ESAS,CABG,and the Personal Experience of Two Palliative Clinicians

Dear Editor:

This letter is in response to the article in the May issue of this journal ¹ regarding disparity about symptom ratings. I recently underwent emergency coronary artery bypass surgery (CABG). Although the length of stay following surgery is usually four to six days, I was in the cardiovascular unit (CVU) for eight days and a further five days on postsurgical ward due to several complications. Our palliative care unit (PCU) had recently implemented the revised Edmonton Symptom Assessment System (rESAS) ² and as I emerged from intubation, I noted the excellent recording of vitals, IV rates, O₂ sats, etc. by CVU staff. I then asked my wife to bring an ESAS sheet so we could also track my symptom scores. I did this in part for personal benefit but also to encourage the CVU staff to become interested. Further, I felt I should “walk my own talk.”

A quality improvement survey conducted in our PCU had shown that many staff did not feel ESAS was clinically helpful, was time consuming, and patients didn't like it. A sample survey of patients however indicated otherwise, assuming staff were using this for monitoring care. (As a palliative nurse, I have incorporated “pieces” of ESAS into my practice, mainly rating pain, nausea, and dyspnea. I had previously felt that asking people to rate all ESAS symptoms was tiring or overwhelming for patients and time consuming for me as the assessor. I felt I had very good assessment skills and trusted my own observations.)

We began q12h assessments centered around shift change. Despite complications with moderate to severe symptoms, I found it quick and easy to score as my wife read each item to me. What became somewhat astonishing is that when I would tell her my rating, she sometimes replied, “Really? I would have marked it differently (often lower).” (One day after my husband had rated his dyspnea at 9/10, on my observation he appeared more settled at 4/10, yet his own rating was still high at 8/10. It happened time and again that such discrepancies among several symptoms were significant and surprising. I realized that the “outside looking in” approach is far inferior to the patient's actual experience). This underscored the fact that clinicians cannot truly understand the intensity the patient is experiencing simply by observing and using “personal palliative experience.” And in our case, both of us have been in this field for over 25 years. (What I also realized was the value in looking not only at pain and dyspnea, but more the total experience including anxiety, well-being, fatigue, etc. It was quickly apparent how closely linked and additive symptoms can be.)

So we both call for palliative clinicians to use validated tools like rESAS in addition to clinical experience to better understand patient distress whether in ICUs ³ or palliative care programs.^4,5 Although several CVU nurses and doctors expressed some interest, it seemed evident they were not yet prepared to incorporate this. However, my family physician was most intrigued and asked if she could use my example in teaching medical students.