Table 3

Joanne's assessment and plan (integrating spiritual issues with the psychosocial and physical)

Joanne is a 68-year-old woman with end-stage metastatic breast cancer, severe pain managed on opioids, medication-associated nausea, constipation, occasional insomnia, and spiritual and existential distress
PhysicalContinue with current pain regimen, add 5-HT3 antagonists, add trazodone prn, and bowel regimen referral to ortho-oncologist for possible surgery to treat pain and improve mobility so patient can travel.
EmotionalSupportive counselling, presence
SocialEncourage family meeting to discuss prognosis, goals of care, encourage patient sharing if she would like.
SpiritualSpiritual counselling with chaplain, team continues to be present, exploring sources of hope, life story, meaning.