Support the evaluation of physical, environmental, social, cultural, emotional, psychosocial and spiritual needs
Comprehensive assessment enables the evaluation of physical, environmental, social, cultural, emotional, psychosocial and spiritual needs. Comprehensive assessment can also determine the need for inclusion of an Aboriginal liaison officer or palliative care Aboriginal health worker, as required, or the use of the Health Care Interpreter Service.
Processes are in place to ensure comprehensive, culturally appropriate and holistic assessment is undertaken for all people identified as having end of life and/or palliative care needs.
Comprehensive assessment is important to facilitate identification of all End of life and palliative care needs for the person, their family and carers throughout their experience.
Holistic assessment should be multidisciplinary and occur through a combination of dedicated services or specified referral pathways to existing services, as appropriate. This may require virtual care access where resources are limited.
Assessment is to include use of a validated symptom assessment tool, distress screening tool, and a screening or assessment tool for identification of carer needs, availability and capability.
Examples of assessment tools include Resource Utilisation Groups-Activities of Daily Living (RUG-ADL), Australia-modified Karnofsky Performance Status (AMKPS), Symptom Assessment Scale (SAS) and Palliative Care Problem Severity Score (PCPSS).
Referrers should consider the questions and use the tools and information below when providing virtual palliative and end-of-life care.
Inform the patient, their family or carer of the virtual care modalities available, and document their preferences. Based on availability and mutual agreement, this could include their ability and willingness to travel due to wellbeing, ease and cost of travel, personal and family commitments, spiritual needs, and available technology. More on consumer support.
If in-person assessment is not needed, which available virtual care modality will provide the highest quality assessment? Be aware that 55% of communication comes from facial expressions and body movement. More on ways of delivering virtual care.
Tell the patient how they can change an appointment type when mutually suitable alternatives are available. This will vary depending on the specific service.
Has the patient, family or carer received information and support on how to use the technology to access their virtual appointment? Consider awareness of calls from private phone numbers, and/or access to the link for their virtual appointment (i.e. link to videoconferencing platform/virtual room).
Should others attend the appointment? Consider the multidisciplinary advantages of having a GP, specialist, other health professionals, family and other important people attending the appointment in a virtual or hybrid context.
Do all people attending the VC appointment understand virtual care processes and etiquette? Consider factors such as lighting, framing, background, background noise levels, position of the camera and screens. Clinicians may need to provide information, model good etiquette and provide direction to patients, family and carers attending.
If an appointment is urgent, is there enough travel time or is virtual care a more viable option?
Does the patient, family or carer need support to navigate the virtual care platform? Consider the need for an additional clinician, family or carer to be available to support the patient. Provide virtual care education resources as required.
Does the patient need a pre-appointment test run? This should be performed using the same device that will be used in the virtual appointment. It is also preferable to conduct this from the normal location where the appointment will occur. It can be helpful to provide a demonstration when the patient, their family and carer are attending an appointment in-person. A troubleshooting guide is available to assist patients resolve any technical issues.
Who else needs to attend the appointment? Any person who can support the patient can be included in a virtual consultation with their consent. If the patient does not have decision-making capacity, is the person responsible attending the appointment? Is a support person needed? Has the patient identified a family member/carer to be included in their care discussions? Has the clinician considered the multidisciplinary advantages of having the GP, family, specialist, other health professionals and other relevant people to attend the appointment?
What happens if the patient, family, or carer deteriorates, or the technology fails while I’m providing care virtually? Each team should have its own protocols for escalating care or managing technology failures during an appointment. Measures could include:
For more virtual care resources, see:
Aboriginal and Torres Strait Islander Care
Resources and information to help the healthcare workforce and carers provide palliative care.
CareSearch | Information | 2017
Supportive Care - Into the Dreaming
A guide for Aboriginal and Torres Strait Islander people through 'Sorry Business'.
Hunter New England Local Health District | Toolkit | 2019
Aboriginal people refer to the period of cultural practices and protocols associated with death as Sorry Business. Sorry Business is an important time of mourning that involves responsibilities and obligations to attend funerals and participate in other cultural events, activities or ceremonies with the community. We value the importance of advance care planning yarning so this resource has been developed to provide culturally appropriate, respectful, and mindful information to encourage Aboriginal people in opening up conversations about their rights, wishes and how to plan ahead when circumstances change through life.
