Palliative Care Plan Template with Examples

Palliative Care Plan Template

This Palliative Care Plan Template is designed to help clinicians document and manage the evolving needs of patients with terminal illnesses. It provides a structured format for capturing symptom progression, care goals, family support, and interdisciplinary coordination. When used with Heidi, the AI medical scribe for clinicians, this template helps palliative care providers easily:

• Capture detailed observations on physical status, pain levels, nutritional intake, medication adjustments, and psychosocial well-being during routine or follow-up visits.
• Coordinate care with family members and hospice professionals by documenting caregiver capabilities, education provided, and equipment needs like oxygen or hospital beds.
• Plan for next steps in care, including follow-up visits, prescriptions, and interdisciplinary communication with the broader care team. 

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What is a Palliative Care Plan Template?

A palliative care plan template is a structured clinical document used by healthcare providers to plan, document, and monitor care for patients with serious, chronic, or terminal illnesses. Its primary purpose is to ensure that medical, emotional, and comfort-focused care provided is aligned with the patient’s needs, preferences, and goals.

A structured template can support both early palliative care, which typically begins upon the patient’s diagnosis alongside curative treatments, and late-stage palliative care, also known as end-of-life care, where the focus shifts towards protecting the patient’s comfort, dignity, and quality of life. 

In this article, we’ll be focusing on early palliative care, and talk about the 4 essential components of palliative care plan templates, discuss the “7 Cs” of palliative care plans in a hospital context, provide tips on how to create a patient-centered palliative care planning with examples, and most importantly, share ready-to-use and AI-enabled palliative care plan templates for use in your daily practice.

4 Essential Components of Palliative Care Plan Templates

To maximize their effectiveness, palliative care plan templates must guide healthcare providers to be comprehensive in their documentation, without sacrificing flexibility given the changing nature of patient needs.

Below, we’ll discuss the four “core components” of palliative care plan templates that ensure clinical consistency, patient-centeredness, and interdisciplinary coordination:

1. Clinical Assessment and Symptom Tracking

The first of the four core sections captures the patient’s current clinical status. This includes their pain levels, appetite, hydration, respiratory function, bowel and bladder health, and cognitive state. Objective findings such as the patient’s vital signs, as well as physical exam or head-to-toe assessment and lab results, should be included in this section to support evidence-based symptom management.

Be mindful of documenting ongoing updates in between visits to ensure the care plan reflects changes in the patient’s condition over time.

2. Medication and Symptom Management Plan

The subsequent section outlines the patient’s current medications, dosages, recent changes, and treatment responses. For the symptom management plan, it’s important to clearly document the strategies used for managing common symptoms such as pain, anxiety, constipation, or breathlessness.

Lastly, don’t forget to highlight medication side effects, medication delivery logistics, and clear instructions for the patient’s caregivers. 

3. Family Support and Patient Education

The third section focuses on clarifying the role of the patient’s family, as well as the involvement of assigned caregivers in implementing and maintaining the established palliative care plan. Documentation should include the caregiver’s capabilities, any patient education topics provided, and any emotional or spiritual support included in the care plan at the patient’s request.

The inclusion of this information helps facilitate shared decision-making between the care providers and the patient, an important aspect of patient-centered care that respects the patient’s values, preferences, and quality-of-life goals throughout their palliative journey. 

4. End-of-Life Planning and Follow-up Coordination

Since early palliative care plans often transition to end-of-life planning as the patient’s illness progresses, the final section of the template covers elements such as prognosis discussion, potential hospice referrals, and the documentation of the patient’s comfort care preferences. 

This last section should also include the patient’s preferred funeral arrangement, advance directives, and a Do-Not-Resuscitate (DNR) order if applicable.

What are the 7 Cs of Palliative Care Plans in Hospitals?

The “7 Cs” framework is a practical way hospitals and care teams ensure that palliative care plans are comprehensive, compassionate, and most importantly, aligned with patient-centered values. Each “C” represents a critical component that supports holistic care, from symptom relief to ethical decision-making.

Let’s talk through each “C” and how they guide care teams in creating and implementing successful palliative care plans:

1. Comfort

Palliative care plans must ensure the patient is as comfortable as possible. This is typically done by focusing on pain relief and the alleviation of physical symptoms through both medicinal and non-pharmacologic comfort strategies such as music therapy, warm compresses, or positioning, especially for bedridden patients. Remember that comfort is the primary goal of palliative care. 

