What should be included in a treatment plan for a patient requiring palliative care?

Comprehensive Treatment Plan for Palliative Care Patients

A comprehensive palliative care treatment plan should be developed by an interdisciplinary team and include systematic symptom management, psychosocial support, advance care planning, and ongoing reassessment based on the patient's estimated life expectancy and changing needs. 1

Core Components of a Palliative Care Treatment Plan

Initial Screening and Assessment

• Screen for uncontrolled symptoms, moderate-to-severe distress related to diagnosis/treatment, serious comorbid conditions, metastatic disease, and life expectancy ≤6 months 1
• Conduct comprehensive assessment of symptoms, psychosocial/spiritual distress, personal goals/expectations, educational needs, and cultural factors affecting care 1
• Develop care plan through an interdisciplinary team including physicians, nurses, social workers, mental health professionals, chaplains, and dietitians 1

Symptom Management

• Implement systematic pain management using appropriate pharmacological approaches (NSAIDs, opioids, bisphosphonates for cancer-related pain) 2, 3
• Address dyspnea with opioids for unrelieved symptoms, oxygen therapy for hypoxemia, and appropriate positioning 1, 2
• Manage other common symptoms including nausea, anxiety, depression, and excessive secretions with appropriate medications 1
• Consider both pharmacological and non-pharmacological interventions for all symptoms 4

Psychosocial and Spiritual Support

• Provide educational, psychosocial, and emotional support for patients and families 1, 3
• Address depression with appropriate interventions including medications (tricyclic antidepressants, SSRIs) and psychosocial support 2, 3
• Include spiritual support appropriate to patient's beliefs and values 1
• Screen and support family caregivers for practical and emotional needs 3

Advance Care Planning

• Discuss and document advance directives, including living wills, powers of attorney, and specific limitations regarding life-sustaining treatments 1, 3
• Ensure MOLST/POLST (Medical/Physician Orders for Life-Sustaining Treatment) are documented and accessible across all care settings 1
• Determine patient preferences regarding place of death and implement plans accordingly 1
• Review and update advance care plans when significant clinical changes occur 3

Tailoring Treatment Based on Life Expectancy

Years of Life Expectancy

• Discuss whether anticancer therapy is palliative or curative, reviewing benefits and burdens 1
• Provide appropriate disease-specific treatments alongside palliative interventions 1
• Focus on symptom prevention and management related to disease and treatments 1
• Prepare patient psychologically for possible disease progression 1

Months of Life Expectancy

• Confirm patient's understanding of disease incurability 1
• Offer best supportive care with referral to specialized palliative care or hospice 1
• Redirect goals and hopes to those achievable based on prognosis 1
• Consider discontinuation of anticancer treatments with limited benefit 1
• Provide guidance regarding anticipated disease course 1

Weeks to Days of Life Expectancy

• Discontinue anticancer therapy and intensify palliative care 1
• Focus on symptom control and comfort measures 1
• Provide guidance regarding the anticipated dying process 1
• Foster patient participation in preparing loved ones 1
• Refer to specialized palliative care/hospice team if not already involved 1

Ongoing Reassessment and Quality Measures

• Regularly reassess symptom control, patient/family distress, and sense of control 1
• Evaluate effectiveness of interventions with modification as needed 1
• Measure outcomes including adequate symptom management, reduction of distress, acceptable sense of control, relief of caregiver burden, strengthened relationships, and optimized quality of life 1
• Intensify palliative interventions if reassessment shows unacceptable outcomes 1

Common Pitfalls to Avoid

• Undertreatment of pain and dyspnea due to unfounded concerns about opioid side effects 2, 5
• Delayed referral to specialized palliative care services or hospice 1, 6
• Inadequate attention to psychosocial and spiritual dimensions of suffering 4, 7
• Failure to regularly reassess and adjust the care plan as the patient's condition changes 1, 7
• Lack of coordination among healthcare providers across different care settings 6, 7
• Insufficient support for family caregivers 3, 8