To ensure that a program delivers quality services, palliative care should be considered from referral to discharge:

Appropriate Palliative Care Referrals
Handling Referrals
Patient Assessments
Care Planning
Treatment and Symptom Control
Discharge Planning
Patient Environment

Appropriate Palliative Care Referrals

• Team/patient/family needs help with complex decision-making and determination of goals of care
• Unacceptable level of pain or other symptom distress for more than 24 hours
• Uncontrolled psychosocial or spiritual issues
• Frequent visits to emergency department (eg, more than one time per month for the same diagnosis)
• More than one hospital admission for the same diagnosis in the last 30 days
• Prolonged length of stay (greater than 5 days) without evidence of progress
• Prolonged stay in ICU and/or transferred from ICU to ICU setting without evidence of progress
• In an ICU setting without evidence of progress
• Principles of Effective Communication

Handling Referrals

Positioning the program to generate, receive and effectively handle referrals is crucial to success. The team must develop policies for identifying eligible patients likely to benefit from palliative care, as well as methods for prioritizing and responding to referrals in a timely manner. Appropriate Palliative Care Referrals provides additional information on referrals.

Patient Assessments

The palliative care team must perform comprehensive, formal assessments of the patient and family, documenting reasons for admission, and reviewing problems and symptoms prior to developing the plan of care. Physical, psychosocial, social, cultural and spiritual needs should be assessed. See Assessment Tools for examples.

Care Planning

After the initial assessments by the appropriate professionals, a care plan is developed. It should address:

• Symptom and side effect management
• Family and patient understanding of disease status, preferences regarding treatment goals and hopes for outcome of medical care
• DNR status
• Advance directives
• Religious/cultural rituals preferred
• Wishes for care before and at the time of death
• Care setting (e.g. space for families, privacy and attention to a home-like environment)
• Goals for medical care
• Decision-making needs and priorities
• Discharge options

Treatment and Symptom Control

The team may opt to employ clinical protocol/pathway or treatment algorithms for each priority problem (e.g., pain management, dyspnea, nausea and vomiting, anorexia, dehydration, anxiety, depression). Some institutions have developed standing order forms for major protocols and pathways. However, many palliative care clinical practice guidelines are in early stages of development. Pain management guidelines are one example of well-defined evidence based practices.

Discharge Planning

Comprehensive discharge planning begins on admission. Social needs assessments can help identify family structure and relationships. Understanding the patient and family’s work setting, finances, living arrangements, caregiver availability, support and any legal issues relevant to discharge planning can help determine needs and availability. Access to transportation, prescription and over the counter medicines, and medical equipment will also affect discharge decisions.

Patient Environment

Consider the patient’s quality of life while in your program. Inpatient units should furnish rooms with more home-like décor such as rugs, curtains and comfortable chairs or beds for family members. Religious articles should also be available. Consultative models can have these items stored for patient use as needed.