South Western Sydney Primary Health Network | Information | 2021
Aboriginal Health and Medical Research Council - Palliative Care Resource Centre
The My Journey to Dreaming Diary is a place for people to keep personal and medical information and includes mindful activities to prompt reflection, wellness, and gratitude. The Journey to dreaming toolkit has been developed to provide high quality information to help Aboriginal and Torres Strait Islander families and their healthcare workers provide family-centred palliative and end-of-life care.
Aboriginal Health and Medical Research Council of NSW | Information | 2023
Advance Care Yarning Decision Making for End of Life For Aboriginal People in lutruwita/Tasmania
These guidelines aim to help Aboriginal people, their families, and their community who live in Iutruwita/Tasmania to better understand their choices at end-of-life and how to share them with medical and health professionals through advance care yarning.
Palliative Care Tasmania | Information | 2020
Gwandalan Project - e-learning modules
These e-learning modules explore aspects of Aboriginal and Torres Strait Islander history and culture relevant to the palliative and end of life care journey, and the commonly practiced cultural protocols associated with returning to spirit (death and dying). It will support health professionals to provide more impactful, meaningful and culturally safe and responsive palliative care for Aboriginal and Torres Strait Islander patients, families and communities.
Gwandalan | Educational | 2021
Dignity, Respect and Choice: Advance Care Planning for End of Life for People with a Mental Illness
Support people with mental illness with complex issues around advance care planning.
NSW Ministry of Health | Toolkit | 2015
Palliative Care Outcomes Collaboration: Assessment forms
Five tools that help assess the characteristics and needs of patients.
University of Wollongong | Clinical tool | 2021
NSW Health Falls Risk Screening Tools
The Falls Screen is to be completed on admission to identify patients falls risk factors. If falls risks have been identified, a Falls Risk Assessment and Management Plan (FRAMP) is to be completed and interventions actioned for the falls risk factors that have been identified in the screen. Care planning should also be discussed with the patient or family/carers and falls risk interventions communicated at handover.
Clinical Excellence Commission | Clinical tool | 2025
Australia-Modified Karnofsky Performance Score (AKPS)
The AKPS scale is a measure of the patient’s performance across the dimensions of activity, work and self-care. The AKPS results in a single score between 0 and 100. For PCOC, the scores from 10 through to 100 are reported. AKPS is completed by a clinician. It is based on observations of a patient’s ability to perform common tasks relating to activity, work and self-care.
University of Wollongong | Toolkit | 2005
FACIT-Pal: Functional Assessment of Chronic Illness Therapy - Palliative Care
A series of questionnaires informing clinical management of chronic diseases and cancers. The tool measures physical wellbeing, social/family wellbeing, emotional wellbeing, functional wellbeing and a palliative care subscale.
FACIT Group | Toolkit | 2013
A suite of tools and resources to facilitate early identification of patients who are dying, planning for optimal symptom management and addressing social, spiritual and cultural needs.
Clinical Excellence Commission | Toolkit | 2017
Needs Assessment Tool for Carers [NAT-C]
A two-part intervention to identify carers’ needs to be systematically identified and managed by their GP. It comprises of a brief checklist of common concerns, the Needs Assessment Tool - Carers (NAT-C) and a matching GP Toolkit of resources. Carers complete the NAT-C and use it to identify their concerns and needs to the GP.
CareSearch | Clinical tool | 2022
Needs Assessment Tool for Carers [NAT-PD]
Clinical assessment tool aiming to assist in matching the types and levels of need experienced by people with progressive chronic diseases (e.g. cancer, heart failure, COPD) and their caregivers with the most appropriate people or services to address those needs.
CareSearch | Clinical tool | 2010
Needs at the End-of-Life Screening Tool (NEST)
Clinical assessment and outcome measurement instrument for end of life care (Needs, Existential, Symptoms, and Therapeutic).
National Palliative Care: Research Centre | Clinical tool | 2006
The Palliative Care Phase tool is commonly used in clinical practice to describe a patient's current condition or phase-assessment; stable, unstable, deteriorating, terminal and bereaved. The palliative care phase is determined by a holistic clinical assessment which considers the patient and their family and carers' needs.