2. Communication

Clear and ongoing dialogue between care providers, patients, and families is essential to ensuring that high-quality care is given consistently throughout the palliative journey. This ensures that the patient’s changing needs and preferences are always front-of-mind, so care plans can be adjusted as needed. 

3. Coordination

Palliative care often involves interdisciplinary care provided by nurses, doctors, social workers, and chaplains if the patient requests spiritual support and guidance. To keep the entire care team on the same page, it’s important to update the palliative care plan after each consultation and to ensure that the document is easily accessible to all involved care providers across shifts, departments, or care settings. 

4. Continuity

Even in changing settings, be it hospital, home, or hospice, palliative care plans must provide consistent, high-quality care. Within the template, outline how the plan is designed to preserve continuity of care to ensure that patient preferences are respected beyond a single encounter. 

5. Caring

A palliative care plan isn’t simply a list of clinical tasks to be done. Displaying compassion, empathy, and presence during the palliative journey is paramount to its successful implementation. For example, something as simple as a nurse sitting at the patient’s bedside listening as they express fears about dying alone, and offering presence and reassurance even when no solutions exist, can go a long way in making their ordeal easier to bear. 

6. Choice

One of the most important considerations for palliative care plans is that it must reflect the patient’s autonomy and informed consent. Make sure to include the patient’s decisions about treatment limits, including DNR orders, Do-Not-Intubate orders (DNI), and comfort-focused care only.

Especially while the patient is of sound mind and is capable of clear communication, their advanced care directives must be documented so the care team can honor their choices once their health eventually starts to deteriorate. 

7. Closure

More than the completion of medical interventions, closure in the context of palliative care is about addressing feelings of grief, helping the patient reflect on their life meaningfully, and providing opportunities for final conversations, religious rituals, or farewells. Whether spiritual or secular, it's important to acknowledge that these actions help patients experience a sense of peace while also allowing their families to begin their own process of healing.

Together, the “7 Cs” form the foundation of effective and humane palliative care. But applying these principles in daily practice, especially amid growing administrative burdens, is an entirely different challenge for care teams. This was the reality at Compass House Surgery, a practice deeply committed to elderly care yet increasingly strained by documentation demands. 

Clinicians at Compass found themselves struggling to balance administrative demands with patient care, often at the expense of their own time and well-being. “At the end of the day, you’re generally a lot more tired, yet I would stay over an hour late, going through documents, writing referrals… It was difficult to manage,” shared Ian Parsonage, nurse partner and lead advanced care practitioner at Compass.

Thankfully, they discovered Heidi. The AI-powered medical scribe not only automated their referrals and documentation, it also streamlined their workflow during patient consultations. “It was life changing,” Ian shared. With Heidi, Compass House Surgery reduced their administrative workload by up to 60%, enhanced its consultation quality, and improved morale across the team. “The more you use it, the more it benefits your team and patients.” 

How to Create a Patient-Centered Palliative Care Plan with Examples

Patient-centered care means that the care provided aligns with the patient’s values, beliefs, wishes, and goals. Because no two patients, even with the same diagnosis, experience illness in the same way, it’s critical that palliative care plans are personalized and approved by the patient themselves. In this section, we’ll walk you through some key steps to achieve palliative care goals and provide sample scenarios for easier reference:

1. Start with the patient’s goals, not just their diagnosis

Don’t assume that all patients want aggressive symptom management or longevity, and ask open-ended questions like “What matters most to you right now?” You should also document the patient’s preferences in terms of comfort, location of care, communication, and any spiritual or cultural interventions, and ensure they are honored consistently throughout the course of palliative care.

Sample Scenario:
Instead of focusing solely on medication for pain, a patient with Chronic Obstructive Pulmonary Disease (COPD) says their goal is “to breathe well enough to attend my granddaughter’s wedding.” You then note in the care plan to include supplemental oxygen adjustments and short-term mobility support to help achieve that goal. 

2. Involve family and caregivers in decision-making

If the patient consents, you should encourage the presence of family in conversations about care planning. During the conversation, clarify who the primary caregiver will be, and assess their capacity and concerns in the performance of their duty. Finally, provide caregiver education and emotional support as needed.

