1. Assessing symptoms and problems
SAS and PCPSS
Before You Start
Make sure you have the assessment tool definitions or the PCOC Clinical Manual

2. SYMPTOM ASSESSMENT TOOLS
Symptom assessment using the PCPSS and SAS
Palliative Care Problem Severity Score
Symptom Assessment Scale
These assessment tools measure symptoms and together they give a total picture of the palliative care patient and family/carer.
pcoc.org.au

3. PCPSS and SAS IN SUMMARY
Clinician Rated
Patient Rated
Summary of problems in 4 domains
Degree of distress relating to individual symptoms
Identifies overall priorities of care
Identifies patient priorities relating to individual symptoms
Includes family / carer assessment
Patient assessment only
Understanding the differences between these 2 assessment tools assists clinicians in understanding how the tools are administered and documented.
The SAS assesses a patient’s distress level in relation to symptoms and the PCPSS assesses severity of problems or issues.
Distress from pain is best assessed by asking; How much distress does this pain cause you? Or How much does this symptom bother you?
Includes psychological / spiritual assessment
pcoc.org.au

4. PALLIATIVE CARE PROBLEM SEVERITY SCORE (PCPSS)
Overview
A clinician rated measure of palliative care problems in four domains:
Other
symptoms
Psychological
/Spiritual
Family
/Carer
Pain
PCPSS definition: The PCPSS is recommended as a clinical tool which can be used for initial screening and ongoing coordination of specialist palliative care (Bostanci, Hudson et al. 2012). Facilitates the global assessment of four palliative care domains: pain, psychological/spiritual, other symptoms and family/carer. The fourth domain measures family/carer problems associated with a patient’s condition or palliative care needs. (CM page 33)
pcoc.org.au

5. PALLIATIVE CARE PROBLEM SEVERITY SCORE (PCPSS)
Definition:
Family/carer domain measures problems associated with a patient’s condition or needs
Facilitates the global assessment of four palliative care domains
Clinical tool for initial screening and ongoing coordination of specialist palliative care
PCPSS definition: The PCPSS is recommended as a clinical tool which can be used for initial screening and ongoing coordination of specialist palliative care (Bostanci, Hudson et al. 2012). Clinician rated, it facilitates the global assessment of four palliative care domains: pain, psychological/spiritual, other symptoms and family/carer. The fourth domain measures family/carer problems associated with a patient’s condition or palliative care needs. (CM page 33)
The overall severity of problems relating to pain is assessed by the clinician through discussion with the patient and family/carer and through observations.
Note this is NOT a distress tool but a measurement of overall problems that trigger a response based on the severity.
Response may include referrals, further assessment and interventions.
The framework below may assist:
Absent 0 = no further action needed
Mild 1 = monitor
Moderate 2 = Review and Discuss with team.
Severe 3 = Urgent action.
pcoc.org.au

6. HOW TO ASSESS PCPSS
Rate the severity of problems for each domain over a 24 hour period 1 2 3
Tips for determining severity of problems ‘Other Symptoms’.
Assessment may be based on 1 symptom or problem or a combination or symptoms and problems.
The PCPSS should relate to the SAS scores. For example PCPSS scores for pain and for other symptoms should be reflected in individual SAS scores.
The PCPSS should relate to the Phase assessment. For example higher PCPSS scores trigger an Unstable phase.
Absent
Mild
Moderate
Severe
pcoc.org.au

7. HOW TO ASSESS PCPSS
Other Symptoms The overall severity of problems relating to symptoms other than pain Psychological / Spiritual The overall severity of problems relating to the patient’s psychological or spiritual wellbeing. May be one or more issues. Family / Carer The overall severity of problems associated with a patient’s condition or palliative care needs. Family / Carer do not need to be present to assess needs. Written, verbal or observational information may be used.
This clinician rated assessment is of total severity of symptoms, specific symptoms are assessed using the SAS. The assessment is based on any symptoms that are present. It may be 1 symptom only or a combination of symptoms.
Ask: “Is the patient experiencing any symptoms? If so what is the overall severity of the symptom or combined symptoms?”
Ask: “Is the patient experiencing psychological or spiritual problems? How much of a problem is psychological or spiritual issues?”
Ask: “Are the family or carers experiencing problems and what is the severity of these problems?”
A severity rating of 2 or 3 for family carer may trigger referral to social work or pastoral care.
Question = What do I score if there is no family?
Answer = Score 0- absent.
Question = If the family are not physically present or rarely involved in care or decision making how do I make an assessment?
Answer = Use any information available such as phone conversation, documentation, communication with the patient about the family, etc. In this case rating could be high as limited contact may be related to the one of the examples above which causes distress, problems or issues.
pcoc.org.au