University of Wollongong | Clinical tool | 2014
Palliative Care Problem Severity Score (PCPSS)
The Palliative Care Problem Severity Score (PCPSS) is a clinician rated screening tool to assess the overall degree of problems within four key palliative care domains (pain, other symptoms, psychological/spiritual and family/carer)
University of Wollongong | | 2021
Resource Utilisation Groups - Activities of Daily Living (RUG-ADL)
The Resource Utilisation Groups - Activities of Daily Living (RUG-ADL) is a four-item scale measuring motor function with activities of bed mobility, toileting, transfer and eating. The RUG-ADL tool is also one of 5 assessment tools used in the national Palliative Care Outcomes Collaboration (PCOC) open to participation by all palliative care services.
University of Wollongong | Toolkit | 2021
Supportive and Palliative Care Indicators Tool (SPICT)
A tool to help clinicians identify people with deteriorating health using general indicators of poor or deteriorating health and clinical signs of life limiting conditions. The tool aids assessment and care planning. SPICT looks at health status and is not a prognostic time frame.
Supportive and Palliative Care Indicators Tool | Clinical tool | 2025
The Gold Standards Framework (GSF) Proactive Identification Guidance (PIG)
A guideline that aims to identify patients early who may be nearing the end of life who may require additional supportive care. This tool is used to identify people based on three different end of life trajectories - those who are experiencing rapid, predictable decline (e.g. Cancer), erratic decline (e.g. organ failure) and gradual decline (e.g. frailty and dementia).
The Gold Standards Framework | Information | 2022
The Caregiver Strain Index is a 13-item tool originally developed to screen for caregiver strain following the hospital discharge by an elderly family member. The tool supports quick identification and measurement of family concerns in the employment, financial, physical, social and time domains.
National Palliative Care: Research Centre | Clinical tool | 1983
Carer Support Needs Assessment (CSNAT)
A self-assessment tool for carers, facilitated by clinicians, to identify their needs and issues and assist them to rate how concerning these needs and issues are for them. The CSNAT is protected by copyright. Go to the Licensing section to download an inspection copy of the full CSNAT.
Carer Support Needs Assessment Tool Intervention | Clinical tool | 2013
CarerHelp is funded by the Australian Government Department of Health and provides a collection of resources for carers supporting someone approaching the end of life.
CarerHelp | Information | 2025
Carers Australia is the national peak body representing Australia’s carers, advocating on behalf of Australia’s carers to influence policies and services at a national level.
Carers Australia | Information | 2025
Carers NSW is the statewide peak organisation for carers and they have a suite of resources for carers supporting someone at the end of life. This link shares videos of carers sharing their experiences and insights of caring for someone living with a chronic condition or terminal illness as information factsheets. This page also takes you to an interactive online learning module called ‘Caring for someone with a life-limiting illness’.
Carers NSW | Information | 2025
Palliative Care Australia is the peak national body for palliative care and have resources for clinicians, patients, families and carers. The link below takes you directly to the carer resources.
Palliative Care NSW | Toolkit | 2025
Palliative Care NSW is the peak body in NSW representing palliative care providers and those with an interest in palliative care. This link takes you to the Carer Hub on their website with resources to support carers supporting someone as they approach the end of their life.
Palliative Care NSW | Toolkit | 2025
Family meetings in palliative care: multidisciplinary clinical practice guidelines
Guidelines for health professionals working with cancer and palliative care patients.
Centre for Palliative Care Education and Research | Information | 2009
Multidisciplinary Case Conferences
Specifications for MBS payments for multidisciplinary case conferences.
Department of Health, Disability and Ageing | Information | 2025
A tool that provides a framework for communicating distressing information in an organised and empathetic way.
End-of-Life Essentials | Clinical tool | 2000
FICA Tool for Spiritual Assessment
A short series of questions opening up the matter of existing sources of strength and support within conversations in the clinical setting. The tool is copyright protected and requests for permission should be directed to the publishers.
George Washington Institute for Spirituality and Health | Clinical tool | 2025
A 20-item scale specifically developed to measure quality of life at the end of life. Contact the author at robin.cohen@mcgill.ca to complete the User's Agreement and obtain a copy of this tool.
National Palliative Care Research Centre | Clinical tool | 1997
Measuring the Quality of Life of Seriously Ill Patients (QUAL-E)
A tool to assist in the evaluation of the quality and effectiveness of interventions targeting improved care at the end of life.
