1. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Osteopathic EPEC Osteopathic EPEC Education for Osteopathic Physicians on End-of-Life Care Based on The EPEC Project, created by the American Medical Association and supported by the Robert Wood Johnson Foundation. Adapted by the American Osteopathic Association for educational use. American Osteopathic Association AOA: Treating our Family and Yours

2. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Module 3 Whole Patient Assessment

3. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Objectives Disease history Physical symptoms Osteopathic structural exam Psychological symptoms Decision-making capacity Information sharing Social Spiritual Practical Anticipatory planning for death Know how to identify, assess

4. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Why skill at assessment is important Patients expect relief of suffering Key diagnostic tool Coordinates team of health professionals Can have therapeutic effects Develops the physician-patient relationship Applying osteopathic principles provides additional diagnostic and therapeutic tools

5. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours The physician’s role Listen Acknowledge Analyze Offer information, practical suggestions Introduce sources of support

6. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours 9 dimensions of assessment 1.Illness / treatment summary 2.Physical 3.Psychological 4.Decision making 5.Communication 6.Social 7.Spiritual 8.Practical 9.Anticipatory planning for death

7. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Illness / treatment summary Primary diagnosis Secondary concurrent illnesses Treatment summary

8. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Physical assessment Symptoms Physical function, impairments Physical examination, including osteopathic structural exam Minimize tests

9. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Common symptoms Pain Weakness / fatigue Breathlessness Insomnia Weight loss Confusion Constipation Anxiety Nausea / vomiting Depression

10. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Symptoms – causes Multiple causes the primary illness an effect of therapy psychological, social, spiritual, practical issues another medical condition

11. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Pain as a model for symptom assessment High prevalence Can be well controlled Often undertreated Adequate treatment requires adequate assessment Gateway to other assessments

12. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Pain assessment Location (1°, referral pattern) Quality Timing Severity Radiation Modifying factors Impact on function Effect of treatments Patient perspectives

13. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Function Relationship between structure and function Motor function Sensory function Effect on activities Effect on relationships Patient perspectives

14. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Psychological assessment... Cognition Delirium, dementia Affect Anxiety, depression Emotions prompted by the life- threatening illness

15. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours... Psychological assessment Coping responses Suicidal ideation Fears Loss of control, burden, abandonment, indignity Unresolved issues

16. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Emotional responses to illness Avoidance, denial Fear, anger Lability, irritability Intellectualization Grief Acceptance, spiritual peace

17. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Fears Loss of control, dignity Loss of relationships Being a burden Physical suffering

18. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Unresolved issues Old feuds Last visits Lifetime project, piece of work

19. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Decision-making assessment Capacity / competence Goals of care Advance care planning (including clarification/documentation of “code” status) Informed consent

20. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Decision-making capacity Global incompetence Decision-specific capacity

21. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Decision-specific capacity Understand authorization role Rational use of information, including risk, uncertainty Insight into consequences Non-coerced

22. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Communication assessment... Is there someone to share fears with? talk to? plan with? Is the information clear? understandable? What the patient wants to know Child’s parents

23. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours... Communication assessment Who else to talk to Limits of confidentiality Is language an issue?

24. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Social assessment Family, family dynamics Community Environment Financial

25. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Community Culture Sources of assistance Religious Disease groups Local

26. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Financial Spending down Medical bills Family sacrifice

27. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Spiritual assessment Meaning, value – personal, of the illness Burden, control, independence, dignity Faith Religious life, spiritual life Spiritual leader

28. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Meaning of illness Fears and concerns Illness Death & dying Changes and losses Family / self / role Control

29. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Spiritual activities Religious denomination (past or present) Activity level Prayer / scriptural resources

30. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Spiritual leaders From community From health system (chaplain)

31. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Rituals Special prayers, actions Last prayers, declarations

32. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Spiritual crises... Search for meaning or purpose in one’s life Loss of a sense of connection Feelings of guilt or unworthiness

33. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours... Spiritual crises Questioning of faith Desire for forgiveness Sense of abandonment by God

34. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Approach to spiritual assessment Suspect spiritual pain Establish a conducive atmosphere Express interest, ask specific questions Listen for broader meanings Be aware of own beliefs, biases

35. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Practical assessment Caregivers Domestic needs Dependents

36. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Caregiver Who? At what sacrifice? Comfortable relationship? Unmet needs?

37. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Domestic needs Chores of day-to-day living Cooking Cleaning Shopping Banking Bill payment Transportation

38. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Family Dependents Children Elders Infirm Pets

39. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Anticipatory planning for death Current losses Anticipated losses Advance care planning Advance planning for last hours and after death

40. EPECEPECEPECEPEC American Osteopathic Association AOA: Treating our Family and Yours Whole Patient Assessment Summary