PaulHackerMD.com
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Copy of Paul Hacker’s Pain Scale

The most common way that palliative care practitioners assess symptom control is with a structured questionnaire that includes rating various symptoms on a scale of 0 to 10. The scale most commonly used in Canada is the Edmonton Symptom Assessment Scale, or ESAS.
 
Why I'm not a fan of the ESAS
Why I'm not a fan of the ESAS
The ESAS is a simple tool, but patients universally dislike completing it, for many reasons:
  • Symptoms are hard to quantify in a numerical scale
  • Some of the symptoms are vague and broad
  • Symptoms change through the course of the day and are dependent on activity and other factors
 
I personally have some issues with it as well:
  • Every patient has their own internal scale, so a rating of, for example, 4/10 for pain could mean very different things to different patients. The ESAS never really answers the questions I need to be answered, which are things like “How are your symptoms affecting you?” And “How tolerable are your symptoms right now?”
  • The scale starts from zero, which seems to set zero as a goal for symptom control. This is an unrealistic goal for many patients, and anchors them to that goal.
  • The ESAS, and other numerical symptom rating scales, do not give me the information I need in order to know “do I need to act on this?”
 
Finally, at least one study has shown that almost 1 in 5 people who rate their pain as 4-6/10 on a numerical scale actually feel their pain is intolerable, and almost half of people who rate their pain as 7-10/10 actually feel their pain is tolerable.
My overall impression is that numerical pain and symptom scales are not an efficient way of assessing patients’ symptom control. They may be helpful in statistical analysis of research studies, but without better contextual information, the performance of “doing an ESAS” may actually distract from more relevant symptom assessment in clinical practice.
 

My simpler, more clinically relevant symptom scale:

Over the years of practice, I have developed a pain and symptom scale that works for me, is easier for patients to understand and report, and most importantly, directs me to perform action when needed. My scale has four simple descriptors:
 
Minimal: The symptom is either not present, fleeting and not severe, or never bothersome
Mild: The patient is aware of the symptom only when they stop to think about whether it is present or not
Generally, minimal or mild symptoms do not need action, but knowing that a patient is experiencing the mild level is helpful in knowing what to monitor for change.
Moderate: The patient is aware of the symptom but it does not prevent them from thinking about other things or performing activities such as having a conversation or physical activity, during which the awareness of the symptom is reduced or nonexistent.
Moderate symptoms generally do require intervention, since distraction should not be necessary to manage symptoms unless other approaches cause unwanted side effects. Intervention in this situation can be slow and cautious in order to avoid such side effects.
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For example, if even a small increase in pain medication to treat moderate pain causes unacceptable drowsiness, then distraction may be an acceptable approach if it is effective.
Severe: The symptom is front of mind most or all of the time, and is not minimized significantly by distraction/activity.
Severe symptoms always require intervention, and more aggressive management. In this situation, we might treat the symptom with higher doses of medication quickly in order to bring the symptom under control, and then titrate the medication to reduce any side effects that occur.
 
  • By using this scale, I think that patients understand better what the goals of symptom management are, and why I might recommend some change in management.
    • They can anticipate when I will think about making changes and sometimes use this knowledge to think about whether they feel changes are needed or not.
      • I have had patients tell me that their pain is moderate but they don’t want to make changes right away, even though they know that I will recommend this.
        • I think this allows patients and caregivers to be a more active part of their care plan and gives them some control over their own management.
         
This scale can apply to pain, nausea, dyspnea, anxiety, depression, and fatigue, but doesn’t really work well for the other symptoms from the ESAS: appetite and “well-being”.
 
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