Needs Assessment
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Needs Assessment

Key messages

  • A needs assessment identifies physical, psychological, social, and spiritual needs to guide personalised palliative care.
  • Regular reassessment is important, especially after major health changes, hospitalisation, or at the family request.
  • Validated tools help identify key needs early and guide referrals.
  • Continuity of care improves when the same assessor conducts reviews.
  • Inclusive assessments consider the needs of people with dementia, carers, and diverse communities.

What is a needs assessment?

A needs assessment is a structured process for identifying the physical, psychological, social, and spiritual needs of people receiving palliative care. This ensures care is holistic and tailored to their unique circumstances. [1] The process involves comprehensive assessment at the start of care, at regular intervals, and when needs change. [2] Validated tools play a key role in guiding care planning and identifying when referral to palliative care may be appropriate. [3-5]

Are needs rounds the same as needs assessment?

A significant part of a needs assessment is having a plan to address deterioration and understand the degree of escalation needed to care for an older adult. In the residential care setting, ‘needs rounds’ are monthly meetings where care staff, led by a specialist palliative care clinician, use a checklist to assess and prioritise care for residents at risk of dying without a proper plan or symptom control. [6-8] These meetings help staff build confidence in discussing death, planning care goals, and managing symptoms. [7-9] They have been shown to reduce hospitalisations and improve the quality of death, decreasing the likelihood for hospitalisation and increasing the likelihood that residents die in their preferred place. [9-11]


Why needs assessments matter in aged care

For needs to be addressed, they must first be identified. Effective and holistic needs assessments are core to good palliative care. [12] They involve close collaboration with older people, their families, and carers and should be conducted regularly to ensure care remains responsive to changing health conditions and circumstances. [2]

Outcome 5.7 of the Aged Care Quality Standards emphasises the importance of recognising and addressing an older person's needs, goals, and preferences for palliative and end-of-life care. [2] The Quality Standards also highlight the need for cultural competence, ensuring inclusive care for Aboriginal and Torres Strait Islander peoples, culturally diverse communities, and those with dementia. [2]


What the evidence tells us

Needs assessments should ideally be conducted at the time of diagnosis of a life-limiting condition. Reassessment is then important during major health changes, deterioration, hospitalisation, shifts in family or social support, at the family’s request, or at the start of the terminal phase. [13] Continuity of care is improved when the same assessor conducts both initial assessments and follow-ups. [13]

Tools for needs assessment

Validated assessment tools support structured and effective evaluations. [1] They can help clinical staff recognise increasing symptom burden and identify palliative care needs early. [5] The choice of assessment tool can be guided by the person’s characteristics such as age, illness, role (older person/carer), and key symptoms. [1] Brief screening tools provide a quick overview of a person's needs and are useful when time is limited or participation is difficult. [1] This can be followed by a more detailed assessment of any identified needs. [1,5]

Examples of widely used tools for assessing a person’s palliative care needs include:

Tools to assess carer needs are discussed below.

SPICT™ is a tool used to identify people with deteriorating health due to serious illnesses, chronic conditions, or frailty in older age. [14,15] You can read more about recognising deterioration here. SPICT™ is simple to use and designed for use by all multidisciplinary team members across care settings. [14,15] It helps timely discussions about care preferences and planning by highlighting clinical indicators such as worsening health, increasing care needs, or repeated hospital visits. [14] It can help assess a person’s readiness for an advance care planning conversation and to explore their expectations, diagnosis, what matters to them, treatment options, and future plans. [5,14] As an illness progresses, it can support adjustments to care goals and the recording of a person’s end-of-life care plans and wishes. [14] The SPICT™ guide offers helpful prompts, tips, and the REDMAP (Ready, Expect, Diagnosis, Matters, Actions, and Plan) framework to support these conversations. [15]

Care of people with dementia

People with dementia often have multiple chronic conditions, making needs assessments more complex. [19] Standardised tools may not always capture their needs effectively, requiring input from family and observations from the clinical care team. [19] The IPOS-Dem tool assesses symptoms and concerns specific to people with dementia over a week, including physical, functional and psychosocial aspects of the person’s life. It also incorporates family perspectives, ensuring a holistic view of the person’s care needs. [17]

Implications for families

A life-limiting illness affects not just the person but their family and carers as well. [20,21] Assessing family needs helps monitor their wellbeing, support their caregiving role, and connect them to appropriate services. [20,21]

Carer needs assessment tools can help you identify the support, resources, and services carers require. Tools include:

Families may also use the SPICT-4ALL™ to recognise early signs of declining health, facilitating timely discussions and support. [24]

By answering the questions in these tools, relatives and family carers can recognise key concerns and decide which ones to discuss with their GP. The tools serve as both a conversation guide and a care planning tool. [22-24]