National Palliative Care Research Centre | Clinical tool | 2005
NSW Health chaplains are accredited through a formal process, ensuring they meet the required standards for providing pastoral care in a healthcare setting. Patient information may be provided to accredited hospital chaplains for the purpose of providing pastoral care services in public hospitals.
NSW Health | Information | 2015
Integrated Palliative Care Outcomes Scale [IPOS]
The IPOS integrating the best of POS, POS-S and the APCA African POS tools as a more streamlined measure which is brief, yet which still captures their most important concerns - both in relation to symptoms, but also extending to information needs, practical concerns, anxiety or low mood, family anxieties, and overall feeling of being at peace.
Palliative Care Outcome Scale | Clinical tool | 2015
Edmonton Symptom Assessment System (ESAS)
The ESAS measures the severity of common symptoms experienced by patients receiving palliative care.
Edmonton Regional Palliative Care Program, Capital Health, Edmonton, Alberta | Toolkit | 2004
A widely used multiple-choice self-report inventory for measuring the severity of depression. Designed for ages 13+ and used in a variety of settings, including palliative care. Important in terms of differentiating between grief and depression in this context. The original form comprised 21 items while the rapid version (BDI-SF) comprises 13 items. Registration and payment is required and can be purchased through www.psychcorp.com.
Indiana State Medical Association | Clinical tool | 1961
Braden Pressure Ulcer Assessment or Braden Scale
A pressure ulcer risk scale based on six unique indicators with total scores ranging from 6-23. Lower scores are associated with higher levels of risk for pressure ulcer development. The scale has been widely validated in palliative care populations demonstrating good sensitivity and specificity.
Indiana Department of Health | | 1988
Confusion Assessment Method (CAM)
The CAM instrument is brief (less than 5 minutes) and is used to screen for overall cognitive impairment and has demonstrated good psychometric validity with close conceptual fit to DSM-IV criteria for delirium. A training manual is available online.
Hospital Elder Life Program | | 2014
The distress thermometer (DT) has been widely used in research and cancer service settings to detect clinically significant distress. One rating scale (distress thermometer) (0- 10) 'Extreme distress' to 'No distress'. Plus 33 statements (Yes/No). Requirement for registration and payment: As the tool is copyright protected.
National Comprehensive Cancer Network | Clinical tool | 2025
MOCA or Montreal Cognitive Assessment
MOCA is designed to aid health professionals in the detection of mild cognitive impairment. The MOCA is brief, well-validated and available in 35 languages.
MoCA Cognition | | 2005
Nursing Delirium Screening Scale (NuDESC)
The NuDESC is an observational 5-item scale used to assess delirium. The scale has reportedly demonstrated good psychometric validity and reliability, has a close conceptual fit to DSM-IV criteria, and due to its short length, can be completed at the end of each nursing shift providing continuous 24-hour assessment.
Journal of Pain and Symptom Management | Clinical tool | 2005
Other pain assessment tools (ELDAC)
This website includes links to common pain assessment tools used at end of life including the Abbey pain scale, Pain numeric rating scale, Verbal descriptor scale (pain thermometer) and the Modified resident’s verbal brief pain inventory (M-RVBPI).
ELDAC | Toolkit | 2025
Pain Assessment in Advanced Dementia Scale (PAINAD)
This tool was developed to assess pain in patients who are cognitively impaired, non-communicative, or suffering from dementia and unable to use self-report methods to describe pain.
NSW Agency for Clinical Innovation | Clinical tool | 2003
Patient Assessment of Constipation Quality of Life (PAC-QOL)
The PAC-QOL is an instrument generated from the literature, expert consultation and patient’s reports to evaluate constipation over time. Registration and payment is required in the instance of funded studies or those in other languages.
The Pelvic Floor Society | Information | 2008
Represents an aide-memoire considering the patients holistic needs described in acronym (PEPSI COLA; e.g., S refers to Social support). Individual domains identify possible patients concerns via cue questions. Rationale is for a documented assessment that can be transferred to relevant health professionals involved in multidisciplinary team care. Intended to complement medical discharge summary to document unique care aspects of palliative care patients. Registration is required as the guide is copyright protected but no payment is required.
National Gold Standards Framework Centre | Information | 2009
Prolonged Grief Disorder [PG -13]
PG-13 is a diagnostic screening tool for PGD. A person who endorses experiences consistent with PGD are likely to benefit from specialised assessment by a mental health professional and treatment. The PG-13 was revised in 2021 to reflect contemporary understandings of PGD and incorporate more user-friendly language (PG-13R). It may be used clinically as a screening tool or as part of a comprehensive assessment to help identify probable PGD.
