This topic stresses the importance of using an interdisciplinary assessment of patient and family to form the plan of care. The assessment should include:

During the assessment, make sure to investigate the patient’s and family’s expectations, their goals for the patient’s life and care, their understanding of the patient’s disease and prognosis, and their preferences for the type of care the patient will receive and where that care will take place.

When developing a care plan, solicit input from:

Always keep in mind that patient and family preference should underlie the types of care and the services the patient receives. Make sure you respect the patient’s cultural and religious values and integrate them into the plan of care. The palliative care team should communicate at least weekly to review the plan, staffing needs, quality of care, and clinical practices that affect the patient and family. Also, the palliative care team should coordinate respite and volunteer services for families and caregivers.

If the patient receives care away from home, the palliative care team must ensure the patient’s safety, flexible visiting hours, appropriate space for family meetings, and privacy. Referrals to specialists and community services may be needed based on the needs and preferences of both patient and family. Likewise, the staff will need access to emotional support, educational resources, and continuing professional education — and should document their use.

This aspect of the guidelines also includes evaluation of palliative care programs by patients, families, health professionals, and community members to help maintain continuous quality improvement and identify and promote helpful changes. This process helps the important goal of integrating evidence-based research and quality procedures and policies into palliative practice.

The guidelines specify that physical aspects of care must be delivered by professionals trained and skilled in managing the symptoms of terminal illness, which commonly include:

You’ll need to provide ongoing assessment, including assessment of any adverse effects of treatment and changes in the patient’s functional ability.

The guidelines stress that symptom management should be based on the best available clinical evidence and should focus on the safe and prompt reduction of symptoms for as long as they last. Keep in mind that the patient is the one who determines his level of tolerance for symptoms. Treatment should be tailored accordingly. It may include drug, nondrug, and complementary or supportive therapies. Make sure to address the patient’s physical, psychological, social, and spiritual dimensions in the treatment plan.

Teach the patient and family about the patient’s disease and its prognosis, expected symptoms, the patient’s level of functional impairment, treatments that may help, and the adverse effects of treatments. Also, teach family members how to keep the patient safe and how to provide comfort measures. In particular, teach about the importance of pain management. Many people — including some health care providers — are anxious about opioid analgesics. They fear that opioids will cause addiction, heavy sedation, and an earlier death. However, when a patient is receiving end-of-life care, these fears inappropriately take the focus off the patient’s comfort and quality of life. (See Putting the patient first, pages 52 and 53.) Make sure you have a risk management plan that addresses the use of controlled substances for long-term symptom management and that it’s reviewed and implemented by the palliative care team.