Article of the Month
Carla Ripamonti, MD
(Italy)
Symptom evaluation in palliative medicine:
patient report vs systematic assessment
Author(s): Homsi J, et al.
Journal: Supportive Care in Cancer 2006 ; 14 : 444-453
According to the literature, advanced cancer patients present with median of 11 symptoms (range 1-27). The most frequently reported symptoms are fatigue, dry mouth, pain and anorexia.
In a population of seriously ill advanced cancer patients, the authors carried out a prospective study to compare the number of symptoms reported by the patients (volunteered symptoms) during a 10 minute interview, versus those chosen by the patients on a 48-item checklist survey (systematic assessment).
All inpatients and outpatients who did not have signs and symptoms of delirium, sedation and coma who were referred to the the Harry R. Horvitz Center for Palliative Medicine at the Cleveland Clinic Taussig Cancer Center during a 5-month period were screened.
During the interview, questions were asked such as “How are you feeling today? What symptoms are you having now? What is bothering you today? Is there anything else?” the patients were asked to rate every volunteered symptom as mild, moderate or severe. Symptom distress was also noted.
The systematic assessment consisted of a 48-item symptom checklist developed by the investigators that requires the patient to assign intensity for each specific symptom; the degree of symptom distress was also evaluated.
Two hundred patients entered the study (median age 65 years, 56% were outpatients, 54% were men).
Of the 2397 symptoms identified, 14% were volunteered (median 1, range 0-6) and 86% (median 10, range 0-25) (p<0.001) were the result of the systemic assessment. No significant differences were found related to gender or ethnic background.
Of the 322 volunteered symptoms, 51% of them were reported severe and 17% mild; 292 (91%) were distressing. Of the 2075 systematically assessed symptoms, 17% were reported to be severe and 48% were mild; 1101 (53%) were distressing. In all cases, the percentage of distressing symptoms increased as the severity increased.
Overall, the ten most common symptoms were fatigue, dry mouth, pain, anorexia, weight loss, early satiety, insomnia, dyspnea, drowsiness and constipation.
During open-ended questioning, the patients’ most frequently reported symptoms were pain (moderate or severe in 83%), followed by fatigue (49%) and dyspnea (27%).
Amongst the ten most distressing symptoms, pain was volunteered in 85%, fatigue in only 42% and anorexia in 31% whereas early satiety, dry mouth, insomnia and weight loss was less than 10%, and reported as distressing.
Less than 10% of patients volunteered early satiety, drowsiness, dry mouth, insomnia, and weight loss. In contrast, the most common assessed symptoms were dry mouth, weight loss, fatigue, early satiety, anorexia, insomnia, drowsiness, dyspnea, constipation and depression.
The median number of symptoms was tenfold higher using the systematic assessment compared to the volunteered. Moderate to severe symptoms, or distressing symptoms, were most frequently reported spontaneously as well as after systematic assessment.
Pain was 70.3 times more likely to be volunteered than any other symptoms and may be the result of education programs for both patients and professionals about the need to report pain, to assess it and to treat it.
Why I chose this article
In the palliative care setting, symptom assessment is considered to be paramount for adequate and personalized symptom management. Many assessment tools for physical as well as emotional symptoms have been studied and validated. This article helps us to reflect once again on the importance of validated assessment tools and a checklist of symptoms as well as those symptoms volunteered by the patients. Moreover, evaluation of distress caused by each symptom should not be underestimated because this could be high even though the symptom is only of slight or mild intensity
Regards,
Carla Ripamonti, MD
Member of the Board of Directors, IAHPC
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