8. CASE SCENARIO - PCPSS
John was admitted to the inpatient unit for terminal care. He and his family had planned for him to stay home until he died. However, his symptoms became increasingly difficult for his family to manage and they were unable to continue his care at home. Shortly after John’s admission his partner became visibly upset. On talking with her it is clear she is aware of John’s poor prognosis and is accepting of his admission. She kindly declines offers of support and is comforted by her adult daughter.
pcoc.org.au

9. CASE SCENARIO - PCPSS
What PCPSS would you give for John’s family / carer?
Absent (0) – John’s partner is upset as she wanted John to stay home. No further action required at this time.
Mild (1) – John’s partner is upset because he is no longer able to be cared for at home and she is anticipating his death. Monitor.
Moderate (2) - John’s partner is upset by his deterioration and admission, and is refusing support although staff feel she needs it. Discuss with team.
Severe (3) – John’s partner is refusing support and probably feels like she failed in not being able to care for John at home. Urgent referral to social work, consider pastoral care input and update the team.
Answer is B
John’s partner is showing signs of distress because she is aware John has been admitted for terminal care. This is an understandable grief reaction that requires monitoring.
pcoc.org.au

10. CASE SCENARIO - PCPSS
Annia is 86 years old and after 10 years of haemodialysis for renal disease has recently made the decision stop. While comfortable with her decision she is tearful. She has a strong faith and prays regularly. Annia never married and has no children. Her only family is an estranged sister who lives in New Zealand. Annia had one close friend, who died last year. Annia reports multiple symptoms. She has pain but says she feels the oral medication works well. Loss of appetite, moderate fatigue and a low level of nausea are also present. Her main complaint is that she is ‘itchy’ all over and it “drives her mad”. You can see scratch marks on her arms, legs and torso.
pcoc.org.au

11. CASE SCENARIO - PCPSS
What are Annia’s Palliative Care Problem Severity Scores?
Pain 3, Other Symptoms 1, Family / caregiver 3, Psychological / spiritual 0
Pain 0, Other Symptoms 1, Family / caregiver 1, Psychological / spiritual 1
Pain 0, Other Symptoms 3, Family / caregiver 3, Psychological / spiritual 0
Pain 1, Other Symptoms 3, Family / caregiver 0, Psychological / spiritual 1
The answer is D
PCPSS
Pain 1
Other symptoms 3
Family / carer 0
Psychological / spiritual 1
pcoc.org.au

12. KEY MESSAGE:
It is important to recognise and understand what is considered an appropriate / normal reaction and to anticipate the expected response of the patient and carers as the patient’s condition declines
Inappropriate assessment may lead to unnecessary (and possibly burdensome) referral or treatment
pcoc.org.au

13. SYMPTOM ASSESSMENT SCALE (SAS)
Overview:
A patient rated tool assessing individual symptom distress
Seven items
are the most
common
symptoms
Symptoms
may
be added
Refer to clinical manual: SAS form for completion by patients.
This assessment is used to capture the patient’s perspective on the degree of individual symptom distress.
pcoc.org.au

14. SYMPTOM ASSESSMENT SCALE (SAS)
A measure of symptom distress
Appetite
problems
Difficulty
sleeping
Breathing
problems
Fatigue
Symptoms
These symptoms are identified as the 7 most common symptoms experience by palliative care patients in Kristjanson et al 1999.
Using the SAS, it is possible to identify the effectiveness of clinical interventions as well as measure changes in symptoms, improvements or deterioration.
It further identifies the patient’s priorities in terms of distress, tracking individual symptoms over time.
Pain
Nausea
Bowel problems
pcoc.org.au

15. SAS is a Patient Reported Outcome Measure
This form can be found in the Clinical Manual or by visiting the PCOC website. Palliative care is leading the way in routine patient reported outcome measurement.
pcoc.org.au

