House-wide Policy Template



_______-Scope of Service Palliative CareEffective Date: Number:Supersedes: Page: Prepared by and manual to be contained in:Authority/Approved by: Palliative Care Consult Team Title: FORMTEXT Palliative Care Department - Scope of Service PURPOSE: At __________________Medical Center, we believe that our primary focus is patient-centered care, with dignity. We seek to enhance quality of life primarily by preventing illness and restoring health, but we also recognize that alleviating suffering and caring for the dying are essential aspects of our mission and values. The Palliative Care Department functions as a consultation service to provide ongoing consultations, support and education to hospital professionals to improve the care of seriously ill patients and their families. We seek to provide relief from suffering, enhance communication about illness and death, and increase the quality of living for patients and their families. The team will serve to coordinate care where needed, to assist the healthcare team, patients and families in the delivery of safe, excellent, compassionate and seamless care through the continuum.DEFINITION: Palliative Care at ___________ Medical Center is defined as: comprehensive, interdisciplinary care focusing on relieving suffering and improving quality of life for patients living with a serious or advanced illness and their families, assuring physical comfort and psychosocial support.POLICY STATEMENT: The Palliative Care Consult Team is comprised of trained healthcare professionals to include, but not limited to nurses, social workers, physicians on the case, and chaplains. The team provides services to inpatients, but may extend across the continuum to some outpatient services as well. The team will partner with home health and hospice professionals, skilled nursing facilities and others in the community to continue care that is in accordance with the patient’s goals for care. Palliative Care is appropriate for any patient, regardless of age, time of illness, and/or diagnosis, depending upon the needs and wishes of the individual patient. Palliative Care may very well accompany disease-modifying or curative therapy.Patients and families who may benefit from Palliative Care include:Seriously ill and/or dying patients whose distressing symptoms are difficult to managePatients and families who are struggling with decision-making about complex medical issuesPatient and family whose goals of care appear to be in conflict and/or futilePatients in need of coordination of care through the course of a very complex illnessPatients with chronic conditions inclluding, but not limited to: CHF, COPD, Renal Failure and CancerKEY COLLABORATORS: Spiritual Care, Nursing Staff, Medical Staff, Respiratory Therapy, Case Management, any patient care area, Ethics Committee, and Administration.HOURS OF SERVICE:Palliative Care operates from 8:00 am until 4:30 pm, Monday through Friday. The Palliative Care Coordinator is responsible on a 24-hour basis, and is available via pager or phone for immediate needs.REFERRAL PROCESS TO PALLIATIVE CARE CONSULT TEAM:Any medical, nursing or other staff member coming into contact with the patient may identify and refer a patient who might benefit from the Palliative Care Consult TeamConsultation requests may also be made via phone or verbally in personThe Palliative Care Team will confirm with the attending MD and enter the request into CPOE Once a referral is made, a Palliative Care Team member will visit the patient - within 48 business hoursA consultation typically involves review of medical record, medications, and assessment of the patient PALLIATIVE CARE CONSULT TEAM PLAN: Palliative Care Team member will review medical record, medications and assess patient The patient and family or patient’s loved ones are considered one unit, and the entire group is treated with respect and dignityClarification for the patient of the physician’s care plan and prognosisHelping the patient and family determine their goals of care based on prognosis and treatment optionsRecommendations to the attending physician for pain and symptom managementEnhance communication between the patient/ family and healthcare team regarding patient’s choicesAfter initial visit, follow up visits occur as needed for each patient. Staff may call to request follow up visitsAttend to the emotional, spiritual, social and practical needs and goals of the patient and familyProvide healing presence to patients, families as well as staff membersPalliative Care Team will document findings and recommendations on the Progress Note section (see attached Palliative Care Progress Note for initial visit)The Palliative Care Team will meet monthly to review progress and make recommendations as identified for patients receiving the serviceThe Palliative Care Coordinator meets weekly or as needed to support the members of the Palliative Care Team regarding individual casesCRITERIA FOR PALLIATIVE CARE CONSULT:Activities are limited because of:Pain, dyspnea, nausea, vomiting, constipation, diarrhea, insomnia or fatigueEmotional or spiritual distress for either patient, family or loved one:Angry, isolated, despairing, stressed, grieving, anxious, depressedPersonal affairs need resolving:Code status, Advance Directives, caregiver-experiencing burden of care, post hospital care dilemmaOther criteria:Over age of 80, lives alone, and/or frail caregiver, on a ventilator over 5 days, poor prognosis, or there is a struggle about decision-makingCITATIONS: Clinical Practice Guidelines for Quality Palliative Care written by the National Consensus Project for Quality Palliative Care in April, 2004 ................
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