Healthcare Palliative Care Document

PALLIATIVE CARE CONSENT AND CARE PLAN

Patient Information

Date of Birth:   Gender:

Phone:   Email:

Emergency & Decision Contacts

Relationship:   Phone:

Relationship:   Phone:

Document authorizing surrogate (select all that apply):

Durable Power of Attorney for Health Care    Healthcare Proxy    Court-appointed Guardian    None on record

Insurance

Policy Number:   Group Number:

Medical History & Current Status

Advance directives on file: Living Will DNR / Comfort Measures Only POLST / MOLST Other

Referral, Goals of Care, and Preferences

Primary goals of care (select all that apply):

Comfort-focused care / symptom control    Life-prolonging treatments as available    Symptom management only    Other

Full Code (attempt CPR, intubation, advanced measures)    Do Not Resuscitate (DNR)    Do Not Intubate (DNI)

Accept full artificial nutrition/hydration if indicated    Trial period acceptable    Decline artificial nutrition/hydration

Description of Palliative Care Services; Risks, Benefits, and Alternatives

Purpose: Palliative care focuses on relief of symptoms, management of pain, emotional and spiritual support, and care coordination in the setting of serious illness. The team will work with the primary clinician to align treatment with stated goals of care and to provide support for the patient and family.

Services: Services may include clinical assessment, medication management (including opioid analgesics and sedatives as indicated), wound care, advanced care planning discussions, psychosocial support, and coordination with home health, hospice, and other care providers. Treatments may be provided in the hospital, clinic, or home setting.

Risks and Benefits: Potential benefits include improved symptom control, clearer care goals, and reduced unnecessary interventions. Risks may include side effects from medications (for example, sedation, constipation, or respiratory depression when opioids or sedatives are used), and the potential for treatments to limit certain life-prolonging interventions depending upon documented preferences. Alternatives include continued usual care without palliative involvement or referral to other specialty services. Refusal or withdrawal of palliative services will not affect the patient's right to other medical treatments.

Coordination and Limits: The palliative care team will coordinate with other treating clinicians. Palliative care does not require withdrawal of curative therapy unless requested by the patient or surrogate and documented in the plan of care.

Authorization to Share Information (HIPAA-Related)

I authorize the palliative care team and other treating providers to exchange protected health information necessary to provide palliative care, coordinate treatment, and communicate with persons I designate below.

Revocation: This authorization may be revoked by written notice to the palliative care team, except to the extent that action has already been taken in reliance upon it.

Acknowledgment and Consent

By signing below I acknowledge that I have had the purpose, nature, risks, benefits, and alternatives of palliative care explained to me in a manner I understand. I have had the opportunity to ask questions which were answered to my satisfaction. I understand that I may refuse or withdraw consent at any time and that my decision will be documented in the medical record.

I authorize the palliative care team to provide services described above and to prescribe and administer medications necessary for symptom relief, including opioid analgesics and other medications that may cause drowsiness or respiratory depression when clinically indicated.

Patient or authorized representative initials to indicate discussion topics were addressed:

Comfort goals discussed:   Medication risks discussed:   Surrogate identified:

Additional comments or limitations requested by patient/surrogate:

Sign Now