Symptom assessment in palliative care

Eagar, Gordon, , 2004Eagar, 1997Eagar, Green, 2004Kurtz, 2003

Clinical assessment can help guide the management of the symptom, cause, or underlying life-limiting illness. The assessment may determine that the symptom is due to:

  • an acute intercurrent illness (which may be treatable)
  • a temporary relapse (which may be reversible)
  • irreversible disease progression
  • imminent death.

Comprehensive symptom assessment for patients with palliative care needs involves several aspects, summarised in Aspects of symptom assessment in palliative care.

Figure 1. Aspects of symptom assessment in palliative care

Take a detailed history; consider:

  • the patient’s description of the symptom, including severity, and factors that exacerbate or relieve it
  • whether treatments (nonpharmacological and pharmacological therapy, including complementary therapies) have already been tried, and the outcome [NB1]
  • the impact of the symptom on the patient and the presence of other symptoms.

Perform an examination and request appropriate investigations; consider:

  • clinical examination findings, including the patient’s baseline, phase of illness and current functional status
  • investigations—these are only appropriate if the results will influence decision-making about treatment options
  • whether symptom is due to disease progression, treatment, drugs, comorbidities or multiple factors.

Ask the patient about their priorities; consider:

  • where the patient is in the course of their life-limiting illness and their understanding of their disease and prognosis
  • what the patient thinks is causing the symptom and what concerns them about it
  • whether there are any other practical issues that might influence the patient’s choice of treatment (including health beliefs, financial, social, cultural, spiritual and geographical factors, as well as availability of carer and family support)
  • the patient’s current and intended place of care.
Note: NB1: The CareSearch website has an overview of complementary therapies used in palliative care.

Using the steps outlined for communicating in difficult conversations, discuss with the patient, their family and carers to enhance their understanding of the disease and inform their decision-making. This may reduce their anxiety. A new symptom does not necessarily mean the disease has progressed. However, disease progression may prompt discussion of the implications and prognosis, and review of the patient’s priorities and goals of care.

Many tools are available to assist in the systematic assessment, measurement and monitoring of a patient’s symptoms, performance and functionClapham S, 2021. Tools in frequent clinical use in Australia include tools to assess symptoms and tools to assess performance or function.

Tools to assess symptoms include:

  • Symptom Assessment Scale (SAS)—a patient- or proxy-rated numeric rating scale (NRS) to measure the amount of distress caused by 7 of the most common physical symptoms in palliative care; a visual analogue scale (VAS) is also availableAoun, 2011
  • Palliative Care Problem Severity Score (PCPSS)—a clinician-rated assessment of the severity of physical, psychological and spiritual symptoms of patients and their families.

Tools to assess performance or function include:

  • Australia-modified Karnofsky Performance Status (AKPS) score—a clinician-rated performance score determined from observations of ability to perform common tasks relating to activity, work and self-careAbernethy, 2005
  • Resource Utilisation Groups–Activities of Daily Living (RUG–ADL)—a clinician-rated functional score that measures motor function in relation to the 4 activities of daily living of bed mobility, toileting, transfers and eatingFries, 1994.

These are available in the Palliative Care Outcomes Collaboration [PCOC] clinical manual.