📋 Key Information Summary
- Structured assessment tools are essential for consistent symptom evaluation, functional scoring, prognostication, and service planning in Australian palliative care.
- AKPS (Australia-modified Karnofsky Performance Status) is the standard performance measure endorsed by Palliative Care Australia; scores range 0–100 and guide prognosis and service eligibility.
- RUG–ADL (Resource Utilization Groups – Activities of Daily Living) classifies care needs by ADL dependency, informing residential aged care resource allocation under AN-ACC funding.
- SAS (Symptom Assessment Scale) is a patient-rated 0–10 tool covering seven core symptoms (pain, nausea, vomiting, appetite, bowel, breathing, sleep, fatigue, mood) used in routine palliative care review.
- PCPSS (Palliative Care Problem Severity Score) is a clinician-rated tool capturing physical, psychological, social, and spiritual/existential problems on a 0–3 severity scale per domain.
- SPICT (Supportive and Palliative Care Indicators Tool) helps identify patients who may benefit from palliative care through general and specific clinical indicator triggers.
- FAST (Functional Assessment Staging Tool) maps seven stages of dementia progression, aiding prognostication and timely palliative care referral in advanced dementia.
- These tools are complementary, not interchangeable — use AKPS for performance, SAS/PCPSS for symptom burden, RUG–ADL for care needs, and SPICT/FAST for identification and prognostication.
- SAS and PCPSS are mandated in state-funded palliative care services across most Australian jurisdictions (e.g., Qld, NSW, Vic, SA, WA).
- SPICT-Au is the Australian adaptation of the original Scottish SPICT, with local clinical indicators and referral pathways.
- Aboriginal and Torres Strait Islander communities face unique barriers to palliative care access; tools should be applied with cultural sensitivity and yarning-based approaches where appropriate.
- Regular reassessment using these tools supports goals-of-care conversations, advance care planning, and timely transition to specialist palliative care.
- All tools are freely available and do not require special licensing, though training is recommended for reliable inter-rater use.
Introduction & Australian Context
Palliative care assessment in Australia relies on validated, standardised tools that capture symptom burden, functional status, performance capacity, care needs, and prognosis. These tools serve multiple purposes: they guide clinical decision-making, facilitate communication between multidisciplinary team members, support funding and resource allocation, and enable quality benchmarking across services.
This topic gathers the most widely used high-yield tools across Australian palliative care education and clinical practice. They are grouped into four domains:
- Performance status — AKPS (Australia-modified Karnofsky Performance Status)
- Functional dependency / care needs — RUG–ADL (Resource Utilization Groups – Activities of Daily Living)
- Symptom and problem assessment — SAS (Symptom Assessment Scale) and PCPSS (Palliative Care Problem Severity Score)
- Identification, screening, and prognostication — SPICT (Supportive and Palliative Care Indicators Tool) and FAST (Functional Assessment Staging Tool)
Key principle: No single tool captures the full complexity of palliative care needs. These instruments should be used in combination, embedded within a comprehensive clinical assessment that includes goals-of-care discussions, advance care planning, and multidisciplinary team review.
Approximately 160,000 Australians access palliative care services annually, with demand increasing by 5–8% per year due to ageing demographics and rising chronic disease prevalence. The Australian Institute of Health and Welfare (AIHW) reports that only 50–60% of people who die each year receive formal palliative care, highlighting the importance of early identification tools such as SPICT and FAST. Palliative Care Australia's National Palliative Care Strategy 2018 and the National Consensus Statement: Essential Elements for Safe and High-Quality End-of-Life Care (ACSQHC) emphasise routine use of structured assessment tools to ensure equitable, high-quality care.
AKPS — Australia-Modified Karnofsky Performance Status
Background & Purpose
The AKPS is the Australian adaptation of the original Karnofsky Performance Status (KPS) scale, modified by the Australasian Palliative Care Association (now Palliative Care Australia) to improve its applicability in palliative care settings. It provides a single numerical score (0–100) reflecting a patient's overall functional performance, and is widely used for prognosis, service eligibility, and research stratification in Australian palliative care.
The AKPS differs from the original KPS by adding descriptors at each 10-point decrement that are more relevant to the palliative care population (e.g., explicitly capturing symptom burden and care dependency rather than focusing on ability to work or carry on normal activity).
