Guidelines for a Palliative Approach in Residential Aged Care

(see Fainsinger, Miller and Bruera (1991) [111] in Reference List for example). Assessment of
common problematic symptoms in this group of residents assists in the provision of adequate
and timely care. The common areas of symptom distress include nutritional problems, bowel
problems, dyspnoea, fatigue, insomnia, pain, nausea and dysphagia [108] (Level III-2).
A detailed assessment is the cornerstone of all symptom management, and includes a
review of possible causes, the history of the symptom and the impact of the symptom on
all aspects of the resident’s daily function. The quality of the assessment depends upon the
communication skills of the aged care team in ensuring that the experiences and distress
of the resident are understood and accurately interpreted. A comprehensive assessment
of the resident’s concerns, including early identification of their main symptoms, leads to
appropriate treatment plans [112] (Level IV). Central principles to assessment include: [112–115]
(Level IV; Level IV; Level IV; Level QE)
• ongoing assessment, not a single event;
• self-reporting (for the cognitively intact, this is the most accurate source of information);
• identification of the best proxy (for residents unable to communicate) to ensure the resident’s
wishes are considered;
• discussion of the efficacy of any interventions tried or being considered (assessment should
not be limited to an exploration of symptoms);
• clear documentation of all assessments;
• all relevant members of the aged care team providing input;
• a focus on psychological, social and spiritual domains;
• agreement, whenever possible, on the goals of care by the resident and/or family/proxy; and
• consideration of the disease trajectory/ageing process for each resident, as this may have
implications for management.
RACFs already use a variety of tools to assess residents’ symptoms. Various tools that have been
validated will be highlighted throughout these Guidelines. It is anticipated that RACFs can
adopt these tools for use; however, there is no one tool that is recommended.
The use of symptomatic assessment can result in a quicker response to symptom control. If a
systematic assessment of symptom distress is not undertaken, then this increases the likelihood these
symptoms will be under-treated. Overall, assessment tools have demonstrated an improvement in
the management of symptoms when used in conjunction with a detailed clinical interview.
There are tools for assessing specific conditions such as pain, shortness of breath and
depression (See Sections 6.2, ‘Pain management’, 6.9, ‘Dyspnoea’, and Chapter 7,
‘Psychological support’, for further information on specific assessment tools). As the distress
of symptoms is a subjective matter, the ‘gold standard’ is the resident’s own assessment [116]
(Level III-3). Unfortunately, few tools are validated in RACFs; therefore, those from
palliative settings may be the best currently available.
Three symptom screening tools used in a palliative approach that have been successfully used
with older persons are listed below.
70 Guidelines for a Palliative Approach in Residential Aged Care