Background: The concept of palliative care consisting of five distinct, clinically meaningful, phases (stable, unstable, deteriorating, terminal and bereavement) was developed in Australia about 20 years ago and is used routinely for communicating clinical status, care planning, quality improvement and funding. Aim: To test the reliability and acceptability of revised definitions of Palliative Care Phase. Design: Multi-centre cross-sectional study involving pairs of clinicians independently rating patients according to revised definitions of Palliative Care Phase. Setting/participants: Clinicians from 10 Australian palliative care services, including 9 inpatient units and 1 mixed inpatient/community-based service. Results: A total of 102 nursing and medical clinicians participated, undertaking 595 paired assessments of 410 patients, of which 90.7% occurred within 2 h. Clinicians rated 54.8% of patients in the stable phase, 15.8% in the unstable phase, 20.8% in the deteriorating phase and 8.7% in the terminal phase. Overall agreement between clinicians' rating of Palliative Care Phase was substantial (kappa = 0.67; 95% confidence interval = 0.61-0.70). A moderate level of inter-rater reliability was apparent across all participating sites. The results indicated that Palliative Care Phase was an acceptable measure, with no significant difficulties assigning patients to a Palliative Care Phase and a good fit between assessment of phase and the definition of that phase. The most difficult phase to distinguish from other phases was the deteriorating phase. Conclusion: Policy makers, funders and clinicians can be confident that Palliative Care Phase is a reliable and acceptable measure that can be used for care planning, quality improvement and funding purposes.

Context In Australia, patients at the end of life with complex symptoms and needs are often referred to palliative care services (PCSs), but little is known about the symptoms of patients receiving palliative care in different settings.Objective To explore patients' levels of pain and other symptoms while receiving care from PCSs.Method PCSs registered through Australia's national Palliative Care Outcomes Collaboration (PCOC) were invited to participate in a survey between 2008 and 2011. Patients (or if unable, a proxy) were invited to complete the Palliative Care Outcome Scale.Results Questionnaires were completed for 1800 patients. One-quarter of participants reported severe pain, 20% reported severe 'other symptoms', 20% reported severe patient anxiety, 45% reported severe family anxiety, 66% experienced depressed feelings and 19% reported severe problems with self-worth. Participants receiving care in major cities reported higher levels of depressed feelings than participants in inner regional areas. Participants receiving care in community and combined service settings reported higher levels of need for information, more concerns about wasted time, and lower levels of family anxiety and depressed feelings when compared to inpatients. Participants in community settings had lower levels of concern about practical matters than inpatients. ConclusionsPatients receiving care from Australian PCSs have physical and psychosocial concerns that are often complex and rated as 'severe'. Our findings highlight the importance of routine, comprehensive assessment of patients' concerns and the need for Specialist Palliative Care clinicians to be vigilant in addressing pain and other symptoms in a timely, systematic and holistic manner, whatever the care setting. Questionnaires were completed for 1800 patients. One quarter of participants reported severe pain, 20% reported severe "other symptoms", 20% reported severe patient anxiety, 45% reported severe family anxiety, 66% experienced depressed feelings, and 19% reported severe problems with selfworth. Participants receiving care in major cities reported higher levels of depressed feelings than participants in inner regional areas. Participants receiving care in community and combined service settings reported higher levels of need for information, more concerns about wasted time and lower levels of family anxiety and depressed feelings when compared to inpatients. Participants in community settings had lower levels of concern about practical matters than inpatients. Conclusion:Patients receiving care from Australian PCSs have physical and psychosocial concerns that are often complex and rated as "severe". Our findings highlight the importance of routine, comprehensive assessment of patients' concerns and the need for Specialist Palliative Care clinicians to be vigilant in addressing pain and other symptoms in a timely, systematic and holistic manner, whatever the care setting.

The Palliative Care Outcomes Collaboration focuses on supporting palliative care services in Australia to measure service- and patient-level outcomes, and to use these data to drive continuous quality improvement. The introduction of a suite of clinical assessment tools nationally has resulted in important enhancements to care provision at individual service level. Improved communication, enhanced assessment of patient needs, and improved identification of triggers for the need to change care plans or for referral have resulted from this change.

This discussion paper sets out some major concerns with the introduction of critical paths into the Australian health care system. It is argued that in their current form as devised in North America, critical paths may not be appropriate to our organisation of health care and may in fact be detrimental to the development of nursing practice. The discussion centres around the socio-political context of the development of managed care in North America, as well as research findings from the implementation of critical paths in an Australian hospital.

Recognising and addressing problems in clinical practice and service delivery is an important way for nurses to ensure quality care for patients; however, they need support in developing the skills and knowledge that are essential to successful QI activities.