Scale & Scoring
| AKPS Score | Descriptor | Functional Interpretation |
|---|---|---|
| 100 | Normal; no complaints; no evidence of disease | Fully active, able to carry on all normal activities |
| 90 | Able to carry on normal activity; minor signs/symptoms | Active; minor restrictions |
| 80 | Normal activity with effort; some signs/symptoms | Ambulatory; capable of self-care |
| 70 | Cares for self; unable to carry on normal activity or work | Limited activity; some assistance needed |
| 60 | Requires occasional assistance; cares for most needs | Needs intermittent help |
| 50 | Requires considerable assistance and frequent medical care | Disabled; significant care needs |
| 40 | Disabled; requires special care and assistance | Predominantly bed/chair-bound |
| 30 | Severely disabled; hospitalisation indicated (death not imminent) | Bed-bound; extensive nursing care |
| 20 | Very sick; hospitalisation and active supportive treatment needed | Totally dependent |
| 10 | Moribund; fatal processes progressing rapidly | Dying |
| 0 | Dead | — |
Prognostic Utility
The AKPS is a strong independent predictor of survival in palliative care populations. Key prognostic thresholds used in Australian practice:
- AKPS ≥ 70: Median survival generally > 6 months — suitable for community palliative care with periodic review.
- AKPS 40–60: Median survival 2–4 months — consider increased frequency of review, specialist palliative care involvement, goals-of-care discussion.
- AKPS ≤ 30: Median survival days to weeks — consider end-of-life care planning, palliative care inpatient admission if symptom burden is high.
- AKPS ≤ 10: Imminently dying — activate end-of-life pathway (e.g., Qld End-of-Life Care Pathway, Vic EPiC).
Clinical tip: Serial AKPS scores (e.g., fortnightly) are more informative than a single measurement. A decline of ≥10 points over 2–4 weeks is associated with significantly increased 3-month mortality and should prompt goals-of-care review.
Administration
- Who scores it: Clinician-rated (doctor, nurse, or allied health with training). Patient self-assessment correlates poorly with clinician ratings at lower AKPS scores.
- Time to complete: 1–2 minutes.
- Setting: Community, inpatient, residential aged care, hospice.
- Frequency: At initial assessment, at each change in clinical status, and at minimum 4-weekly in stable patients.
- Training: Free online training available through Palliative Care Australia and state-based palliative care peak bodies.
Limitations
- Subject to inter-rater variability; moderate inter-rater reliability (weighted κ ≈ 0.60–0.75) without training.
- Less sensitive to change in symptom burden compared to SAS or Edmonton Symptom Assessment System (ESAS).
- Does not capture psychological, social, or spiritual domains — must be used alongside PCPSS or equivalent.
- Single-digit granularity (10-point increments) may miss subtle functional decline.
RUG–ADL — Resource Utilization Groups – Activities of Daily Living
Background & Purpose
The RUG–ADL is a resident classification system originally developed in the United States for the Resource Utilization Groups (RUG) case-mix classification system. In Australia, it is used extensively in residential aged care to classify residents according to their dependency in activities of daily living (ADLs), which directly informs care staffing levels, funding allocation, and care planning.
With the introduction of the Australian National Aged Care Classification (AN-ACC) model on 1 October 2022, replacing the previous Aged Care Funding Instrument (ACFI), RUG–ADL items remain an important component of functional assessment. AN-ACC uses mobility and self-care domains informed by ADL assessments to classify residents into 13 funding classes.
Components & Scoring
The RUG–ADL scores four core ADL activities on a 4-point scale:
| ADL Item | Score 1 (Independent) | Score 2 (Supervision) | Score 3 (Limited Assist) | Score 4 (Extensive Assist / Dependent) |
|---|---|---|---|---|
| Bed mobility | Independent turning/repositioning | Verbal cueing or standby assist | Hands-on assist for part of movement | Total lifting or full assist |
| Transfer | Independent bed-to-chair | Standby or minimal cueing | Hands-on assist for part of transfer | Full mechanical lift or two-person assist |
| Toilet use | Independent toileting and hygiene | Cueing or standby for safety | Assist with clothing, positioning, hygiene | Catheter, commode, or total assist |
| Eating | Independent eating and drinking | Cueing, setup, or supervision | Partial feeding assist | Total tube feeds or full oral assist |
Composite score range: 4 (fully independent) to 16 (totally dependent). Higher scores indicate greater care needs and resource utilisation.
Application in Palliative Care
- Care planning: RUG–ADL scores inform the intensity and type of nursing care required, including staffing ratios, repositioning schedules, and feeding assistance protocols.
- Funding: Under AN-ACC, functional dependency data (aligned with RUG–ADL concepts) determines the resident's classification and funding level. A RUG–ADL composite score ≥12 generally corresponds to high-care needs.
