1. Assessing Palliative Care Phase
Before You Start
Make sure you have the assessment tool definitions or the PCOC Clinical Manual

2. PHASE ASSESSMENTS In palliative care the focus is on
Patient need, goals & priorities rather than disease
Patient & family or carers as the unit of care
Why phases were developed?
Phases were based on these principles:
In palliative care, the focus is on patient needs, goals and priorities rather than the disease.
In palliative care, the patient and their carers are the unit of care.
Palliative care patients have episodes of care that include acute exacerbations .
Such episodes are applicable at home or hospital (Smith 1993).
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3. PHASE ASSESSMENTS Phases Provide a Framework Care planning
Communication between teams
Triage
What is a palliative care phase?
The phases provide a framework for care planning, triage and referrals as well as communication between teams.
Why do we assess phase?
We assess phase as it assists the clinical team to recognise the particular point in the patient’s journey and to ensure that the documented care plan is modified to incorporate the needs of the patient and family at this time.
Phase may be of assistance in the allocation of resources within the team.
Phase may be of assistance in the triage process
At the patient level phase can determine the frequency of assessment required.
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4. PHASE ASSESSMENT Stable Unstable Deteriorating Terminal Post Death
What are the Phases?
Stable, there are no new needs and what you are doing for the patient and family is working.
Unstable, there are new needs or sudden changes in the needs of the patient and or family.
Deteriorating, the patient and family have increased needs that were anticipated in the care plan.
Terminal, the patient is likely to die in a matter of days.
Stable
Unstable
Deteriorating
Terminal
Post Death
Support
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5. PCOC Clinical Manual www.pcoc.org.au pcoc.org.au
Make sure you have the Clinical Manual on hand before progressing with this package
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6. STABLE: START
Patient’s problems and symptoms are adequately controlled by established plan of care
and
Further interventions to maintain symptom control and quality of life have been planned
Patients who are not unstable, deteriorating or terminal are assessed as stable. The stable phase may be used as a trigger to discharge a patient or review the frequency of medial assessment or community visit for example.
and
Family / carer situation is relatively stable and no new issues are apparent
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7. STABLE: END
The needs of the patient and / or family / carer increase, requiring changes to the existing plan of care
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8. Continue as per plan of care
Actions for Stable Phase
Continue as per plan of care
Commence discharge planning if appropriate
PCOC assessment and response protocol
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9. Family/ carers circumstances change suddenly impacting on patient care
UNSTABLE: START
An urgent change in the plan of care or emergency treatment is required because:
Patient experiences a rapid increase in the severity of a current problem;
Patient experiences a new problem that was not anticipated in the existing plan of care,
Family/ carers circumstances change suddenly impacting on patient care
and/ or
and/ or
Urgent refers to changes in the care plan and interventions that need immediate attention. Examples may include medical review, palliative care consultant review, referrals (for urgent action), tests and procedures, medication changes.
Assessment of a patient as unstable could be used as a trigger for palliative care consultant review.
Questions = The patient is not experiencing any symptoms or problems that require a change in management but the family requires urgent intervention and a change in the care plan. Is this patient assessed as Stable or Unstable?
Answer = The assessment is Unstable because there is a worsening severity of problems relating to the family require urgent interventions.
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10. UNSTABLE: END
The new plan of care is in place, it has been reviewed and no further changes to the plan of care required. This does not necessarily mean that the symptom/crisis has fully resolved but there is a clear diagnosis and plan of care (i.e. patient is stable or deteriorating)
and/or
Death is likely within days
(i.e. patient is terminal)
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11. Actions for the Unstable Phase
Urgent intervention and escalation required
Change plan of care
Urgent medical review and / or allied health services
Review within 24 hours
PCOC assessment and response protocol
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12. DETERIORATING: START
The plan of care is addressing anticipated needs but requires periodic review because
Patient
experiences a gradual worsening of existing problem
Patient’s overall functional status is declining
Patient experiences a new but anticipated problem
Family/carers experience gradual worsening distress that impacts on the patient care
and/ or
and/ or
and/or
This phase may trigger interventions such as referral to physiotherapist for mobility or social work for family or pastoral care for patient/family. These interventions are not “urgent” as in the unstable phase. For example the addition of a new medication for an existing symptom or an expected worsening of a symptom such as nausea.
