7.2 the measurement of, and tools for, pain and other symptoms

Question 1

What is the predominant difference between a symptom and a sign

Answer 1

a symptom is ‘a physical or mental feature which is regarded as indicating a condition of disease, particularly such a feature that is apparent to the patient’, inherently subjective.

signs, which are objective indicators of disease, and from pathological processes or diagnoses.

Question 2

Symptom assessment tools seek to measure subjective symptom experiences. What is the best primary source of information for such tools? What are three situations where this is not possible?

Answer 2

patient self report
Not possible in pre-verbal patients and those with cognitive impairment from delirium or dementia

Question 3

List three specific dimensions of a symptom that can be measured

Answer 3

Frequency
Severity
Distress

Question 4

List three specific factors that symptom impact on can be measured. List two global constructs that can be impacted by symptoms and which can be measured

Answer 4

Other physical and psychological symptoms or diagnoses

Function

Family, social, financial, spiritual, and existential resources and concerns

Global constructs: Global symptom distress, Health-related quality of life

Question 5

List four temporal dimensions of a symptom which can be measured

Answer 5

onset (abrupt or insidious)

duration

trajectory (worsening or improving)

daily pattern (continuous or intermittent)

Occurrence of discrete episodes of worsening symptoms

Question 6

The impact of a symptom on QOL is most strongly associated with what dimension of a symptom? What is a common tool for measuring this dimension?

Answer 6

the impact of symptoms on QOL was maximized by concurrent measurement of other factors, including ‘symptom distress’ and either frequency or intensity. Of the
three dimensions assessed, distress was the most informative.

The Distress Thermometer

Question 7

List four factors that modulate a pathophysiological process and influence the experience of symptoms

Answer 7

physical strengths
coping and adaption
family, social, financial supports
spiritual and existential resources

Question 8

List three factors that influence the perception of symptoms (fig 7.2.1)

Answer 8

physical symptoms
psychological symptoms
disturbances in function

Question 9

What two forces interact with one another to cause suffering and impaired QOL in PC (figure 7.2.1)

Answer 9

pathophysiological processes and perceptions?

Question 10

Outcomes in PC are improved when routine use of symptom assessment tools is augmented by what two things

Answer 10

clinical pathway implementation and access to expert consultation

Question 11

The routine use of symptom assessment tools improves what two primary outcomes? Less robust data exists for what two secondary outcomes

Answer 11

• patient-centred care in cancer settings, particularly in relation to patient-provider communication and patient satisfaction
• relation to the monitoring of treatment response and the detection of unrecognized problems.

-evidence is weak or non-existent in relation to the impact on changes to patient management and improved health outcomes; changes to patient health behaviour or the effectiveness of quality improvement of organizations; or the transparency, accountability, public reporting activities, and performance of the health-care system

Question 12

A researcher is conducting an observational study and wants detailed information about symptoms that patients experience. What type of tool would be best

Answer 12

Simple, face-valid checklists may be used to determine the incidence
or prevalence of multiple physical and psychological symptoms

Question 13

A researcher is conducting an observational study and wants to determine the prevalence of dyspnea after an intervention. What type of tool would be best

Answer 13

instrument for the measure of a particular symptoms - dyspnea scale

Question 14

A researcher wants to understand the patient experience of nausea and also wants to know the impact of nausea on QOL. The researcher decides to use a QOL measure to collect all the data. Are there any issues with this? Why or why not?

Answer 14

QOL instruments were not developed as symptom assessment instruments. Neither the prevalence rates nor the characteristics and dimensions of the diverse array of physical and psychological symptoms experienced by patients may be captured adequately by these instruments.

Question 15

An intervention is done and shows a reduction in pain severity of 1.2 in Group A and 1.9 in group B. The p value for the difference in pain is <0.01. Are there any issues with this? Why or why not?

Answer 15

• Statistical significance may or may not indicate clinical relevance
• Moreover, this difference reflects average scores and may hide the fact that some patients had very large changes after a treatment, whereas some did not change at all.

-Information about the responsiveness of a questionnaire to clinical changes and the minimal important difference (MID) in scores that depicts a clinically important change are very helpful in determining whether the differences observed during a study actually reflect a clinically meaningful event

Question 16

What is the minimal important difference for pain on a 0-10 scale?

Answer 16

1.2 pain

Question 17

What are four factors to consider when choosing what symptom assessment tool to use?

Answer 17

-understanding of the goals of assessment
-practicality,
-applicability
-acceptability of the instrument in the particular patient population.
-Evidence that the instrument is valid and reliable for the purposes intended should be considered carefully

Question 18

What is the gold standard for instruments for assessing symptoms such as pain?

Answer 18

ESAS - Edmonton symptom assessment system

Question 19

List four barriers to the implementation and use of standardized assessment tools in palliative care. Give an example of each

Answer 19

-professional challenges - conceptual and attitudinal barriers to the use of health status measures in patient care and clinical trials

-systems challenges - enormous variation in the health-care systems that provide care to patients with serious illness

-patient challenges - Patient self-report may be impaired by cognitive impairment or other medical problems associated with progressive illness, or by the highly prevalent symptom of fatigue, cognition, culture/language

-limitations in the instruments used to acquire data - valid measures are still lacking for some common symptoms, and many tools validated in one population have uncertain generalizability to others