End of Life Care Plan (EOLCP)
Patient Identification:
Name: John Doe
Date of Birth: 15 March 1945
Hospital ID: 123456
Date of Admission: 1 November 2024
Current Clinical Status:
John Doe has been diagnosed with advanced metastatic lung cancer. His prognosis is poor, with an estimated life expectancy of less than six months. His medical history includes chronic obstructive pulmonary disease (COPD) and hypertension.
Patient Understanding and Wishes:
John understands that his condition is terminal and has expressed a desire to focus on comfort and quality of life rather than aggressive treatment. He wishes to avoid invasive procedures and prefers palliative care.
Family/Carer Involvement:
Discussions have been held with John's wife and daughter. They are supportive of his wishes and are actively involved in decision-making. They understand the prognosis and are prepared to assist in his care.
Advance Care Planning:
John has a living will and has expressed a Do Not Resuscitate (DNR) order. He has completed a POLST form indicating his preferences for end-of-life care.
Symptom Management Plan:
John is currently experiencing significant pain and breathlessness. A plan is in place to manage these symptoms with appropriate medications, including opioids for pain and bronchodilators for breathlessness.
Psychosocial and Spiritual Needs:
John has expressed feelings of anxiety and fear about the dying process. He is receiving support from a psychologist and has requested visits from a chaplain to address his spiritual needs.
Place of Care Preferences:
John prefers to spend his remaining time at home, surrounded by family. He wishes to avoid hospital admissions unless absolutely necessary.
Care Coordination and Support Services:
- Dr. Emily Smith, Oncologist
- Dr. Sarah Johnson, Palliative Care Specialist
- Nurse Jane Brown, Home Care Nurse
- Referral to hospice services
- Social Worker: Mary Green
- Chaplain: Father Michael
Legal and Ethical Considerations:
There are no current legal concerns or guardianship issues. John has full capacity to make decisions regarding his care.
Care Plan Review Arrangements:
The care plan will be reviewed every two weeks or sooner if there are significant changes in John's condition. Dr. Sarah Johnson will be responsible for coordinating reviews, with input from the home care team.
Clinician Notes:
John has shown remarkable resilience and acceptance of his condition. Continued psychological support is recommended to help him and his family cope with the emotional challenges ahead.
End of Life Care Plan
Patient Identification:
[record patient full name, date of birth, hospital ID, date of admission] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Current Clinical Status:
[document current diagnoses, prognosis, medical history relevant to end-of-life care] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
Patient Understanding and Wishes:
[describe patient's understanding of their condition, goals of care, and preferences for treatment and interventions] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
Family/Carer Involvement:
[document discussions held with family members or carers, their understanding, and involvement in decision-making] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
Advance Care Planning:
[include information on advance directives, DNR/DNI status, living wills, POLST forms, and any previously expressed wishes] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
Symptom Management Plan:
[outline symptoms currently experienced and plan for management, including pain, breathlessness, nausea, agitation etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
Psychosocial and Spiritual Needs:
[describe identified emotional, psychological, cultural or spiritual concerns and supports in place] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
Place of Care Preferences:
[detail preferred place of care and death, including hospital, home, hospice, or other facility] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
Care Coordination and Support Services:
[list key healthcare professionals involved, communication arrangements, referrals to palliative or hospice services, social work, chaplaincy etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.)
Legal and Ethical Considerations:
[document any legal concerns, guardianship issues, capacity assessments, and ethical decisions discussed or made] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
Care Plan Review Arrangements:
[describe timeline and triggers for reviewing this care plan, responsible parties, and contingency plans] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
Clinician Notes:
[include any additional relevant clinical observations, reflections, or decisions not captured above] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)