Psychosocial complexity

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.