Is Palliative Care Right for Me?

Is Palliative Care Appropriate?

This questionnaire is based on the SPICT™ (Supportive and Palliative Care Indicators Tool), a validated clinical screening tool used by healthcare professionals to identify patients who may benefit from palliative care.

It takes approximately five minutes to complete. It is not a diagnostic tool — it is a guide to help you decide whether a conversation with a palliative care specialist is warranted. If you are uncertain, contact your primary medical care provider directly.

Palliative Care Questionnaire

Answer each question about yourself or the person you are caring for.
If you answer YES to two or more questions, we recommend following up with your GP for a formal assessment and referral.

Section A:

General Health & Decline

  • 1

    Has the person’s overall health been declining over the past 6–12 months, even with treatment?

  • 2

    Have there been two or more unplanned hospital admissions in the past 6 months?

  • 3

    Is the person losing weight unintentionally, or finding it harder to eat or drink?

  • 4

    Is the person becoming increasingly dependent on others for daily activities (dressing, washing, moving around)?

Section B:

Symptoms &
Quality of Life

  • 1

    Is the person experiencing persistent or difficult-to-control symptoms (pain, breathlessness, nausea, fatigue)?

  • 2

    Is the person spending more time in bed or resting than they were 3–6 months ago?

  • 3

    Has the person been told they have a life-limiting illness, or do they have a condition that is likely to shorten their life?

Section C:

Choices, Communication
& Family

  • 1

    Has the person — or their family — expressed concern about what the future holds, or asked questions about what to expect?

  • 2

    Are there unresolved decisions about future care, such as resuscitation preferences, place of care, or end-of-life wishes?

  • 3

    Is the family or caregiver struggling — practically, emotionally, or physically — with the demands of caring for this person?

If YES to 2
or more questions:

Based on your responses, specialist palliative care is likely to be of significant benefit.

We recommend contacting your primary healthcare provider for a formal assessment and referral. There is no obligation — the first conversation is simply to understand your situation and explain how palliative care may be able to help.

If YES to fewer than 2 questions:

Based on your answers, palliative care may not be the most pressing need at this time.

If your situation changes, or if you have questions, we are always available for a conversation.