KEY PRINCIPLES OF SYMPTOM MANAGEMENT First, the preferred choice of the patient Second, open communication involving not

olving not only patients and family members but also include all relevant health professionals who will facilitate informed decision making. Third, listen to patients own story (past & present life experiences) will assist the professional to understand the impact of symptoms from the patients perspective. Impact of physical or psychological symptom manifests in a degree suffering, however, the severity of unrelieved symptoms is not necessarily directly related to suffering. Suffering more concerned with a sense of hopelessness and futility. Suffering can be exacerbated by the disruption of personal identity (Kissane 2000). Health professionals find it less traumatic to focus on occurrence of symptoms that the experience of the individual patient (Aranda 2003). Look on the patient as an individual, caregivers can create an environment that facilitate inner healing, thus reducing suffereing (Kearney, 2000). Symptom management in palliative care is much more than using evidence-based interventions; involves fostering hope and showing by our actions and words that we consider patients to be worthwhile even if they themselves do not (Regnard & Kindlen, 2002). Achieving this involves a degree of giving oneself in facilitating a therapeutic relationship with the patient (Kabel & Roberts 2003, Ramfelt et al 2002).

Symptoms are multidimensional = adopt a multiprofessional approach = Use interdisciplinary therapeutic model encompassing all dimEnsions of care. Allows members to share information through discussion and working together to formulate goals. TAKE NOTE: one must be cautious when discussing symptom incidence and prevalence data because patient cohorts, symptom checklists and study methodologies differ. Core Symptoms related to Hospice admissions: Fatigue, Pain, Dyspnea, and Constipation. THE PROCESS OF SYMPTOM MANAGEMENT The Five Main Principles: EEMMA EVALUATION Establish cause of symptoms Effectiveness of interventions already implemented Physical examination Because of complexities, determine if the symptom is due to: - the disease itself - the treatment - concurrent medical conditions - or a combination of all three

 Regardless of the cause, a decision must be taken as to whether the symptom is reversible, treatable or a terminal event for the patient. A comprehensive explanation of the management plan should be given to the patient and family. If the patient is dying, appropriate terminal event symptom management should follow. Important: Patient-reported evaluation (mandatory) Assessment instruments - Self-reporting instruments (most accurate and often over/underestimated) - Used to supplement professional judgment and aid assessment. - Issues: - problems in practical application (patient and staff burden) - although comprehensive, are cumbersome and requires time and effort from both patient and health professional. - Benefit of using this tool must outweigh the burden of the patient. - Recommendations: - the simpler and briefer the tool, the more applicable. - Examples: Verbal Rating Scales and Visual Analogue Scale A plethora of general and disease-specific instruments exists, but what is important is that practitioners should choose a measurement tool that best suit the patient and measure the dimension of the symptom that is being assessed. EXPLANATION Explanation about the care and treatment options is vital to the delivery of effective care and empowers patients and caretakers to be involved as equal partners in the decision-making process. Information about the disease process and significance of symptoms should be provided to patients when they need it, and not at a time convenient for the caretakers. Information should be provided in a sensitive manner. Poor communication skills in relation to information giving can have a detrimental effect on patient outcomes. MANAGEMENT Identify the cause and determine what is reversible or treatable Health professionals should work in partnership with the patient. Patients priorities must be considered, and realistic goals set in conjunction with the patient and then documented in the management plan. Treatment interventions should be tailored to meet the needs of the patient. Team cohesiveness is crucial to achieving successful outcomes. In order to achieve cohesiveness and be efficient, it may be useful for the interdisciplinary team to incorporate elements of collaborative practice. MONITORING Will not only determine the efficacy of interventions, but also facilitate regular reassessment of the severity of the symptoms and impact on the patient. Outcomes should be discussed.

 Have a contingency plan; this can have the effect of empowering the patient and again, limiting any time-wasting. ATTENTION TO DETAIL If done erroneously - will have significant consequences for the patient. Throughout the process of symptom management, any missing detail by the health professionals can have significant consequences. Crucial time can be wasted: - by not actively listening to the patient at the initial assessment stage - by prescribing but not ascertaining the practical availability of medications and assessing side effects - by failing to ask the right questions to elicit the correct information when monitoring interventions. Key Points: Meticulous assessment and multiprofessional input will increase the chances of getting it right first time. Involve the patient in decision-making partnership by exploring the symptom experience together. Never give up hope or underestimate the effect that showing that you truly care about the patient will have on treatment outcomes.