Assessing complex needs

Multi-dimensional aspects of need, existing co-morbidities, intractable symptoms and complicated social and psychological issues can all increase perceived complexity.

Key points

  • When a patient’s problems do not respond to usual management, or are particularly complex, an assessment of the issues that are contributing is needed.
    • Patients’ physical, psychological and social issues interact. Patients with progressive, life-limiting conditions often require a broader response than just identifying and managing specific symptoms
    • Sharing care is often essential.
  • A complete assessment includes all domains. This may reveal the barriers to improving care. Factors that frequently contribute include:
    • Unidentified depression, panic, anxiety, or other significant psychiatric conditions
    • Coping styles (e.g. anger, denial, or controlling behaviour) and/or difficult family dynamics 
    • Substance misuse issues
    • Somatisation
    • Unresolved grief or life issues, religious or existential concerns
    • Patients who are socially or economically marginalised
    • Very young patients, and patients with young children
    • Patients with very stigmatising or traumatic symptoms
    • Patients with whom the GP identifies in some way (positively or negatively).
  • When patients have challenging psychosocial issues, wherever possible a number of practitioners should be involved to share the load.
    • Involve appropriate specialist and community resources
    • Also consider sharing the care of such a patient within the GP practice.
  • These complex patients are the group who derive most benefit from a holistic, multidisciplinary approach, with the GP at its centre coordinating care and advocating for the patient. Appropriate referrals might include:
    • Pain management services to review all the possible modalities and, if appropriate, offer interventions for complex pain (e.g. epidural or intrathecal analgesia or regional analgesia, and non-pharmacological pain management strategies)
    • Palliative care service, to review complex symptoms and assist with coordinating care; also to debrief with if GP wishes
    • Psychiatric review
    • Family counselling
    • Drug and alcohol services
    • Respite admissions to a palliative care unit to improve symptom control, to give carers a break and provide further assessment
    • Community social worker involvement to assist with practical, legal and financial matters, and to assist with mobilising psychosocial supports
    • Spiritual advisers from the person’s faith community
    • Complementary therapies like massage, relaxation etc, which are now offered by many palliative care services, may be a way to convey support in a less clinical environment
    • Early referral to bereavement counselling services for long-term follow up if family members are felt to be at high risk.

Last updated 24 August 2021