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Home Care Clinical Care
- Advance Care Planning
- Recognise End of Life
- Assess Palliative Care Needs
- Provide Palliative Care
- Work Together
- Respond to Deterioration
- Manage Dying
- Bereavement
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Palliative care is person and family-centred care provided for a person:
- with an active, progressive, or advanced disease
- who has little or no prospect of cure
- who is expected to die
- for whom the primary goal is to optimise the quality of life.
Palliative care helps people live their life as fully and as comfortably as possible with a life-limiting or terminal illness. It identifies and treats symptoms which may be physical, emotional, spiritual or social. [1]
Assessing palliative and end-of-life care needs in the home is vital to ensure that older people with life-limiting illnesses receive comprehensive, person-centred care. This means that all types of their needs are addressed including physical, psychological, social, and spiritual needs.
Early detection and correct assessment of palliative and end-of-life care needs is an ongoing process, essential for care planning and continuity of care.
All older people who are identified as being at the end of life by using the SPICTTM (pdf) screening tool should then have a palliative or end-of-life care needs assessment. The holistic life experiences of a person, such as age, culture, religion, ethnicity, or experience should be considered.
Re-assessment should occur regularly and at key transition points in the older person’s trajectory, for example:
- if there has been a significant functional or medical decline
- if there is a sudden acute event
- if discussions around goals of care are required, particularly around futile treatment
- following hospitalisation.
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How to undertake a palliative care needs assessment
The Palliative Care Needs Assessment Guidance [2] provides a framework across four domains:
- Domain 1 – Physical Wellbeing
- Domain 2 – Social and Occupational Wellbeing
- Domain 3 – Psychological Wellbeing
- Domain 4 – Spiritual Wellbeing. [2]
Check to see whether your service or organisation provides any guidance regarding assessing these domains. Within each of these domains, there are some specific tools or scales that might be useful to understand the needs of the older person and their family and carers.
Each older person will have an individual symptom profile and requires a comprehensive assessment undertaken by a clinician or palliative care specialist.
Symptom Assessment Scale (SAS)
The SAS can be used as a self-report tool and provides a report of whether a symptom is present and an indication of the impact of that symptom. The SAS is based on a rating scale of seven common symptoms and has space to add additional symptoms. SAS also allows for rating by proxy when assessing an older person who has cognitive impairment or is non-verbal. The Palliative Care Outcomes Collaboration (PCOC) has a brochure explaining the Symptom Assessment Scale (pdf).
Where a symptom has been identified, further assessment using specific tools can provide more details that might help identify the underlying cause of the symptom or assist with treatment options. The following is a suggested list of tools in addition to the SAS.
Comprehensive Pain Assessment
- The Brief Pain Inventory (short form) (pdf) can be used to assess the severity of pain and the impact of pain on daily functions.
Dyspnoea (shortness of breath) Assessment
- Modified Borg Scale (mBORG) (pdf) is used to measure the self-reported intensity of the sensation of breathlessness with a numeral rating linked to verbal descriptors.
Delirium Assessment
- 4AT. A validated screening tool used as an initial assessment to detect delirium and cognitive impairment.
Nutrition Assessment
- The Mini-Nutritional Assessment Short-Form (MNA®-SF) (pdf) is a screening tool used to identify older adults over 65 years of age who are malnourished or at risk of malnutrition.
Oral Health Assessment
- The Oral Health Assessment Tool (pdf) is used to assess older people who are unable to reliably self-report and when a clinical assessment of oral health status is required.
Frailty Assessment
- Clinical Frailty Scale (Rockwood) (pdf) is used to assess the degree of frailty.
Pressure Ulcer Risk
- The Braden Pressure Ulcer Risk Assessment (pdf) evaluates risk for pressure ulcer development.
For people with cognitive impairment or dementia see the ELDAC Dementia Toolkit Assess Palliative Care Needs section for specific tools.