Sample Scenario:
A daughter caring for her father expresses anxiety about administering morphine. The care team includes a home nurse visit and printed instructions, ensuring she feels confident and supported rather than overwhelmed. 

3. Adapt the care plan to the patient’s changing condition

Set a schedule to regularly assess the care plan as goals can shift during the progression of illness. Since the rate of progression for chronic and terminal illnesses can vary significantly based on a number of factors, note possible triggers for plan updates to supersede set review schedules. Finally, be transparent with the patient and their family with regards to changes in prognosis and available care options as their illness progresses.  

Sample Scenario:
Initially, the patient wishes to remain at home, but as their symptoms escalate and fatigue worsens, they request inpatient hospice support. You then promptly revise the plan to coordinate the transition. 

4. Respect cultural, religious, and personal values

Ask about the patient’s spiritual beliefs, traditional rituals, and dietary restrictions, then integrate them into the care plan. Where necessary, make sure to use culturally appropriate language when speaking with the patient and request interpreter assistance to address potential language barriers. Lastly, remember to document and honor the patient’s non-medical preferences in the care plan.

Sample Scenario:
A devout muslim patient prefers same-gender caregivers and daily prayer time accommodations. The plan reflects these needs and includes coordination with an imam for spiritual guidance. 

Palliative Care Plan Template Example

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Palliative care plans require detailed documentation and seamless coordination between members of the care team. Attempting to tick all of these boxes manually can be tedious and complex. Thankfully, an AI-powered medical scribe can now simplify this process while ensuring both accuracy and efficiency in recording care plan notes. 

Easily Complete and Carry Out Palliative Care Plans with Heidi

Heidi is the AI medical scribe designed to help care teams complete palliative care plan templates in real time. With your patient’s permission, simply hit record and let Heidi work as you go. Here’s how Heidi helps you complete your palliative care plan:

• Transcribe – Open Heidi on your computer or mobile device and press Start transcribing so Heidi can capture your conversation with the patient in the background. For information that you don’t want to verbalize, you can type it under the context notes to be considered later.
• Customize – After the session, simply select your preferred palliative care plan template and watch as Heidi perfectly transcribes the details of your conversation and context notes in the appropriate fields and format.
• Transform – Once Heidi generates your completed palliative care plan template, you can ask it to give additional documentation, including hospice documentation as needed.

Heidi supports over 1.5 million patient consults every week, complying with global standards and regional regulations, ensuring data localization for customers in Australia, Canada, the United States, the United Kingdom, and beyond. Read more about our patient safety and data security compliance.

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Free Palliative Care Plan Templates

Initial Palliative Care Plan Template

This Initial Palliative Care Plan 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. 

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Palliative Care Assessment Template

This template is designed for nurses and healthcare professionals involved in palliative care. It facilitates the documentation of the patient’s physical, cognitive, and emotional status during hospice care and includes sections for ESAS scores, cognitive assessments, depression screening, and psychosocial evaluations. 

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Hospice Comfort Care Plan Template

This template is an essential tool for hospice nurses and other palliative care professionals, as it facilitates the detailed record-keeping of patient identification, care preferences, and symptom management plans. It ensures that all aspects of hospice care, including legal and compliance documentation, are meticulously noted. 

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FAQs About Palliative Care Plans

What are the assessments used in palliative care? 

Palliative care assessments typically include pain and symptom scales like the Edmonton Symptom Assessment Scale (ESAS), and the Pain Assessment in Advanced Dementia Scale (PAINAD) where applicable. It also involves quality of life evaluations, psychosocial and spiritual assessments, as well as functional status tools like the Palliative Performance Scale (PPS). 

What is the truth clinicians should know about palliative care in hospitals?

Palliative care isn’t just for end-of-life situations. It should be integrated early in the treatment journey to improve the patient’s quality of life, reduce their day-to-day suffering, and support more informed decision-making as soon as they are diagnosed with a serious, chronic, or terminal illness. 

How often should palliative care plans be reviewed or updated? 

Palliative care plans should ideally be reviewed at every clinical encounter with the patient or whenever there’s a significant change in the patient’s condition. Heidi, the AI medical scribe for all clinicians, helps streamline this process by capturing real-time updates during each patient visit, ensuring the care plan remains current and accessible across the entire care team.