensity, character, location, aggravating/alleviating factors, impact on daily activities, any previous treatments (medications, physical therapy, injections) and responses, etc.: Sarah's lower back pain started approximately 6 months ago, gradually worsening. It is constant, a 7/10 on average, and radiates to her left leg. It is aggravated by walking and standing and partially relieved by lying down. She previously tried over-the-counter pain relievers with minimal effect. Her dyspnea has worsened over the past month, limiting her ability to perform household chores. 3. Goals of Care: - Focusing on hopes for the future, personal worries or concerns, treatment wishes, preferences for how medical information is shared, coping mechanisms, strengths, challenges, communication preferences, etc.: Sarah's primary goal is to remain at home, comfortable and free from severe pain. She hopes to be able to continue seeing her grandchildren regularly. Her main worry is becoming completely bed-bound and losing her dignity. She prefers information to be shared openly with her and her daughter present. Her strength lies in her resilience and strong family support. 4. Hospice Discussion: - Any discussion or information regarding introducing hospice, hospice at home, GIP hospice inpatient, GIP hospice house, routine-level hospice care at home or in a facility, etc.: Hospice care at home was introduced and discussed with Sarah and her daughter. They expressed interest in exploring routine-level hospice care at home to support Sarah's wish to remain in her familiar environment. Information about the benefits of hospice for symptom management and family support was provided. 5. Code Status Discussion: - Any discussion or information regarding code status including DNR, full code, limited or partial code, intubation, and information regarding POLST or Portable DNR, allow natural death, etc.: Sarah has an existing 'Allow Natural Death' order documented. She reiterated her wish not to undergo intubation or other aggressive life-sustaining measures. Discussion included ensuring her POLST (Physician Orders for Life-Sustaining Treatment) form is readily accessible. 6. Advance Directives: - Any discussion or information regarding advance directives, healthcare proxy or proxies, living will wish, power of attorney for healthcare, nominated decision makes, artificial nutrition or hydration, no life sustaining measures, heroic measures, etc.: Sarah has a living will outlining her wish to decline artificial nutrition and hydration. Her daughter, Jane Smith, is her nominated healthcare proxy and has a power of attorney for healthcare. These documents were reviewed and confirmed to be up-to-date. “Consent for the use of AI-assisted tools for documentation was obtained from the patient and all other participants in the visit prior to this encounter. All questions were answered. Patient understands that they may decline the use of AI-assisted tools.”