- Trajectory monitoring: Serial RUG–ADL assessments (minimum 3-monthly, or with clinical change) allow tracking of functional decline, which is prognostically important in advanced disease.
- Palliative care-specific utility: In the last weeks of life, progressive RUG–ADL score increases (particularly bed mobility and eating) correlate with shortened survival and can support transition to end-of-life care pathways.
Important: RUG–ADL should not be used as the sole criterion for palliative care referral. It captures physical function only and does not address symptom burden, psychological distress, or goals of care. Combine with AKPS, SAS, and PCPSS for a comprehensive palliative care assessment.
Administration
- Who scores it: Registered nurse or enrolled nurse with training, based on observation and documentation over the preceding 7 days.
- Time to complete: 5–10 minutes per resident.
- Setting: Primarily residential aged care facilities; also applicable in hospital-based palliative care units and transitional care.
- Frequency: At admission, at minimum every 3 months, and with any significant change in condition.
SAS & PCPSS — Symptom Assessment Scale and Palliative Care Problem Severity Score
Symptom Assessment Scale (SAS)
The SAS is a patient-rated symptom assessment tool widely mandated across Australian state-funded palliative care services. It asks the patient to rate the severity of seven core symptoms on a 0–10 numerical rating scale (NRS) over the preceding 24 hours.
| Symptom Domain | Score 0 | Score 1–3 | Score 4–6 | Score 7–10 |
|---|---|---|---|---|
| Pain | None | Mild | Moderate | Severe |
| Nausea | None | Mild | Moderate | Severe |
| Vomiting | None | Mild | Moderate | Severe |
| Appetite | Normal | Mildly reduced | Moderately reduced | Severely reduced |
| Bowel problems | None | Mild | Moderate | Severe |
| Breathing | No dyspnoea | Mild | Moderate | Severe |
| Sleep / Fatigue | Normal | Mild disruption | Moderate disruption | Severe / unable to sleep |
| Mood / Anxiety | No distress | Mild | Moderate | Severe distress |
Clinical thresholds:
- Score ≥ 4 in any domain → triggers clinical review and active symptom management.
- Score ≥ 7 in any domain → urgent review; consider specialist palliative care involvement.
- Cumulative SAS (sum of all domains) ≥ 25/70 → high overall symptom burden; reassess treatment plan.
Palliative Care Problem Severity Score (PCPSS)
The PCPSS is a clinician-rated tool used alongside the SAS. It captures the clinician's assessment of problem severity across four domains:
Score 0
No Problem
Domain functioning well; no clinical concern.
Score 1
Mild Problem
Minor issue present; manageable with current plan.
Score 2
Moderate Problem
Requires active intervention; affecting quality of life.
Score 3
Severe / Crisis
Major uncontrolled problem; urgent specialist input needed.
| PCPSS Domain | What It Captures | Examples |
|---|---|---|
| Physical | Symptom burden (pain, dyspnoea, nausea, etc.) | Uncontrolled bone pain, intractable vomiting |
| Psychological | Emotional and mental health | Anxiety, depression, delirium, existential distress |
| Social | Family, carer, and social support issues | Carer burnout, family conflict, isolation, financial stress |
| Spiritual / Existential | Meaning, purpose, and spiritual needs | Loss of meaning, fear of death, religious distress |
Using SAS and PCPSS Together
Best practice: SAS (patient-rated) and PCPSS (clinician-rated) are designed to be administered together at each palliative care contact. Discrepancies between patient and clinician ratings in the same domain should prompt further discussion — the patient's experience is the gold standard for symptom severity.
- SAS captures the patient's subjective experience of symptom severity.
- PCPSS captures the clinician's holistic assessment including social and spiritual dimensions not easily captured by a patient-rated tool.
- Both tools feed into the Palliative Care Outcomes Collaboration (PCOC) national benchmarking dataset, which tracks outcomes across Australian palliative care services.
- PCOC requires SAS and PCPSS at admission, at each phase change, and at discharge/death.
Administration
- SAS: Completed by the patient (paper or electronic). If patient is unable, a proxy (family/carer) may complete with clinician guidance. Time: 2–5 minutes.
- PCPSS: Completed by the treating clinician (medical, nursing, or allied health). Time: 2–3 minutes.
- Frequency: At every clinical contact or phase of care change (PCOC requirement). Minimum weekly in community palliative care; each shift or daily in inpatient settings.
- Training: Free PCOC training modules available at palliativecarenc.com.au.
