End of Life Care Plan Template - GPSC

CARE PLAN
PATIENT NAME
DOB
PHN
OTHER
ADDRESS
DIAGNOSIS
Main Diagnosis Date of Diagnosis Secondary Diagnosis Date of Diagnosis
Ht
Wt
Drug / Environmental Allergies
Patient Values/Preferences/Key Goals
Estimated Prognosis
Family/SDM: Values/Preferences/Key concerns
Preferred Place Of Death
CONTACTS / CARE TEAM
Primary Health Provider Phone Primary Care Giver
Substitute Decision Maker Phone Key Family Members Phone.
Key Family Members Phone Specialists (Oncologist/Palliative/Other) Phone
Specialists (Oncologist/Palliative/Other) Phone Specialists (Oncologist/Palliative/Other) Phone
Specialists (Oncologist/Palliative/Other) Phone Pharmacist Phone
Home Health Phone Community Nurse(s) Phone
Palliative Care Team Phone Home Oxygen Phone
Support Services (Home Support, Hospice Community) Phone Funeral Home Phone
Other Phone Other Phone
CARE PLANNING DOCUMENTATION
DOCUMENT COMPLETED DOCUMENT COMPLETED
Home Health Referral
Palliative Care Benefits (Pharmacare) (HLTH 349)
My Voice © workbook
No Cardiopulmonary Resuscitation (HLTH 302.1)
Hospice/Palliative Care Registration
Compassionate Care Benefits
(SC INS5216B)
Advance Directive/ Greensleeve
Notification of Expected Home Death
(HLTH 3987)
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CARE PLAN
PATIENT NAME
DOB
PHN
OTHER
ADDRESS
COLLABORATIVE CARE PLANNING
KEY: 1 = Patient 2 = Family Members 3 = Professionals (Please write names
Date Who was present Issues/Outcomes
Followup
(see Key)
ASSESSMENT
ESAS-r
0-Best10-Worst
ASSESSMENT DATES
ESAS-r
0-Best10-Worst
ASSESSMENT DATES
LAB Hb PAIN #1/#2
GFR
TIREDNESS
NAUSEA
DEPRESSION
PPS
OTHER
CONSTIPATION
QUALITY OF
LIFE
ANXIETY
DROWSY
APPETITE
WELL-BEING
DYSPNEA
MEDICATION RECORD
MEDICATION START DOSE FREQ DATE DATE DATE DATE DATE
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