Assessing and planning the palliative care needs of older persons

Assessing and planning the palliative care needs of older persons


Assessment and planning (Standard 2) is a critical part of comprehensive care for an older person as they come to the end of their life. This In Focus feature article, addresses how assessment and care planning can help identify and meet palliative care needs. It also highlights useful resources that can help you and your aged care organisation.

Standard 2: Ongoing assessment and planning with consumers

Standard 2 recognises the needs for initial and ongoing assessment done in partnership with the person. The focus of assessment and planning activities is the health and well-being of the consumer, which recognises and respects their needs, goals and preferences.  You can find out more about assessment and planning matters in the Standards Summary: Ongoing assessment and planning with consumers

The palliative care context

The Aged Care Quality Standards describe the right of the consumer to dignity and respect and to make choices about the care and services they wish. As people enter the last period of their life, assessment and care planning is critical. People are approaching the ‘end of life’ when they are likely to die within the next 12 months. 

Palliative care is a form of healthcare provided for people of any age who have a serious illness that cannot be cured. Palliative care is person centred care as highlighted in the Department of Health’s 2018 National Palliative Care Strategy. Recognising end of life and identifying palliative care needs can ensure that the right mix of care is available and that the person’s voice is heard in planning care.

palliAGED resources for Standard 2

palliAGED resources can be used to support consumers, aged care staff and the service when considering how Standard 2 applies in the context of care at the end of life.

Advance care planning

Advance care planning can improve end-of-life care in line with a person’s wishes. It can ensure that a person’s wishes are known and respected when they can no longer speak for themselves. palliAGED has an evidence summary about the role of advance care planning and practice resources to build skills. Advance Care Planning is also covered in Practice Tips for CareWorkers and Practice Tips for Nurses.

Communication skills

Being able to communicate effectively is critical to assessment and care planning. The palliAGED Practice Centre has a range of communication resources and there are Practice Tips on communication for careworkers and for nurses.

There are also specific resources dealing with end of life communication. Communication between a person receiving palliative care, their family, and health professionals is at the core of a positive end-of-life experience.

"I am a partner in ongoing assessment and planning that helps me get the care and services I need for my health and well-being."

Consumer outcome statement for Aged Care Standard 2. Source: Aged Care Quality and Safety Commission website
The use of this image does not constitute an endorsement by the Aged Care Quality and Safety Commission of palliAGED activities.


Providing information on palliative care

Palliative care identifies and treats symptoms which can be physical, emotional, spiritual or social. Providing information on palliative care to the older person and their family can help them understand what is happening and to plan for end of life. There is information for family in the For the Community section of palliAGED. You can also order a copy of CareSearch's Palliative Care Support booklet for your client or resident.

Needs assessment

Needs assessment forms an important part of palliative care in all settings and can improve the quality of life of adults with dementia or those who are at end-of-life. Needs assessments can help to identify what clients or residents and their families consider important and where they need help and support. The practice section provides a variety of resources to support needs assessment.


Referral for specialist palliative care may be appropriate for a person to manage severe symptoms, to respond to extreme distress or provide specific care planning support. Other health professionals may assist in providing comprehensive care or help manage a specific symptom. The Practice Centre has information on referral.

Spiritual care

Recognising that you are going to die can raise questions about meaning. Spiritual care can be an important part of providing individual support and care to the person. There are Practice Tips Sheets on spiritual care for nurses and for careworkers as well Tip Sheets on Talking about Dying.

Learning options for staff

A new Education section in palliAGED provides a wide range of learning opportunities for aged care staff. It includes a section on care planning and assessment.

National Palliative Care Program: Other Assessment and Planning Resources

    This project has five toolkits including residential aged care and homecare toolkits. There is also a set of ELDAC common clinical tools
  • Advance
    This project developed a training package, specifically designed to support Australian general practices to implement a team-based approach to initiating advance care planning (ACP) and palliative care into everyday clinical practice.
  • CareSearch Allied Health
    Allied Health have an increasingly important role to play in aged care. This hub of resources and tools within CareSearch supports allied health in providing care.

Read some of our Palliative Perspectives blogs related to assessment and care planning in aged care:

A Common Set of ELDAC Clinical Tools

Paul Tait from End of Life Directions for Aged Care (ELDAC) discusses how the ELDAC project has identified twelve commonly used clinical tools useful when caring for older people, with palliative care needs. Clinical tools provide standardised ways to assess changes to a person’s health.

The importance of communication in palliative care

Staff at the Aged Care Complaints Commissioner listen to the stories of those dying in aged care. These stories help us to understand the needs of dying people and their families, and to work with service providers to ensure that their palliative care improves. 


HealthPathways - supporting local relevant and consistent palliative care

Many Australians face difficulties in receiving palliative care due to factors such as system fragmentation, gaps in service provision, geographic scarcity of services or health professionals, access barriers for vulnerable populations or living in residential aged care facilities.

Page created 23 September 2019