SPICT & FAST — Identification and Prognostication Tools
SPICT — Supportive and Palliative Care Indicators Tool
The SPICT was originally developed in Scotland by the University of Edinburgh to help clinicians identify patients at risk of deteriorating and dying who may benefit from a palliative care approach. The SPICT-Au is the Australian adaptation, incorporating local clinical language, disease patterns, and referral pathways.
SPICT is a two-part screening tool:
Part A: General Indicators of Decline
If a patient has two or more general indicators, they should be considered for a supportive and palliative care approach.
- Surprise question: "Would you be surprised if this patient died in the next 12 months?" — if the answer is "No," consider SPICT assessment.
- Performance status: AKPS ≤ 50 or equivalent (ECOG 3–4).
- Unplanned hospital admissions in the past 6 months (≥ 2).
- Weight loss > 10% in 6 months (unintentional).
- Persistent symptoms despite optimal treatment of underlying condition.
- Increasing care needs (declining function, needing more help with ADLs).
Part B: Specific Clinical Indicators
Disease-specific indicators that suggest the patient is entering a palliative phase:
- Advanced cancer: Unresectable, metastatic, or progressive despite treatment; no further disease-modifying options.
- End-stage organ failure: Heart failure (NYHA IV, recurrent admissions despite optimal therapy), COPD (FEV₁ < 30%, chronic respiratory failure), liver disease (Child-Pugh C), renal failure (declining or not for dialysis).
- Progressive neurological disease: MND/ALS, advanced Parkinson's disease, advanced MS, Huntington's disease.
- Advanced dementia: FAST stage 7 (see below), recurrent infections, reduced oral intake, weight loss.
- Frailty: Clinical Frailty Scale ≥ 7, recurrent falls, sarcopenia, multimorbidity with functional decline.
FAST — Functional Assessment Staging Tool
The FAST (Reisberg's Functional Assessment Staging) is a seven-stage tool specifically designed for patients with Alzheimer's disease and other dementias. It maps progressive functional decline from normal ageing (Stage 1) through to severe end-stage dementia (Stage 7), with sub-stages within Stage 7 (7a–7f).
| FAST Stage | Description | Typical Duration | Palliative Care Relevance |
|---|---|---|---|
| 1 | No functional decline | — | Not applicable |
| 2 | Subjective forgetfulness; complains of word-finding difficulty | ~15 years to Stage 7 | Early advance care planning |
| 3 | Decreased job function; word-finding and name recall difficulty noticeable to others | ~7 years to Stage 7 | Appoint substitute decision-maker |
| 4 | Requires assistance with complex tasks (finances, travel, shopping) | ~3 years to Stage 7 | Advance care plan documentation |
| 5 | Requires assistance choosing clothing; may need cueing for bathing | ~1.5 years to Stage 7 | SPICT trigger; supportive care approach |
| 6 | Requires assistance with dressing, bathing, toileting; incontinence; personality/behavioural changes | ~2–3 years in Stage 6 | Active palliative care involvement; symptom management |
| 7a | Speech limited to ~6 intelligible words per day | ~1–2 years in Stage 7 | Goals-of-care discussion; consider comfort care focus |
| 7b | Speech limited to single intelligible word per day | — | Review all medications; cease non-essential treatments |
| 7c | Loss of ambulatory ability | — | Consider residential aged care; focus on comfort |
| 7d | Loss of ability to sit up unsupported | — | Intensive comfort care; pressure injury prevention |
| 7e | Loss of ability to smile | — | End-of-life care; consider syringe driver for symptom control |
| 7f | Loss of ability to hold head up independently | — | Imminently dying; activate end-of-life pathway |
Critical point: Patients with advanced dementia (FAST 7a–7f) are among the most under-referred population for palliative care in Australia. Studies show that only 15–20% of people dying with dementia receive specialist palliative care. Use FAST staging to trigger timely palliative care referral and advance care planning discussions — ideally before the patient loses capacity (FAST ≤ 4).
Integrating SPICT and FAST
SPICT and FAST are complementary. SPICT is a broad identification tool applicable to any life-limiting condition; FAST is specific to dementia but provides granular prognostic information. In clinical practice:
- Use SPICT as the initial trigger for palliative care consideration in any patient with a serious illness.
- For patients with dementia, add FAST staging to determine where the patient is on the dementia trajectory and to guide goals-of-care conversations.
- FAST stages 7c–7f have a median survival of weeks to low single-digit months — equivalent to AKPS ≤ 30 in the cancer population.
- Both tools should prompt the clinical team to initiate or review advance care plans, resuscitation orders, and place-of-care preferences.
