Assessment and Care Planning
Assessment and Care Planning
Hospice and palliative assessment is continuous, multidimensional, and driven by the patient's goals. A candidate must know the domains: physical symptoms; functional status; psychological, social, spiritual, and cultural needs; caregiver capacity; safety; and prognosis. Use validated tools when appropriate-for example, PPS for function, ESAS for symptoms, and CAM for delirium-but remember scores support, not replace, clinical judgment. The interdisciplinary team translates assessment into a documented, measurable care plan with problems, goals, interventions, and responsible disciplines, revised at intervals and with change of condition.
Traps: assuming a single assessment is enough; accepting family report without attempting patient self-report; confusing delirium with dementia or depression; treating a low score as a goal; and writing a plan that is discipline-specific rather than patient-centered. Prognosis questions often hinge on functional decline, weight loss, dyspnea at rest, and performance status. Another trap is equating comfort-focused care with no assessment.
Worked example/rule of thumb: if a patient with advanced dementia is newly agitated and a family member says it is just the dementia, screen for pain, constipation, urinary retention, infection, and medication effects before labeling it behavioral. Document the trigger, findings, and revised plan. Rule: assess, treat, reassess; every symptom report gets a differential and a follow-up time.