What is Edmonton Symptom Assessment System

What is Edmonton Symptom Assessment System

To start the week out, I realized that my subject had to change based on the instructor’s feedback and the information I had available to me. I sat down with my mentor, the administrator of the company, and the person in charge of quality for the hospice company I work for. We looked over the QAPI (Quality Assessment and Performance Improvement) scores for the last three quarters and realized that we did not meet our goal of having a skilled nurse visit at least 3 to 6 days before death. Having an increase in nursing visits in hospice is imperative to confirm that the patient is comfortable and has no new symptoms related to death and to help prepare the family.


Like other fields in nursing, hospice relies heavily on good assessment skills and good communication with the patient and family. We are also required to use the Edmonton Symptom Assessment Scale each visit. This scale is a series of 10 questions with a rating of 0-10 (What is Edmonton Symptom Assessment System (ESAS) – Meaning and definition – Pallipedia, n.d.). It is required at each visit to ask the patient or caregiver to rate pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, well-being, and shortness of breath. In theory, the higher the number, the lower the quality of life (Chow et al., 2019). This, therefore, is a predictor of decline and indicates that nursing visits need to increase.


The question is, why did we fail at determining the decline in our end of life patients. There are times when, of course, you can not predict death. In speaking with my mentor, we feel it may be other factors involved in overlooking the decline in our patients. We may not be paying attention to the details of the nursing assessment, such as minor changes in lung sounds, perfusion, blood pressures, or breathing patterns, which may be expected for some patients but not in others. Another factor that would cause the nurse to overlook minor details is not communicating with the patient or families and explicitly asking them the questions in the ESAS each visit or just filling it out based on the nurse’s judgment. We also discussed if the nurse understood the importance of the ESAS and how it can be a good predictor of decline in our client base.




Chow, S., Wan, B. A., Pidduck, W., Zhang, L., DeAngelis, C., Chan, S., Yee, C., Drost, L., Leung, E., Sousa, P., Lewis, D., Lam, H., Chow, R., Lock, M., & Chow, E. (2019). Symptoms Predictive of Overall Quality of Life Using the Edmonton Symptom Assessment Scale in Breast Cancer Patients Receiving Radiotherapy. Clinical Breast Cancer, 19(6), 405–410. https://doi-org.ezp.waldenulibrary.org/10.1016/j.clbc.2019.05.007


What is Edmonton Symptom Assessment System (ESAS) – Meaning and definition – Pallipedia. (n.d.). Pallipedia.Org. Retrieved October 23, 2020, from https://pallipedia.org/edmonton-symptom-assessment-system-esas/#:~:text=Edmonton%20Symptom%20Assessment%20System%20%28ESAS%29%20This%20tool%20is

Hui, D., & Bruera, E. (2017). The Edmonton Symptom Assessment System 25 Years Later: Past, Present and Future Developments. J Pain Symptom Manage, 53 (3): 630-643.

The article discusses that the symptoms of hospice patients often fluctuate with time. This makes it essential to track patients longitudinally and record their symptom decline or progress. Accordingly, Edmonton Symptom Assessment System (ESAS) is to be administered at each clinic visit to record any symptom fluctuations. The article suggests further refinements to ESAS including integrating ESAS in electronic health records, coupling ESAS with individualized symptom goals to optimize symptom response assessment, and utilizing ESAS as a trigger for palliative care referral.

Richardson, L.A; Jones, G.W. (2009). A review of the reliability and validity of the Edmonton Symptom Assessment System. Curr Oncol, 16 (1): 55-70.

This article discusses that ESAS is consistent but its validity is limited, and its utilization needs a logic clinical procedure to assist in interpreting the scores and provide a suitable level of attention. The authors establish that emotional symptoms are normally poorly captured using the depression and anxiety items. This is because the emotional components in ESAS are underdeveloped and need general adjustment. The authors suggests a separate tool to be developed that is similar to ESAS, which addresses more than ten emotional symptoms using nonpsychiatric labels and include symptoms representing additional disorders than just depression and anxiety.

Pereira, J.L., Chasen, M.R., Molloy, S., Amernic, H., & Brundage, M.D. et al. (2016). Cancer Care Professionals’ Attitudes Toward Systematic Standardized Symptom Assessment and the Edmonton Symptom Assessment System After Large-Scale Population-Based Implementation in Ontario, Canada: Systematic Standardized Symptom Assessment, Journal of Pain and Symptom Management, 51 (4): 1-19.

The article states that some hospice patients do not understand aspects of the ESAS, hence can find difficulty completing it. This necessitates healthcare professionals and patients to be coached on the way to use the instrument properly. The authors claim that a person centered approach to care focuses on the call for for care providers to recognize and take into consideration the needs, preference, and illness experience of the patient. The article therefore suggests that the use of ESAS should be aligned with person centered approach to care, and acknowledge and address patient needs.

Rauenzahn, S.L., Schmidt, S., Aduba, I.O., Jones, J.T, Ali, N., & Tenner, L.L. (2017). Intehrating Paliative Care Services in Ambulatory Oncology: An Application of the Edmonton Symptom Assessment System. Journal of Oncology Practice 13 (4): 621-710.

The authors affirm that symptom burden still remains equally high from initial to follow-up encounters. Misunderstanding of the advantages of palliative care services is the greatest barrier to proper use of ESAS. This requires potential criteria to construct and apply a trigger that is supported on patient-rated symptom scores to assist patents and care providers manage symptoms. The article suggests the utilization of ESAS instrument with an electronic medical record-based provider alert that documents a predefined percentage of patients towards improving palliative care, symptom improvement as well as patient outcomes.

Garyali, M.D., Palmer, L., Sriram, Y., Zhang, T., Pace, E.A., & Bruera, E. (2006). Errors in Symptom Intensity Self-Assessment by Patients Receiving Outpatient Palliative Care. Journal of Palliative Medicine, 9 (5): 1059-1065.

The article discusses that there is a possibility of error if nurses do not monitor routinely the way patients have completed ESAS form. It is necessary to be cautious regarding the ESAS scores that are performed by the patients especially for symptoms of appetite, sleep, and pain. The authors suggest that nurses need to carry the ESAS symptom score into rooms of patients and review symptom outcomes to make sure there is consistency. Symptom intensity assessment is very important in minimizing measurement errors among hospice patients since it assists to guide patient care.

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