Clinical Integration & How to Use These Tools Together
The following framework illustrates how the four tool groups map to the clinical workflow in Australian palliative care:
| Clinical Question | Primary Tool | Supporting Tool(s) | Frequency |
|---|---|---|---|
| "Does this patient need palliative care?" | SPICT (+ surprise question) | AKPS, FAST (if dementia) | Once, at identification; re-screen if clinical trajectory changes |
| "How is the patient functioning?" | AKPS | RUG–ADL (if in RACF) | Every clinical contact (AKPS); 3-monthly (RUG–ADL) |
| "What are the patient's symptoms?" | SAS (patient-rated) | PCPSS (clinician-rated) | Every clinical contact; daily in inpatient |
| "What is the overall problem burden?" | PCPSS | SAS | Every clinical contact |
| "What care resources are needed?" | RUG–ADL | AKPS | 3-monthly; with any change |
| "How long might this patient survive?" | AKPS (serial), FAST (if dementia) | SPICT, Palliative Prognostic Score (PaP) | AKPS: every 2–4 weeks; FAST: 3–6-monthly |
PCOC integration: Australian palliative care services participating in the Palliative Care Outcomes Collaboration (PCOC) are required to routinely collect AKPS, SAS, PCPSS, and phase-of-care data. These tools form the backbone of PCOC national benchmarking and quality improvement.
Special Populations
Elderly / Residential Aged Care
- RUG–ADL is the primary functional tool in RACFs; use alongside AKPS and FAST for residents with dementia.
- SAS may need proxy completion for residents with cognitive impairment; visual analogue scales and faces scales may be more reliable than NRS in this population.
- AN-ACC assessment (from October 2022) uses functional data aligned with RUG–ADL for funding classification.
- Frailty assessment (Clinical Frailty Scale ≥ 7) should trigger SPICT screening.
- Consider pharmacological review: deprescribing of non-essential medications is an important palliative care intervention in this population.
Paediatrics
- AKPS and FAST are validated for adult populations. In paediatric palliative care, use the Paediatric Palliative Performance Scale (Paed-PPS) or Lansky Play-Performance Scale for children aged 1–16 years.
- SAS NRS may be used in children aged ≥ 8 years; for younger children, use age-appropriate validated tools (e.g., Wong-Baker FACES for pain).
- RUG–ADL is not validated for paediatric populations; use age-appropriate functional assessments.
- Paediatric SPICT adaptations are available through the Paediatric Integrated Care System (PICS) project.
Chronic Kidney Disease / Renal Impairment
- For patients with CKD stage 5 who are not for dialysis (conservative kidney management), AKPS and SAS are essential tools for monitoring symptom burden and functional decline.
- SPICT-Au includes renal-specific indicators (eGFR < 15 mL/min/1.73 m², declining function on maximum tolerated therapy).
- Uraemic symptoms (nausea, pruritus, fatigue, restless legs) may dominate the SAS profile; score these separately from disease-related symptoms.
Advanced Liver Disease
- Child-Pugh C or MELD score > 20 with declining function should trigger SPICT assessment.
- AKPS and SAS are appropriate; hepatic encephalopathy may impair self-report — use proxy SAS scoring.
- PCPSS spiritual/existential domain often elevated in patients with alcohol-related liver disease; sensitive exploration is needed.
Immunocompromised / HIV
- In advanced HIV (WHO Stage 4, CD4 < 50), AKPS and SAS help monitor palliative care needs alongside ART.
- SPICT can be applied to identify patients with HIV who may benefit from concurrent palliative care.
- PCPSS psychological domain is often elevated; address stigma, disclosure concerns, and social isolation.
Aboriginal and Torres Strait Islander Health Considerations
Aboriginal and Torres Strait Islander Health
Aboriginal and Torres Strait Islander Australians experience a disproportionate burden of life-limiting illness and face significant barriers to accessing culturally safe palliative care. The AIHW reports that Indigenous Australians die from life-limiting conditions at 1.5–3 times the rate of non-Indigenous Australians, yet access specialist palliative care at significantly lower rates. Assessment tools must be applied with cultural sensitivity, and the concept of "wellbeing" in many Indigenous communities extends beyond individual physical symptoms to encompass family, Country, spirituality, and connection to community.
Cultural protocol: Always seek permission before using formal assessment tools with Aboriginal and Torres Strait Islander patients. Explain the purpose of the tool in plain language. Where possible, involve Aboriginal Health Workers/Practitioners in assessment and ensure that the tool supports — rather than replaces — culturally grounded conversations about wellbeing, Country, and end-of-life wishes.
📚 References
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