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Scope and Target Population:
This guideline will assist primary and specialty care providers in identifying and caring for adult patients with a serious (potentially life-limiting, life-threatening or chronic, progressive) illness who may benefit from palliative care. This guideline is appropriate for patients who still desire curative or life-prolonging treatments, or patients who are best served by active end-of-life management. It will outline key considerations for creating a plan of care to meet patient, family and other caregivers' needs throughout the continuum of care.

This guideline will not assist providers in the identification or care for pediatric patients with life-threatening or chronic progressive illness.

Aims:

1. Increase the identification of patients who are in the early stages of a serious illness who would benefit from palliative care.
   
2. Improve the effectiveness and comfort level of primary care clinicians in communicating the necessity and benefits of palliative care with those patients with a serious illness.
   
3. Improve the assessment of the identified patient's palliative care needs utilizing the domains of palliative care.
   
4. Increase the percentage of patients in the early stages of a serious illness who have a care plan identified and/or documented.
   
5. Improve the on-going reassessment and adjustment of the patient's plan of care as the condition warrants, utilizing the domains of palliative care.
   
6. Increase the completion, documentation and ongoing utilization of advance directives for patients with a serious illness.

Clinical Highlights:

• Planning for palliative care should begin early in the patient's journey of a serious illness.
  - Where palliative care consultation is available, referral to this service should be considered early on in the patient's care if there are complex needs. Primary care clinicians should begin palliative care planning early through palliative care conversations with their patients.
  
• Health care providers should complete a systematic review of patients' palliative care needs and document patients' goals for care and advance directives.
  
• Suffering is common in this patient population. It commonly presents itself in physical symptoms, thus controlling symptoms to maximize patient comfort is a cornerstone function of palliative care. Also important are the recognition, assessment and management of non-physical areas of suffering that are important to the patient. These include cultural, psychological, social, spiritual, financial, ethical and legal issues. Where available, consultation with palliative care specialists should be considered for all of these symptoms.
  
• The ability to address these issues depends on the quality of communication with patients and families. Setting realistic goals of care and providing realistic hope are essential. Engaging patients in decisions about their care increases their involvement and satisfaction. Shared Decision-Making (SDM) is one method to engage patients.
  
• Palliative care is compatible with all other medical treatments.
  
• Health care providers play an important role in the grief and bereavement processes by supporting the patient and family throughout the course of illness and following the patient's death.