About this template
This Palliative Consult template is designed for family medicine specialists to document comprehensive assessments for patients requiring palliative care. It includes sections for patient demographics, history of present illness, past medical history, medications, allergies, and social history. The template also covers a detailed review of systems, objective findings, assessment, and a tailored care plan. Ideal for managing complex cases involving pain and symptom management, this template ensures thorough documentation and facilitates effective communication with patients and their families. Use this template to streamline palliative care consultations and improve patient outcomes.
Preview template
Palliative Consult:
Patient ID:
78-year-old female, diagnosed with metastatic breast cancer
Reason for Consult:
"Pain and symptom management"
History of Present Illness (HPI):
The patient presents with worsening pain in the lower back and difficulty sleeping due to discomfort. She reports increased fatigue and occasional nausea. The patient has a history of breast cancer diagnosed 5 years ago, with metastasis to the bone. She has undergone chemotherapy and radiation therapy in the past. Currently, she is taking morphine for pain management and ondansetron for nausea. She lives with her daughter, who is her primary caregiver.
Past Medical History (PMHx):
Breast cancer diagnosed in 2018, hypertension since 2010, osteoarthritis diagnosed in 2015
Medications:
Morphine 15 mg every 4 hours, Ondansetron 8 mg as needed, Lisinopril 10 mg daily
Allergies:
No known drug allergies
Preferred Pharmacy:
Green Valley Pharmacy
Palliative Review of Systems (ROS):
Pain: Severe lower back pain
Nausea: Occasional
Shortness of breath: None
Mood: Depressed
Appetite: Decreased
Functional status: Limited mobility
Bowel movements: Regular
Bladder function: Normal
Social History:
The patient lives with her daughter in a single-family home. She has a strong support system from her family and attends a local church. She has Medicare insurance and receives home care services twice a week.
Code Status:
Do Not Resuscitate (DNR)
Objective:
The patient appears frail and in moderate distress due to pain. Vital signs: BP 130/80, HR 88, Temp 98.6°F. Physical examination reveals tenderness in the lumbar region. Recent imaging shows progression of bone metastasis.
Assessment:
The patient has metastatic breast cancer with significant pain and decreased quality of life. Primary diagnosis: Metastatic breast cancer. Secondary diagnosis: Chronic pain. Palliative Performance Scale (PPS) score: 50%
Plan:
Continue current pain management regimen with morphine. Consider increasing dosage if pain persists. Initiate palliative care consultation for additional support. Discuss goals of care and advance care planning with the patient and family. Schedule follow-up in two weeks. Provide education on pain management and coping strategies to the patient and family.
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