Page updated 13 March 2025
 

  • References

  1. Girgis A, Waller A. Palliative care needs assessment tools [Internet]. In: Cherny N, Fallon M, Kaasa S, Portenoy R, Currow D, editors. Oxford textbook of palliative medicine. 5th ed. Oxford, UK: Oxford University Press; 2015. p. 363-375.
  2. Australian Government Department of Health and Aged Care. Strengthened Aged Care Quality Standards: Draft (February 2025). Canberra, ACT: DoHAC; 2025.
  3. Kawashima A, Evans CJ. Needs-based triggers for timely referral to palliative care for older adults severely affected by noncancer conditions: A systematic review and narrative synthesis. BMC Palliat Care. 2023;22(1):20.
  4. Sharratt P, Zacharias A, Nwosu AC, Gadoud A. Hospital-initiated palliative care interventions for adults with frailty: Findings from a systematic review and narrative synthesis. Age Ageing. 2024;53(9):afae190.
  5. Xie Z, Ding J, Jiao J, Tang S, Huang C. Screening instruments for early identification of unmet palliative care needs: A systematic review and meta-analysis. BMJ Support Palliat Care. 2024;14(3):256-268.
  6. Forbat L, Chapman M, Lovell C, Liu WM, Johnston N. Improving specialist palliative care in residential care for older people: A checklist to guide practice. BMJ Support Palliat Care. 2018;8(3):347-353.
  7. Rainsford S, Johnston N, Liu W-M, Glasgow N, Forbat L. Palliative care needs rounds in rural residential aged care: A mixed-methods study exploring experiences and perceptions of staff and general practitioners. Prog Palliat Care. 2020;28(5):308-317.
  8. Liu WM, Koerner J, Lam L, Johnston N, Samara J, Chapman M, et al. Improved quality of death and dying in care homes: A palliative care stepped wedge randomized control trial in Australia. J Am Geriatr Soc. 2020;68(2):305-312.
  9. Johnston N, Lovell C, Liu WM, Chapman M, Forbat L. Normalising and planning for death in residential care: Findings from a qualitative focus group study of a specialist palliative care intervention. BMJ Support Palliat Care. 2019;9(1):e12.
  10. Forbat L, Liu WM, Koerner J, Lam L, Samara J, Chapman M, et al. Reducing time in acute hospitals: A stepped-wedge randomised control trial of a specialist palliative care intervention in residential care homes. Palliat Med. 2020;34(5):571-579.
  11. Chapman M, Johnston N, Lovell C, Forbat L, Liu W-M. Avoiding costly hospitalisation at end of life: Findings from a specialist palliative care pilot in residential care for older adults. BMJ Support Palliat Care. 2018;8(1):102-109.
  12. World Health Organization. Palliative care [Internet]. Geneva: WHO; 2023 [cited 2025 Feb 12].
  13. National Clinical Programme for Palliative Care. Palliative care needs assessment guidance (2.4MB pdf). Ireland: National Clinical Programme for Palliative Care; 2014.
  14. Mahura M, Karle B, Sayers L, Dick-Smith F, Elliott R. Use of the Supportive and Palliative Care Indicators Tool (SPICT™) for end-of-life discussions: A scoping review. BMC Palliat Care. 2024;23(1):119.
  15. University of Edinburgh. SPICT™ [Internet]. Edinburgh, UK: University of Edinburgh; 2025 [cited 2025 Feb 12].
  16. POS Development Team. The Palliative Care Outcome Scale (POS) [Internet]. London, UK: POS development team; n.d. [cited 2025 Feb 12].
  17. POS Development Team. Integrated POS (IPOS) for dementia and translations [Internet].  London, UK: POS development team; n.d. [cited 2025 Feb 12].
  18. Ward KT, Reuben DB. Comprehensive geriatric assessment. In: UpToDate [Internet]. Wolters Kluwer; 2024 [cited 2025 Feb 12].
  19. de Wolf-Linder S, Reisinger M, Gohles E, Wolverson EL, Schubert M, Murtagh FEM. Are nurse`s needs assessment methods robust enough to recognise palliative care needs in people with dementia? A scoping review. BMC Nurs. 2022;21(1):194.
  20. Chovan J. Principles of patient and family assessment [Internet]. In: Ferrell BR, Paice JA, editors. Oxford textbook of palliative nursing. 5th ed. Oxford, UK: Oxford Oxford University Press; 2019. p. 32–54.
  21. Stajduhar KI, Dionne-Odom JN. Supporting families and family caregivers in palliative care [Internet]. In: Ferrell BR, Paice JA, editors. Oxford textbook of palliative nursing. 5th ed. Oxford, UK: Oxford Oxford University Press; 2019. p. 405-419.
  22. Burridge L, Mitchell G, Jiwa M, Girgis A. Helping lay carers of people with advanced cancer and their GPs to talk: An exploration of Australian users' views of a simple carer health checklist. Health Soc Care Community. 2017;25(2):357-365.
  23. CSNAT-I Collaboration. Carer Support Needs Assessment Tool Intervention (CSNAT-I) [Internet]. United Kingdom: University of Manchester/University of Cambridge; 2022 [cited 2025 Feb 12].
  24. University of Edinburgh. Spict-4ALL™ [Internet]. Edinburgh, UK: University of Edinburgh; 2025 [cited 2025 Feb 12].