Scope and Target Population:
This guideline will assist primary and specialty care providers in identifying and caring for patients with a potentially life-limiting, life-threatening or chronic, progressive illness who may benefit from palliative care. This guideline may be 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.


Clinical Highlights and Recommendations:

• Palliative care planning should begin early in the patient's journey of a progressive, debilitating illness. A key question for providers is "would you be surprised if the patient died within two years?"
  - Where palliative care consultation is available, referral to this service should be done early on in the patient's care.
  - Where palliative care services are not available, primary care providers should begin palliative care planning early.
  
• Health care providers should initiate palliative care conversations with their patients.
  
• Health care providers should complete a systematic review and document patients' goals for care and advance directives.
  
• Pain and physical suffering are common in this patient population, but there are nonphysical areas of suffering that also need to be addressed. These include cultural, psychological, social, spiritual, religious, existential, ethical and legal issues.
  
• The ability to address these issues depends, at least partially, on the quality of communication with patients and families. Setting realistic goals of care and providing realistic hope is essential.
  
• In the delivery of palliative care, aggressive interventions may continue with an increased focus on symptom management.
  
• Health care providers play an important role in the grief and bereavement processes.

Priority Aims:

1. Increase the identification of patients who are in the early stages of a progressive, debilitating disease who would benefit from palliative care planning (for disease specific criteria, see Annotation #1).
   
2. Increase palliative care planning with patients who have been identified in the early stages of a progressive debilitating disease (for disease specific criteria, see Annotation #1).
   
3. Improve the care planning of the identified patients by utilizing the seven domains of care (see Annotations #5-11).
   
4. Improve the continual reassessment and adjustment of the patient's care plan as conditions warrant, utilizing the seven domains of care because more than one condition may change (see Annotations #5-11).
   
5. Increase the completion, documentation and ongoing utilization of advance directives for patients with a progressive, debilitating illness. (Annotation #10)
   
6. Improve the effectiveness and comfort level of the primary care provider in communicating the necessity and benefits of palliative care with those patients with a progressive, debilitating illness. (Annotation #3)