History taking and examination in a
Palliative Care setting including various
scoring systems
Dr Ruparna Khurana
Moderator : Dr Seema Mishra

Why are you special
Our history taking is not just an art but also a
therapeutic intervention

History taking in palliative care setting is so
unique
Understand the patient as a whole and not just the diagnosis :- psychosocial/
spiritual/ economic
Understand ‘suffering’
What patient really needs help with
Go beyond the traditional domains
Respect the patients values, believes and choices

History taking in palliative care setting is so
unique
Often , its associated with breaking the bad news
Prognostication
Formulating a comprehensive care plan
Making the entire family understand about the
disease trajectory and where the patient stands at the
moment

History taking in palliative care setting is so
unique
Respect various care settings…
EOLC Acute
care
setting
Chronic

Challenges
• Severe pain
• Dyspnoea
• Fatigue
• Confused/ delirious
• Depression/ withdrawn

Aim
• To identify the palliative care needs of the patient and their care
givers
• To identify the key areas of in intervention – where the patient and or
the family needs most help with (organise and prioritise)

• To formulate a comprehensive care – medical care plan
accessible health care
social security
care givers
financial status
spiritual well being
anticipatory planning –
advanced directives/ surrogate decision makers
• To make the patient feel understood, cared for (you matter because
you are you)

Skill set
• Open mindedness
• Good communication skills
• Empathy
• Basic knowledge about common and expected symptoms and clinical
scenarios (what the mind doesn’t know the eyes will not see)
• Essential drugs of our domain and their toxicities

Domains
PC
assessment
Physical
Psychological
Prognostication
Spiritual
Social
Continuity
and
coordination
of care across
settings
(personal goals,
expectations,
understanding of
illness trajectory and
risks versus benefits)

General principles
• Use a systematic approach
• Attitude of openness – active listening/ empathy/ tone
• Establish a rapport with the patient
• Maintain privacy and dignity
• Thoroughness, persistence, and patience
• Documentation : clear, accurate and legible

Components
• Source of history and reliability
• Presenting complaint
• History of present illness
• Treatment History
• Past medical and surgical history
• Personal history
• Family history
• Psychological history
• Social history
• Spiritual history

Physical symptoms
• 11 of the most prevalent symptoms in patients with
end-stage illness:
• Pain
• Breathlessness
• Nausea & vomiting
• Constipation
• Delirium
• Depression
• Anxiety
• Fatigue
• Insomnia
• Diarrhea
• Anorexia

Symptom assessment
• Seven cardinal features of a Symptom
• O - Onset
• P - Palliating and Provoking factors - movement, position, breathing, mood, eating
• Q - Quality
• R - Related factors / symptoms
- Response to previous treatment
• S - Severity
- Site
• T - Temporal characteristics - “When did it start? What’s happened over time?
Constant or intermittent?”
• M - Meaning of the symptom / burden to the patient

Scoring systems
• Common language for assessment of symptoms across
languages/cultures/countries/literacy levels
• Systematic and organised data for comparison across centres
• Formulation of cut-offs – therapeutic interventions/ treatments
• Convenient and ease of documentation
• Multiple symptoms at a glance
• Progression over a period of time

• The revised Edmonton Symptom Assessment Scale
• Memorial Symptom Assessment Scale-Short Form
• Condensed MSAS
• MD Anderson Brief Symptom Inventory
• Rotterdam Symptom Checklist
• Symptom Distress Scale

Pain

DYSPNOEA

Psychological assessment
• Distress
• Anxiety
• Depression

• DISTRESS
THERMOMETER
• Score >= 4 suggest
clinically significant
distress.
• Score <4 suggest distress
level is mild

OTHER SCREENING TOOLS

Prognostication
• PPS
• PPI

PPI scoring
• PPI score > 6 = survival shorter than 3 weeks
• PPI score >4 = survival shorter than 6 weeks
• PPI score <4 = survival more than 6weeks

Social assessment

Social assessment
• Family structure and function
• Primary care giver
• Social and cultural support
• Functional limitations that impact activities of daily living (ADLs),
instrumental activities of daily living (IADLs)
• The effect of illness on family – livelihood / education/ neglect /
social isolation

Social assessment
• Financial security
• Living arrangements – accessibility and safety
• Caregivers: needs, availability and capacity
• The need for adaptive equipment, home modifications or transportation
• Access to healthcare : medications

Spiritual

Spiritual…
• Assessment of hopes and fears, meaning and purpose, beliefs about
afterlife, guilt, forgiveness and life review and completion.
• Several formal tools are available for obtaining a spiritual history
• FICA
• SPIRIT
• HOPE

• F – Faith and belief: “Do you consider yourself spiritual?” or “Do you
have spiritual beliefs that help you cope with stress or with what you
are going through?
• If the patient responds “no,” the clinician may ask, “What gives your
life meaning?” Sometimes patients respond with answers such as
family, career, or nature.

• I – Importance: “What importance does your spirituality have in your
life? Has your spirituality influenced how you take care of yourself in
this illness? What role does your spirituality play in your health care
decision-making

• C – Community: “Are you part of a spiritual or religious community? Is
this of support to you, and how? Is there a group of people you really
love or who is important to you?”
• Communities such as churches, temples, and mosques, or a group of
like-minded friends can serve as strong support systems for some
patients

• A – Address: “How would you like me to address these issues in your
health care?”
• If the clinician identifies spiritual distress or resources of strength,
that should be noted in the assessment and plan.

Examination

Examination
General physical examination
• Demeanour : agitated/aggressive/ panting
Facies : comfortable/ / gasping/
gruntling
posturing : stooping / bending
• Performance status

• Built and nourishment : cachexia/ frailty/ emaciated
• Vitals : Pulse
Blood pressure
Temperature
Respiratory Rate
Spo2
PAIN

• Pallor
• Icterus
• Clubbing
• Cyanosis
• Lymphadenopathy
• Edema

Local examination
Guided by the primary tumour/ metastatic site
• Swelling
• Mass
• Ulcer : malignant fungating wounds/ulcers
• Lymphedema

Systemic examination
• Per abdominal
• Respiratory
• CVS
• CNS
• Musculoskeletal

Thank you !
•Welcome to the Department of OAPM, AIIMS