Home Start of Care Visit for Palliative Care: A Structured Approach
The initial home palliative care visit should include a comprehensive assessment of physical symptoms, psychosocial distress, personal goals/expectations, and educational needs, followed by development of an interdisciplinary care plan that addresses symptom management and advance care planning. 1
Pre-Visit Preparation
- Review patient's medical records and referral information
- Ensure appropriate team members are scheduled (physician, nurse, social worker, chaplain as needed)
- Contact patient/family to confirm appointment and explain what to expect
- Gather necessary assessment tools and documentation materials
Initial Home Visit Structure
1. Screening and Assessment
Conduct comprehensive screening for:
- Uncontrolled symptoms (pain, dyspnea, nausea, etc.)
- Moderate to severe distress related to diagnosis and treatment
- Serious comorbid physical, psychiatric, and psychosocial conditions
- Life expectancy indicators (≤6 months, metastatic disease)
- Patient/family concerns about disease course and decision-making 1
2. Physical Symptom Assessment
- Conduct thorough assessment of common symptoms:
Pitfall to avoid: Professionals often over-identify certain symptoms like nausea, vomiting, and constipation, while patients may under-report emotional symptoms. Use validated assessment tools to ensure accurate symptom evaluation. 3
3. Psychosocial and Spiritual Assessment
- Assess illness-related distress
- Evaluate psychosocial, spiritual, or existential issues
- Identify social support and resource needs (home, family, financial)
- Consider using standardized tools like FICA (Faith and Belief, Importance, Community, Address in Care) 1, 2
4. Goals of Care Discussion
- Discuss patient/family understanding of illness and prognosis
- Explore personal goals, values, and expectations
- Assess priorities for palliative care
- Discuss importance of quality of life 1
Pitfall to avoid: Delaying palliative care integration until final days of life rather than introducing it early in the disease trajectory significantly reduces effectiveness of care. 2
5. Advance Care Planning
- Initiate discussion about advance directives
- Document preferences regarding life-sustaining treatments
- Discuss preferred place of care/death
- Address any family conflicts regarding goals of care 2
6. Medication Review and Symptom Management Plan
- Review current medications
- Develop plan for symptom management combining:
- Non-pharmacological interventions (positioning, relaxation techniques)
- Appropriate pharmacological management tailored to symptoms 2
7. Education and Resource Planning
- Provide education about disease trajectory and symptom management
- Discuss available community resources and support services
- Explain palliative care services and how to access them
- Address caregiver support needs and burden 1
Documentation Requirements
- Complete comprehensive assessment documentation
- Develop interdisciplinary plan of care with specific interventions
- Document advance care planning discussions and directives
- Ensure care plan is accessible to all providers across care settings 1
Follow-up Planning
- Establish frequency of follow-up visits based on symptom burden and needs
- Provide contact information for 24/7 support
- Schedule team meetings to review care plan and adjust as needed
- Plan for ongoing reassessment of symptoms and goals 1
Special Considerations
Cultural Factors
- Assess cultural factors affecting care
- Avoid assumptions about end-of-life preferences based on race, ethnicity, culture, or religion
- Ask open-ended questions about impact of culture on medical decision-making 1
Family Involvement
- Establish rapport with family members
- Identify spokesperson if appropriate
- Provide regular counseling and psychosocial support for family
- Address anticipatory grief 1
Interdisciplinary Collaboration
- Ensure coordination between palliative care team members
- Communicate with primary care provider and specialists
- Consider referrals to additional services as needed (mental health, spiritual care) 1
Pitfall to avoid: Focusing solely on pharmacological interventions without implementing non-pharmacological strategies can reduce effectiveness of care. Ensure a balanced approach that addresses all dimensions of suffering. 2
By following this structured approach to the home start of care visit, palliative care providers can establish a comprehensive foundation for ongoing care that addresses the physical, emotional, social, and spiritual needs of patients and their families.