Palliative Care


A key component of high-quality palliative care is the regular assessment of physical, social, psychological, emotional, and spiritual needs.

Standardized tools such as the ESAS-r and the PPSv2 can improve the quality of your  assessment, save you time, and give you a common language when communicating about your patient with other healthcare providers.



The ESAS-r is a tool used to assess nine common symptoms in palliative care patients: pain, tiredness, drowsiness, nausea, lack of appetite, shortness of breath, depression, anxiety and wellbeing. There is also a blank scale for patient-specific symptoms. The patient's perspective regarding severity of the symptoms is considered the "gold standard" for assessment.

How to Use the ESAS-r

The patient should be instructed to rate the severity of each symptom on a scale from 0-10, based on how he or she feels now, where 0 represents tthe absence of the symptom and 10 represents the worst possible severity. The number should be circled on the scale.

You may choose to ask about the severity of symptoms at other times as well (e.g. best/worst in the past 24 hours, week etc.)

Since some of the terms may not resonate with every patient, reviewing meaning with the patient is recommended. For example:

  • Tiredness = lack of energy
  • Drowsiness = feeling sleepy
  • Depression = feeling sad or down
  • Anxiety = feeling nervous
  • Wellbeing = overall feeling

It is good practice to complete and graph the ESAS-r during each telephone or personal contact. If symptoms are controlled and there are no predominant psychosocial issues, the ESAS-r may be completed weekly in the home.

In other settings, the tool should be used upon initial assessment and at each follow-up visit. It should be used daily in hospital and palliative care units.

It is important to refer to the ESAS-r during your visit with the patient. One of the biggest complaints from patients about the ESAS-r is that the health provider does not acknowledge it. This can cause the patient to feel they wasted their time completing it.

Above adapted from Alberta Health Services/Covenant Health Guidelines for using the revised Edmonton Symptom Assessment System (ESAS-r). Retrieved January 23, 2018 from


The Victoria Hospice Palliative Performance Scale (PPS, version 2) is an 11-point scale designed to measure patients' performance status in 10% decrements from 100% (healthy) to 0% (death) based on five observable parameters: ambulation, ability to do activities, self-care, food/fluid intake, and consciousness level.

It is designed to provide a snapshot of functional assessment at the time of assessment.

How to Use PPSv2

Begin at the left column and read downwards until the appropriate ambulation level is reached, then read across to the next column and downwards again until the activity/evidence of disease is located. These steps are repeated until all five columns are covered before assigning the actual PPS for that patient. In this way, “leftward” columns are stronger determinants and generally take precedence over others.

It is not correct to choose a half value, such as 45%. Clinical judgment and “leftward precedence” should determine whether 40% or 50% are most accurate for a patient. 


The ECOG (Eastern Cooperative Oncology Group) is another tool used by clinicians for oncology patients, to assess how a patient's disease is progressing, assess how the disease impacts their ability to perform activities of daily life, and decide upon appropriate treatment and prognosis. Performance status is highly correlated with survival, need for services, and may help predict ability to tolerate therapies. The scale ranges from 0 (fully active) to 5 (dead).

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