The IDT uses the following checklist to ensure consistency and continuity of care as well as to document IDT interventions. You also may download the actual form as part of the complete TCPC toolkit. The issues covered by the checklist are shown in HTML form below, with a picture of the actual form at the bottom of this page. Working together, the IDT completes all tasks on the checklist for each patient. The tasks are not intended to be accomplished all at one time. Rather, they should be carried out at times deemed appropriate to meet the patient and family's needs and service preferences. Many tasks will be completed during the first week of a patient's admission. Others will be completed during subsequent home visits. But all should be completed during the course of the patient's stay in the TCPC Program.
END-OF-LIFE CAREPatient Name: Medical Record #: Please initial each subject to indicate you have addressed, reviewed, and implemented intervention during your home visit with the patient | |
| Basic Assessment Needs | ____ Review and update Advance Directive and DNR |
| ____ Review Hospice Philosophy | |
| ____ Review 4 levels of care. Ascertain preferred place of death | |
| ____ Review call system/Triage. How to contact Hospice 24-hours day. Discuss use of 911 versus calls to Hospice | |
| ____ Continue instructions in funeral planning and what to do when patient dies | |
| ____ Assess for immediate need for other visits, (i.e., MSW, Chaplain, CHHA, M.D.) | |
| ____ Review signs and symptoms of death and dying | |
| ____ Discuss home safety | |
| ____ Consider increased frequency of visits for each discipline | |
| ____ Communicate Plan of Care to team members including Triage as needed | |
| Medications | ____ Syringe for sublingual meds |
| ____ Anticipate for congestion; consider Atropine/Levsin | |
| ____ Consider Tylenol supp. For fever | |
| ____ Instructed on sublingual/rectal administration of meds | |
| ____ Red sticker on Kaiser card for pharmacy | |
| ____ Discussed medication side effects | |
| Equipment Needs | ____ Consider hospital bed, commode, over bed table, wheelchair |
| ____ Anticipate needs for diapers, chux, syringes, toothettes, urinal, bedpan, etc. | |
| ____ Educated/evaluated the use of oxygen and safety precautions | |
| Psychosocial Needs | ____ Assessed for coping mechanism |
| ____ Addressed for possible unfinished issues with family/patient, financial/legal | |
| ____ Assessed for increase social worker intervention through visits, telephone calls | |
| ____ Assessed for cultural beliefs & values, beliefs about death and dying | |
| ____ Assessed for caregiver status | |
| ____ Bereavement risk | |
| Pain Management | ____ Assessed disease process and reviewed pain management |
| ____ Instructed patient/family route of medication (sub-lingual/rectal) - Syringe provided | |
| ____ Instructed regarding frequency of meds, adjusting dosage for patients comfort and what meds to use | |
| ____ Check for adequate supply of pain meds in the home | |
| Constipation | ____ Instructed/reviewed bowel regimen |
| ____ Checked patient for fecal impaction if indicated | |
| ____ Ordered Ducolax supp, fleet enema as needed | |
| Urinary | ____ Assessed when patient last voided – retention |
| ____ Anticipated for foley catheter need | |
| Skin Integrity | ____ Instructed re: skin care, bed repositioning, changing diapers, safety, lotion to bony prominence |
| ____ Oral hygiene care | |
| Anxiety/Pre-terminal Agitation | ____ Assessed patient for hallucination – educate family / caregiver as needed |
| ____ Reviewed medication management, consider Xanax, if Xanax not effective, assess for Thorazine | |
| ____ Assessed for music therapy | |
| Spiritual Needs | ____ Addressed spiritual status/needs, may need to contact patients clergy or pastor as requested |
| Educational Needs/Materials | ____ Provided patient education materials |
| ____ Reviewed disease pathophysiology | |
| ____ Instructed patient/family on self management skills | |
| ____ Instructed patient/family about soft music, massage, aromatherapy, candles, pets, etc. ___________________________________________________________________________ | |
| Signature/Title _____________________________________ Initial/Date__________ | |
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For more information about the TriCentral Palliative Care Toolkit visit www.growthhouse.org/palliative/. All content is Copyright © 2002, 2003 by Richard D. Brumley, M.D. All rights reserved. No part of this toolkit may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publishers. This guide to developing home-based outpatient palliative care services was developed through a grant to the Kaiser Permanente TriCentral Service Area from The Project on Death In America. The Kaiser Permanente TriCentral Palliative Care Program is a Sustaining Member of the Inter-Institutional Collaborating Network On End-of-life Care (IICN) which links major organizations internationally.