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13. DETERIORATING: END Patient’s condition plateaus
(i.e. patient is stable) or
An urgent change in the plan of care or emergency treatment
and / or
Family / carers experience a sudden change in their situation that impacts on patient care, and urgent intervention is required
(i.e. patient is unstable) or
Death is likely within days
(i.e. patient is terminal)
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14. Actions for Deteriorating Phase
Change in plan of care required to address increasing needs
Referral to medical or allied health may be required. Family / carer support may increase
PCOC assessment and response protocol
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15. TERMINAL Start End Death is likely within days Patient diesor
Death is imminent. Other signs such as breathing changes and skin colour changes, fluctuating levels of consciousness, limited oral intake may occur. Many patients with normal aging process or dementia may experience the signs listed on this slide for months however the key question to ask is if death is likely in a matter of days.
Question = Does a rapid increase in current symptoms or new symptoms put the patient into an unstable phase?
Answer = No, if the patient is likely to die in a matter of days they remain in the terminal phase.
Patient’s condition changes and death is no longer likely within days
(i.e. patient is stable or deteriorating)
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16. Actions for the Terminal Phase
Commence end of life care
Communicate changes to family and others important to the patient
If patient not likely to die within days, re-assess Phase
End the Episode of Care when patient dies
PCOC assessment and response protocol
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17. POST DEATH SUPPORT Start End The patient has died
Bereavement support provided to family / carers is documented in the deceased patient’s clinical record
End
Case closure
Note: If counselling is provided to a family member or carer, they become a client in their own right
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18. PHASE IN SUMMARY
Phases are classified according to the clinical need of the patient and their family and carers
Note
Phase is not directly linked to, but encompasses, the clinical condition of the patient. This means, a patient who is still being actively managed can be stable (e.g. pain is present, but the care plan and medication chart have been changed, with contingencies to manage pain).
The first three phases are based around the plan and whether it is working.
Family circumstances can influence phase when the circumstance directly influences care delivery.
For further information please visit
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19. PHASE IN SUMMARY The needs of the patients and family
The frequency of assessments
Level of care required
Determining appropriateness of PC
In determining appropriateness for palliative care a phase assessment can be used in conjunction with the Gold Standard Framework:
1) The surprise question: would I be surprised if this person were to die in 6-12months?
2) Choice and Need.
3) Co-morbidity is the biggest indicator of mortality and morbidity:
Weight loss >10% over 6 mths
General physical decline
Serum Albumin <25g/l
Reduced performance status eg Karnofsky
Referral and Triage
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20. CASE SCENARIO - PHASE
Stephen has hormonally controlled metastatic prostate cancer. Over the last two weeks he has reducing mobility and increasing lethargy. The physiotherapist visited Stephen and moved him into the ‘deteriorating’ phase. Walking aides, education and support were provided. This week, Stephen’s mobility has not changed. He is lethargic but able to manage his mobility. There are no new issues.
Before you start make sure you have the assessment tool definitions or the PCOC Clinical Manal
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21. CASE SCENARIO - PHASE
Should Stephen still be classified as being in a ‘deteriorating’ phase?
Yes - because he is lethargic and has metastatic prostate cancer
No - because the intervention enabled him to mobilise and there are no new issues
Yes - because he did not return to his previous level of mobility
No - because he has hormonally controlled prostate cancer and should be in a stable phase
Answer is B
Although Stephen’s mobility declined, he is currently able to manage his mobility at home and there are no new issues.
When a patient’s condition plateaus, it is appropriate to move them into a ‘stable’ phase. In the ‘stable’ phase, the patient’s problems and symptoms are adequately controlled by the established plan of care, further interventions to maintain symptom control and quality of life have been planned and the family/carer situation is relatively stable with no new issues.1
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22. CASE SCENARIO - PHASE
Sue L. is a 62 year old female with metastatic breast cancer and widespread bone metastases. Sue is admitted in the unstable phase with early signs of spinal cord compression requiring urgent treatment. She has completed three days of a planned treatment schedule with symptom improvement.
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23. CASE SCENARIO - PHASE
Based on this information, should Sue remain in the ‘unstable’ phase today?
Yes –The symptoms have not yet resolved
Yes - A plan of care is in place
No - A new plan of care is in place and no further changes to the plan of care are required
No - A new plan of care is in place and symptoms are resolved
Answer is C
As Sue has completed 3 days of treatment she should be moved from the ‘unstable’ phase into the ‘stable’ phase. She remains in the ‘unstable’ phase until a new plan of care is in place, it has been reviewed and no further changes to the care plan are required . Meeting these criteria signals a phase change appropriate to the patient’s condition is required. This does not necessarily mean that the symptom/crisis has fully resolved, but rather that there is a clear diagnosis and a plan of care is in place, as in Sue’s case.
