Abstract
Dear Editor:
Attention is increasingly being paid to the provision of holistic, patient-centered care. The National Quality Forum (NQF) standard of care maintains that both physical and psychological symptoms should be assessed in every palliative care encounter. 1 As a mature palliative care program we believed that we did a good job at assessing physical symptoms but suspected that the psychological symptoms might be neglected. Knowing that psychiatric symptoms are common in a palliative care population, associated with the significant morbidity and mortality, and are often not reported voluntarily, we wanted to explore how often we assessed these important symptoms.2–5
We chose five symptoms (pain, nausea, delirium, anxiety, and depression) that we believed should be assessed in every visit by the team licensed independent practitioner (LIP). Learners shadowing a LIP monitored the frequency that each symptom was assessed. Symptoms directly asked about by the LIP or reported voluntarily by a patient were considered positive screens. Comatose patients were excluded. Forty-two encounters were enrolled by convenience sample. Our findings demonstrated clear areas for improvement. Of the 42 visits pain was assessed 36 times (86%), nausea 15 times (36%), delirium 12 times (29%), anxiety 8 times (19%), and depression 5 times (12%). In comparison, we asked the LIPs how often they believed that they assessed each symptom. They estimated that they assessed pain 86% of the time, nausea 65%, delirium 56%, anxiety 35%, and depression 34%. While the LIPs accurately estimated how often they screened for pain, they overestimated how often they had assessed the other four symptoms by 1.8 to 2.8 times (nausea and anxiety 1.8, delirium 1.9, depression 2.8).
Even though this study has an imperfect methodology and biases, it highlights both the gap between perceived and actual performance as well as an increased tendency to screen for physical symptoms. In a recent article Dr. Gawande writes about the need to standardize care and follow a common “recipe” in order to provide excellent service. 6 Part of this standardization is routine screening for common symptoms that patients might not self-report but that can have a detrimental impact on quality of life. Often LIPs say they rely on personal judgment to determine when screening is necessary, but in a busy world things are often overlooked and personal judgment may not be adequate to detect these problems, especially psychiatric symptoms. Screening for common psychiatric symptoms is as easy as adding two to three more questions to a repertoire. Simply asking the patient if he or she is confused/depressed/anxious is simple and straightforward and will pick up a majority of problems.7,8 We commonly ask patients if they are having pain, and it's time to also ask if they are sad/depressed. Even if our patients are unable to communicate directly with us (cognitive impairment, endotracheal tube, sleeping, etc.) we can ask the same questions of the caregiver to get more information. Even in time-limited situations, directly asking patient and family about both physical and psychiatric symptoms is both effective and practical and should be part of every patient encounter.