16. HOW TO ASSESS SYMPTOM ASSESSMENT SCALE
Patient rated is the gold standard.
A Proxy Assessment is only used when:
If the patient experiencing symptoms is unable to rate symptom distress, a proxy can be used
A proxy is someone who can answer the SAS items from the patient’s perspective
A patient may not be able to communicate their degree of distress if they are unconscious or are experiencing confusion or delirium. If language or other communication barriers are present you should consider using an interpreter or visual scale or descriptive scale.
Question = What do I do about assessing symptom distress if the patient is confused?
Answer = If the patient is confused, there is still a chance that he or she will be able to report symptom distress using the Symptom Assessment Scale so the opportunity to do this should be provided. When an inability to comprehend what is required is demonstrated, it will be necessary to resort to proxy scoring   
Question = What if the patient is unable to communicate?
Answer = If the person experiencing the symptoms is unable to participate at all, it is appropriate to use a proxy.
pcoc.org.au

17. CASE SCENARIO - SAS
Sam is a 67 year old man in the ‘deteriorating’ phase with metastatic colon cancer to the liver. His appetite has been declining over the last three months. Today he is able to verbalise that he is not hungry, but is unable to provide a Symptom Assessment Scale (SAS) score. He is comfortable not eating or drinking much. There is no carer to provide a SAS score.
pcoc.org.au

18. CASE SCENARIO - SAS
Which SAS score best reflects Sam’s appetite today? 1 4 7 9
Answer is A
As Sam’s declining appetite is not distressing to him, the correct score for his appetite today is 1.
SAS measures the level of distress symptoms are causing the patient, not the severity or intensity of symptoms. If Sam’s SAS for appetite remains low  there is no need to refer to a dietician.
As Sam couldn’t provide his SAS scores today, and there was no family or carer available, it is appropriate that you provide the SAS score as the clinician caring for him.  
pcoc.org.au

19. KEY MESSAGE:
SAS describes the patient’s level of distress relating to individual physical symptoms.
SAS is a patient rated tool. Proxy is only used if patient is unconscious or confused
In Sam’s case, the level of distress was very, very low (1).
In this case, a referral for dietary support may have led to inappropriate advice and possible ineffective but burdensome treatment for Sam
pcoc.org.au

20. ACTIONS FOR SAS and PCPSS
Problem / symptom distress absent.
Continue with current care.
Routine assessment
Phase may be Stable or Terminal
Absent
PCPSS = 0
SAS = 0
PCOC Assessment and Response Protocol
pcoc.org.au

21. ACTIONS FOR SAS and PCPSS
Problem / symptom distress managed by existing plan of care and routine care
Treat problem / symptom according to protocol
Monitor and record relevant information
Phase may be Stable, Deteriorating or Terminal
Mild
PCPSS = 1
SAS = 1-3
PCOC Assessment and Response Protocol
pcoc.org.au

22. ACTIONS FOR SAS and PCPSS
Problem / symptom distress requires change in plan of care, referral and escalation
Document review and implement any new interventions as per care plan
Phase may be Deteriorating or Terminal
Moderate
PCPSS = 2
SAS = 4-7
PCOC Assessment and Response Protocol
pcoc.org.au

23. ACTIONS FOR SAS and PCPSS
Problem / symptom distress requires immediate action
Plan of care is ineffective
Urgent intervention, referral and escalation required
Change of care plan indicated
Review within 24 hours
Phase Unstable or Terminal
Severe
PCPSS = 3
SAS = 8-10
PCOC Assessment and Response Protocol
pcoc.org.au

24. 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
pcoc.org.au

25. Strategies for embedding
As a common language to communicate patient needs across the whole multidisciplinary team
Moderate and severe scores to trigger an action response
To prioritise multidisciplinary team discussions
To trigger allied health and medical review
By incorporating into symptom management protocols
To trigger after-hours services
Utilise SAS & PCPSS
PCOC implementation, embedding and sustaining guide
pcoc.org.au

26. PCOC clinical manual www.pcoc.org.au pcoc.org.au
Please refer to the full definition found in the Clinical Manual
pcoc.org.au

27. Definitions abbreviated
Request lanyard cards
Response to assessment scores
Please refer to your lanyard cards or order yours via the PCOC website
pcoc.org.au

28. PCOC is a national palliative care project funded by the Australian Government Department of Health
Thank You
pcoc.org.au
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
For further information please view the resources contained in the PCOC Clinical Manual, go to or contact your PCOC Facilitator