World Psychiatric Association | Clinical tool | 2021
The Brief Fatigue Inventory (BFI)
The Brief Fatigue Inventory (BFI) is used for rapid assessment of the severity and impact of cancer-related fatigue. An increasing focus on cancer-related fatigue emphasized the need for sensitive tools to assess this most frequently reported symptom. The six inventory items correlate with standard quality-of-life measures.
University of Pennsylvania | Information | 1999
Anxiety and depression checklist (K10)
A self-reporting tool that measures psychological distress and as a measure of outcomes following interventions. The tool comprises 10 questions and uses a five-value response for each question which can be scored from one through to five.
University of NSW | Toolkit | 2025
Depression Anxiety Stress Scale (DASS21)
A self-reporting tool that comprises a 42-item scale that measures depression, anxiety and stress/tension.
Melanoma Institute Australia | Clinical tool | 1995
Hospital Anxiety and Depression Scale (HADS)
The HADS was originally designed to detect symptoms of depression and anxiety in patients attending medical outpatient clinics and excludes somatic symptoms. The scale comprises 14 items, which are summed to provide a total score (HADS-T), as well as two subscales, purporting to measure anxiety (HADS-A) and depression (HADS-D).
Sexual Violence Research Initiative | Clinical tool | 1983
Patient Dignity Inventory (PDI)
The PDI is a Canadian tool designed to give clinicians a broad overview or 'snapshot' of an individual in their care is doing at any point in time. In the PDI questionnaire. Patients are asked to rate their current condition on the basis of 25 different indicators against a five point scale. Each question is based on empirical research into the most common factors influencing people's personal sense of dignity.
Dignity in Care | Toolkit | 2008
Beers Criteria for Potentially Inappropriate Medication Use in Older Adults
A list of potentially inappropriate medications in terms of their use within elderly patient populations.
American Geriatrics Society | Information | 2023
Cancer pain management in adults
Guidelines for health professionals working with cancer patients. Intended to supplement (not replace) clinical judgment and provide short, point-of-care recommendations for screening, assessment and management of cancer related pain.
Cancer Council Australia | Information | 2019
Australian decision support guidelines for clinicians working with chronic obstructive pulmonary disease.
Lung Foundation Australia | Information | 2024
Delirium screen for older adults
This resource assists health professionals identify the presence of delirium and the risk factors that may lead to it in older people.
NSW Health | Information | 2014
Faces Pain Scale (paediatrics)
A tool designed to assess pain levels in paediatrics and said to be more accurate than self-reports
Department of Health, Disability and Ageing | Information | 2013
Provides information and guidance to support palliative care and advance care planning for residents and their families.
ELDAC | Toolkit | 2024
Discussions regarding end of life care and do not resuscitate decisions
Considerations on when the discussion regarding end of life care should occur and with whom.
Dr Sarah Wenham Senior Staff Specialist - Palliative Care Clinical Director - Sub and Non-Acute Care, Far West Local Health Districtt
Medical decision-making and the ethics behind it
A seminar style video, with palliative care health professionals discussing ethical situations that may arise working in palliative care.
A/Prof Richard Chye Director Sacred Heart, St Vincent’s Health Network
The role of carers is integral to community palliative care system. This discussion considers how we identify and support carers in the community.
Jenny Broadbent Retired Senior Social Worker – Palliative Care, Greenwich Hospital
This in depth presentation discusses delirium and depression – two critical conditions that impact upon brain function in advanced illness.
Prof Meera Agar Staff Specialist, Palliative Care, Liverpool Hospital
Pain is a central concern for good palliative care. A discussion with Peter Cleasby of where to start in pain assessment and different strategies to use.
Peter Cleasby Palliative Care Education Program Coordinator, Health Education and Training Institute
Anxiety and sleep disturbances
Anxiety is normal but becomes a problem when its duration and severity exceed normal expectations and impair quality of life.
Dr Sarah Thompson Medical Director and Staff Specialist, Neringah Hospital
Depression remains under-detected and under-treated for patients and their families.
Dr Sarah Thompson Medical Director and Staff Specialist, Neringah Hospital