✅ PROMPTS FOR THE FOUR DOMAINS FOR PALLIATIVE CARE ASSESSMENT

DOMAIN 1 PHYSICAL WELLBEING:
SUGGESTED PROMPTS

Pain
    Somatic, visceral, neuropathic.
    Take a detailed pain history outlining:
        - location, quantity, intensity, duration, frequency
        - associated/aggravating/relieving factors
        - treatment interventions

Fatigue
    Fatigue disproportionate for level of activity or not relieved by rest.

Respiratory
    Dyspnoea, cough, oropharyngeal secretions.

Gastrointestinal
    Anorexia, nausea, vomiting, constipation.

CNS
    Insomnia, confusion, delirium, anxiety, depression.

Other
Functional status, balance problems, oedema, wound problems.


DOMAIN 2 SOCIAL & OCCUPATIONAL WELL-BEING:
SUGGESTED PROMPTS

Family Support
    Invite discussion about family & relationships:
        - who lives with you?
        - any children/adult dependents?
        - any concerns/worries regarding family or personal relationships?

Emotional & Social Support
    Do you have any other support e.g. PHN, home help, private carers, friends, neighbours?
    Do you need more support? What would help?

Practical Concerns and Advance Care Planning
    Discussion about practical issues:
    How are you managing?
    Any difficulties in: mobilising, managing the stairs, household chores e.g. washing cooking etc?
    Any concerns about future care needs, income, finances, sorting out your affairs?

What are the person's wishes regarding:
    goals of care?
    acceptable levels of intervention?
    preferred place of care (person and family)?



DOMAIN 3 PSYCHOLOGI CAL WELLBEING:
SUGGESTED PROMPTS

Mood & Interest
    How is your mood?
    During the last month have you:
        - been feeling down and/or hopeless? Lost enjoyment ininterests?
        - are you depressed? Do you feel tense or anxious?
        - have you ever had a panic attack?
        - Are there things you are looking forward to?

Adjustment to IlIness
    What is your understanding of your illness?
    Note the time since diagnosis and see if the person is still in shock, or has had a period of emotional adjustment (sadness and anger).
    Sensitively explore the person's expectations/goals.

Resources and Strengths
    What is a source of support for you? Look for a range: people, hobbies, faith, beliefs.

Total Pain
    Uncontrolled multidimensional pain e.g. psychological, spiritual pain.
    Consider whether distress is contributing to physical symptoms.
    Are there psychological, emotional, social, spiritual issues that may be contributing to symptoms?

Pre-existing Mental IlIness
    Persons with a history of current or past mental health problems may be particularly at risk of psychological distress



DOMAIN 4 SPIRITUAL WELL BEING:
SUGGESTED PROMPTS

Sources of Hope
    What gives you hope (strength, comfort, peace) in the time of illness?

Organised Religion
    Are you part or member of religious or spiritual group? Does it help you? How?

Personal Spirituality & Practice
    What aspects of your spiritual beliefs do you find most helpful and meaningful personally?

Effect on Medical Care and End of Life Issues
    How do your beliefs affect the kind of care you would like me to provide over the next few days/weeks/months?
   
https://www.hse.ie/eng/services/publications/clinical-strategy-and-programmes/palliative-care-needs-assessment-guidance.pdf