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24. CASE SCENARIO - PHASE
Lisa M. is a 72 year old female with metastatic cancer from an unknown primary. Yesterday her phase was ‘deteriorating’. She was mostly bedbound but able to walk to the toilet with minimal assistance. She ate some yoghurt for breakfast and soup for dinner, and had Sustagen during the day. The family reported she was a little bit vague. Today, Lisa is unable to walk to the bathroom, unable to swallow or even take sips of fluid. She is very drowsy and not able to speak to her family. Her AKPS is 20 and no reversible causes for this change were identified.
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25. CASE SCENARIO - PHASE
What is Lisa’s phase today and your subsequent action?
Deteriorating: AKPS 20 - address symptom management
Terminal: AKPS 20 – Document and action symptom management and contact family
Deteriorating: AKPS 20 - Document and action symptom management and contact family
Terminal: AKPS 20 - contact family
Answer is B
Lisa’s condition has declined today compared to yesterday. She is unable to walk, swallow or take sips of fluid today. An AKPS  of 20 describes a patient who is totally bedfast and who requires extensive nursing care. Identifying Lisa’s phase change to ‘terminal’ will ensure appropriate end of life care.
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26. CASE SCENARIO - PHASE
Sarah S. is an 80 year old lady in ‘stable’ phase with metastatic ovarian cancer. 48 hours prior to her planned discharge the woman in the next bed, with whom she has struck up a good relationship, dies suddenly. Sarah is very distressed by the situation so you have requested social/spiritual staff to come as quickly as possible to assess this new situation and to provide support. You also arrange for her to be seen by medical staff as soon as possible.
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27. CASE SCENARIO - PHASE
Should Sarah’s phase be changed given that she became very distressed with the death of the patient next to her?
The phase remains stable as she did not have any problems with worsening pain or other physical symptoms.
The phase remains stable as she was already assessed as being in the stable phase.
The phase should be changed to unstable because the patient required urgent psychosocial and medical review.
The phase should be changed to deteriorating because the patient’s psychosocial condition had become worse suddenly.
Answer is C
The sudden psychosocial distress required changes to her existing plan of care as this was a new problem that was not anticipated in the existing plan of care. Her phase should be changed to ‘unstable’ because a new management plan was initiated and implemented to manage Sarah’s acute psychosocial distress.
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28. The Phase algorithm is a useful aid in making a decision about the most appropriate phase. It can be found in the Clinical Manual.
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29. Strategies for education and training
PCOC assessments are part of multidisciplinary orientation
Staff have full definitions and lanyard cards
PCOC is included in in-service style education programs
Staff have access and use the PCOC Essentials online course
All 5 assessment tools are routinely used to assess needs and this is supported by a local protocol
Identified PCOC champions and leads
Local Processes
PCOC implementation, embedding and sustaining guide
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30. Strategies for embedding phase
In clinical handover to prioritise care and standardise response
To determine frequency of review or frequency of contact with the patient and family/carer
As a common language to communicate patient needs across the whole multidisciplinary team
To trigger referral to allied health and for medical review
To trigger after-hours services
Utilise Phase
PCOC implementation, embedding and sustaining guide
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31. KEY MESSAGE Remember – palliative care phases are not sequential.
If you are not sure about changing a patient’s phase, consult with a colleague / multidisciplinary team
Remember, palliative care phases are not sequential - a patient can move back and forth between phases. It is appropriate to move a patient from ‘deteriorating’ into the ‘stable’ phase if the symptoms/problem are adequately controlled.
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32. Definitions abbreviated
Request lanyard cards
Response to assessment scores
You will need the hard copy version of these lanyard cards. You can request cards to be posted to you by contacting PCOC via our website.
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33. PCOC is a national palliative care project funded by the Australian Government Department of Health
Thank You
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Prepared by Clapham S for the Palliative Care Outcomes Collaboration (2018) Australian Health Services Research Institute (AHSRI), University of Wollongong, NSW 2522 Australia. © PCOC 2018
This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without permission from the Palliative Care Outcomes Collaboration (PCOC).
Requests and enquiries concerning reproduction and rights should be addressed to:
Manager, Palliative Care Outcomes Collaboration (PCOC)
Australian Health Services Research Institute (AHSRI)
Building 234 (iC Enterprise 1) Innovation Campus
University of Wollongong NSW 2522
Phone: (02) Fax: (02)
For further information please view the resources contained in the PCOC Clinical Manual, go to or contact your PCOC Facilitator