This domain explores the person’s experience in relation to:
- their background
- family and carers support
- emotional and social support
- practical concerns, and
- impact on their usual functioning.
For instance, consider the older person’s:
- Experience of family/carers and relationships: ‘Do you have any concerns or worries about your family/carers or personal relationships?’
- Experience of support: ‘Who is around to support you? What kind of support do they give? Has this been helpful?’
- Practical concerns, including any worries about finances, sorting affairs, and advance care planning.
The Needs Assessment Tool for Carers (NAT-CC-Caring for you) (pdf) is a self-reported tool for carers supporting someone with a chronic illness. The tool identifies the care needs of someone living with a chronic condition, and the level of concern this causes the carer. This provides prompts for the carer and/or the health professional to discuss these issues.
Older people with life-limiting conditions often have psychological concerns. These can include anxiety, depression, and past experiences of trauma. Proactive assessment of these concerns is important.
- An open question such as ‘Is there anything worrying you?’ can be a helpful place to start.
- Depression is common in older people. The Kessler Psychological Distress Scale (K10) (pdf)) is a simple clinician administered measure of psychological distress as a measure of outcomes following treatment for common mental health disorders. The K10 asks 10 self-reported questions with a 5-value scale. The maximum score is 50 indicating severe distress and the minimum score is 10 indicating no distress. Referral for psychological support may be required.
A person’s spiritual care includes faith, cultural background, beliefs, traditions, and any other ways an older person makes sense of their world and experience. Older people have the right to express their spirituality in a way that is meaningful for them. The identification of spiritual needs and offering of basic spiritual care is the responsibility of all who work in aged care, in ways that are appropriate to their role.
- palliAGED provides a summary of spiritual care.
- Hope Spiritual Assessment Tool: A Step-by-Step Guide aids in better understanding an older person’s spiritual beliefs and needs. This enables the team to provide meaningful spiritual care.
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How to build knowledge, confidence and skills in assessing palliative care needs in home care
- Watch the ELDAC Home Care Toolkit educational video on Assess Palliative Care Needs that describes the importance of person-centred and holistic assessment. The video identifies the four domains of wellbeing used in palliative care assessment and recognise the importance of care planning to support end-of-life care.
- Use the ELDAC Case Study about Ravi to build your understanding of how to holistically assess palliative and end-of-life care needs within the physical, social and occupational, psychological and spiritual wellbeing domains.
- The free Equip Aged Care Learning Modules are produced by the Wicking Dementia Research and Education Centre at the University of Tasmania. A range of aged care related topics are covered, including palliative and the end-of-life care.
- The Agency for Clinical Innovation hosts a free palliative care video library. These videos were developed with Australian healthcare specialists to assist in the delivery of appropriate palliative care. There are videos on topics for physical and clinician, psychological, and spiritual and cultural.
- Learn how to use the Symptom Assessment Scale (SAS) from this short video by the Palliative Care Outcomes Collaboration (PCOC). PACOP ‘Clinical Bites’ has a video about using the SAS for care workers.
- Explore the guidance available for assessing specific symptoms:
- 4AT: The about the 4AT web page includes the user guide, scoring summary, FAQs and case studies.
- Braden Scale: Information on pressure injuries and scoring the Braden Scale.
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Information for families and carers
This website offers a range of tools, videos and information to support carers, including managing symptoms at home:
- Tip sheets for families and carers about how to identify and manage various end-of-life symptoms.
- A short video for families and carers on how to recognise breakthrough symptoms, and rate the distress they cause.
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References
- Australian Government Aged Care Quality and Safety Commission. Draft Glossary of Terms: Guidance material for the strengthened Aged Care Quality Standards for review and discussion (pdf). 2024 [cited 12 Feb 2026].
- The National Clinical Programme for Palliative Care, HSE Clinical Strategy and Programmes Division. Palliative Care Needs Assessment Guidance. HSE Ireland. 2014 (reviewed 2016). [cited 8 Dec 2025].
Page updated 22 September 2026
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