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What is the Edmonton Symptom Assessment Scale (ESAS)?

The ESAS is a tool that was developed to help assess nine symptoms that are common in palliative care patients: pain, tiredness, drowsiness, nausea, lack of appetite, depression, anxiety, shortness of breath, and wellbeing. There is also

a blank scale for patient-specific symptoms.

The ESAS is intended to capture what symptoms you are having and how severe. However, in some situations it may be necessary to obtain a caregiver’s perspective. This is not a one time use kind of tool but instead is used repeatedly to help track changes in symptom severity over time.

The ESAS is only one part of a holistic clinical assessment and should not be thought of as a complete symptom assessment. Any symptoms scoring 5 or greater to be further assessed in depth using the Symptom Assessment Acronym OPQRSTUV assessment tool (article to be coming soon)

How do I use the ESAS?

If possible, especially the first time you use the ESAS, complete it with someone from your health care team.

The severity of each symptom is rated on a scale of 0 to 10. Zero means the symptom is absent and 10 is that the symptom is at it's worst possible severity.

Rate each symptom according to how you feel today. For example, is there no issues with nausea? Then circle the number "0" on the scale.

Your health care team member may ask you additional questions related to your answer, such as: When is you symptom the worst in the past 24 hours? When is it absent?

On the back side of the ESAS is a body diagram to indicate sites of pain. Circle the spots that are giving you pain symptoms.

ESAS-r Numerical Scale
Download PDF • 148KB

When do I do the ESAS?

In palliative care, it is a good practice to complete and graph the ESAS during each telephone or personal contact at each follow-up visit.

If symptoms are in good control, the ESAS can be completed weekly for patients in the home.

In hospice and hospital palliative care units, the ESAS should be completed daily.

ESAS-r Graph
Download PDF • 180KB

Who should do the ESAS?

It is preferable for you, the person experiencing the symptom to rate the symptom severity.

If you cannot provide the ratings of symptom severity but can still provide input (e.g. when the patient is mildly cognitively impaired), then the ESAS is completed with the assistance of your caregiver (a family member, friend, or health professional closely involved in your care).

If you cannot participate in the symptom assessment at all, or refuses to do so, the ESAS is completed by your caregiver alone. The caregiver assesses the remaining symptoms as objectively as possible.

The following are examples of objective indicators:

Pain – grimacing, guarding against painful maneuvers

Tiredness – increased amount of time spent resting, lack of energy

Drowsiness – decreased level of alertness, increased sleepiness or sleeping

Nausea – retching or vomiting

Appetite – quantity of food intake

Shortness of breath – increased respiratory rate or effort that appears to be causing distress to the person

Depression – tearfulness, flat affect, withdrawal from social interactions, irritability, decreased concentration and/or memory, disturbed sleep pattern, feelings of sadness

Anxiety – agitation, flushing, restlessness, sweating, increased heart rate (intermittent), shortness of breath, increased nervousness

Wellbeing – how you feeling overall

If it is not possible to rate a symptom, the caregiver may indicate “U” for “Unable to assess” on the ESAS and ESAS Graph.

The method of completion of the ESAS is indicated in the space provided at the bottom of the ESAS and the ESAS Graph as follows:

Top of ESAS-r Numerical Scale completed by (check one):

• Patient

• Family caregiver

• Health care professional

• Caregiver-assisted

Bottom of ESAS Graph completed by (use letter key)


P = Patient

F = Family caregiver

H = Health care professional

A = Caregiver-assisted

U = Unable to assess

Where to document the ESAS?

The ESAS is always done on the ESAS numerical scale and the results later transferred to the ESAS Graph.

The ESAS can be laminated and you can use a wipeable felt marker to document each time you fill out the ESAS and then the results are transferred to the ESAS Graph.

Graphing symptom severity directly onto the ESAS Graph without the use of the numerical scale invalidates the ESAS as it nor a reliable method of symptom assessment.

ESAS-r Numerical Scale
Download PDF • 148KB

ESAS-r Graph
Download PDF • 180KB

Other information about the ESAS

The ESAS Graph contains space for the Palliative Performance Scale (PPS) is also provided.

Taking Action Using ESAS data

For ESAS symptom scores of 3 or less (considered stable), symptom management and nursing care are usually continued as per you, the patient, orders.

For ESAS symptom scores of 4-6, further assessment recommended by using Symptom Assessment Acronym OPQRSTUV assessment tool (article to come in the future). Further consultation with your physician and palliative team members may be required.

If your ESAS score is 4-6, the goal is to stabilize symptoms down to ESAS score 3 or less within 4 hours.

For ESAS symptom scores of 7 or greater, this is an unstable symptom and requires urgent attention. Further assessment recommended using Symptom Assessment Acronym OPQRSTUV assessment tool is required. Consultation with physician and other palliative team members required.

If your ESAS score is 7 or higher, the goal is to stabilize that symptom to an ESAS score of 5 or less within 4-6 hours, and then to stabilize that symptom to an ESAS score of 3 or less within 12 hours.

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