Assessing Symptoms

Key points

• Assess and manage holistically
  • Consider which problems most affect the person’s quality of life (physical, emotional, social, spiritual). Many symptoms are multifactorial, or occur in clusters, and some causes may be more or less reversible than others.
• Manage pre-emptively
  • Given the nature of this person’s disease, consider what problems may need to be planned for, and ensure that essential medications can be accessed when they are needed.
  • As the person’s condition deteriorates, they will lose the ability to swallow. This can be sudden, and planning can ensure that the individual’s symptoms continue to be managed. To avoid delays, e.g. over a weekend, it is advisable to write up the medication and ensure that it is available within a facility prior to its being needed. This pre-emptive action is referred to as anticipatory prescribing.
  • Safer Care Victoria has developed guidance on Anticipatory medicines in palliative care
     
• Assess and reassess frequently
  • Consider using simple assessment tools such as the Symptom Assessment Scale (SAS), Distress Thermometer, or a pain diary to screen for and monitor symptoms. Check for adverse effects of treatments, as well as benefits, regularly.
• Assess whether problems are likely to be due to reversible or irreversible causes
  • Consider and discuss the likely burden associated with various treatment options (cost, difficulty of undergoing investigations, realistic improvement that might be expected etc).
• Consider both pharmacological and non-pharmacological management options
  • If prescribing, ensure that medications are easily accessible and actually available in community pharmacies and are on the Pharmaceutical Benefits Scheme (PBS). Using the Palliative Care Schedule of the PBS and/or providing authority scripts allows core palliative care medications to be prescribed in larger quantities, and may cost the patient less.
• Medicines that are for symptom management may need to be switched to subcutaneous equivalents (eg analgesics or antiepileptics). 
  • For medications listed under the pharmaceutical benefits scheme see www.pbs.gov.au 
  • Note that some medicines in the prescribers bag can be useful in managing symptoms expected in the terminal phase
  • Until the chemist opens Palliation from the doctor’s bag - this is  a useful guide for prescribers. However, while it still holds true for many of the medicines, there have been some changes to the PBS listing.
  • There is a term called the prescribing cascade - when a new medicine is prescribed to 'treat' an adverse drug reaction associated with another medicine, in the mistaken belief that a new medical condition requiring treatment is   present
     
• Timely referral
  • If a problem does not respond to primary care management, or is complex, refer to specialist palliative care for further advice.