Recognising the Need for Palliative Care

Assessing care needs and prognosis in acute care

Acute care is the place of death for approximately 50% of all deaths in Australia. [1] Within the acute care setting many patients will be identified as requiring palliative care. Some will require ongoing care within the hospital and/or after discharge, others will be actively dying and require terminal care. Individuals currently receiving palliative care may be admitted if their condition deteriorates or complexity increases requiring acute medical or surgical intervention, pain management, or symptom control. Recognising that a person is approaching end-of-life is essential to:

ensure appropriate care is received,
prepare the person and their family for this outcome,
help clinicians make timely referral to other services as appropriate.

It is also important to recognise whether the person is actively dying and death imminent.

Need for palliative care

There are a number of tools currently in use within the acute care setting to assist health professionals in the identification of patients with palliative care needs. These support but do not replace clinical judgement and effective use requires collaboration and a multidisciplinary approach. [2]

Triage tools
RUN-PC Tool
- An evidence-based tool to aid in the prioritisation of patient referral to specialist palliative care services.
- For inpatient unit setting, hospital consultation setting, or community setting.
- An online calculator for rapid assessment based on 7 items across physical, psychosocial and caregiver domains.
- A pdf of outcomes can be printed or saved.
- Takes approximately 5 minutes to complete.
SPEED
- Screen for Palliative and End-of-life care needs in the Emergency Department.
- For patients with cancer.
- Symptom assessment tool which covers: social, therapeutic, physical, psychological and spiritual
- 13 questions.
Prognosis tools
The Surprise Question (367kb pdf)
- Can aid in the identification of patients changing needs.
- For patients with advanced disease of progressive life limiting conditions.
- One question.
Supportive & Palliative Care Indicators Tool (SPICT)
- Helps clinicians identify people with one or more general indicators of poor or deteriorating health and clinical signs of life-limiting conditions for assessment and care planning.
- Provides indictors which clinicians can use to identify when it may be appropriate to initiate end-of-life care discussions with patients and their families or carers, as well as substitute decision makers.
- Has 6 general indicators of deteriorating health and increasing care needs, including trigger events.
- Outlines 6 core aspects of palliative care and future care planning.
- Takes approximately 5 – 9 minutes to complete.
- CareSearch interactive versions of the SPICT (571kb pdf) and SPICT-4ALL (571kb pdf) forms for online use.
NAT-PD (128kb pf)
- Needs Assessment Tool: Progressive Disease. In generalist settings (e.g. general practice, oncology and cardiology) it can be used to determine which needs may be met in that setting and which needs are more complex and may be better managed by specialists.
- One page assessment tool that can be completed by health professionals across a range of disciplines.
- 73 questions.
Gold Standards Framework – Proactive Identification Guidance (PIG) – 7th edition.
- This stepped framework helps clinicians to identify patients early, based on general and condition specific indicators, assess needs and wishes, and to plan care tailored to the patients’ choices.
- Uses 3 triggers to identify patients nearing end of life: Includes the Surprise Question (Would you be surprised if this patient were to die in the next few months, weeks, days?); general indicators of decline; and specific clinical indicators related to certain conditions.
- Predicting needs rather than an exact prognostication.
Australian-modified Karnofsky Performance Scale (AKPS)

Physical performance state also has prognostic significance, especially in advanced cancer. The Australian-modified Karnofsky Performance Scale (AKPS) is a measure of a patient’s overall ability to undertake activities of daily living.
- A single score between 10 and 100 is assigned by a clinician, based on observing a patient’s ability to perform everyday activity, work and self-care tasks.
- A score of less than 40 correlates to a median survival of around 3 months for patients with advanced cancer.
Recognise active dying
The signs that a person may be entering the terminal phase include:
- Deteriorating day by day or hour by hour
- Becoming bed-bound for most of the day
- Extreme tiredness and weakness
- Sleepiness and drowsiness
- Being less responsive and less able to communicate
- Needing help with all personal care
- Little interest in food or drink
- Difficulty swallowing food, fluids and oral medication
- Reduced urine output
- New urinary or faecal incontinence
- Changes in their normal breathing pattern
- Noisy chest secretions
- Mottled skin and cold skin particularly hands and feet
- Delirium
- The person telling you they may feel like they are dying.
Knowing whether a person is entering the last days of life or stabilising or if there is potential for even temporary improvement can be difficult, as signs might be inconsistent or fluctuating.

Useful Tools include:

Use the End-of-life Essentials toolkit action checklist to guide recognising dying.

Responding to palliative care needs

Care for the person with palliative care needs will depend on individual needs and phase of illness.

The CareSearch Acute Care Responding to patient needs webpage provides guidance on assessing and responding to patient needs.
For patients in the terminal phase check if your organisation has an end-of-life pathway.

Referral:

If available refer to referral pathways in your organisation for palliative care specialist input.
Where unavailable consider contacting one of the specialist palliative care advice services listed in Planning for Palliative Care Delivery.
The Palliative Care Status Form can be used by medical practitioners and nurse practitioners to refer patients to residential aged care for palliative care.

Watch Professor Paddy Stone discuss the role of prognostic information and the role it plays in reducing the prevalence of burdensome treatments at the end-of-life.

Prognosis in palliative care webinar

Video from Palliative Care NSW

References
1. Australian Institute of Health and Welfare (AIHW). Deaths in Australian hospitals 2014-15 [Internet]. Canberra: AIHW, 2017 [cited 2022 Nov. 22].
2. Rumbold B, Aoun SM. Palliative and End-of-Life Care Service Models: To What Extent Are Consumer Perspectives Considered? Healthcare (Basel). 2021 Sep 28;9(10):1286. doi: 10.3390/healthcare9101286.