How is the Hospice Plan of Care created?

10 May How is the Hospice Plan of Care created?

Learn how a personalised hospice plan of care is created by the interdisciplinary team in collaboration with the patient and family to provide tailored support and comfort.

Entering hospice care means shifting the focus from curative treatment to maximising comfort and quality of life. A cornerstone of this approach is the hospice plan of care.

What is the Hospice Plan of Care?

The hospice plan of care is a written document that outlines all aspects of the care and services to be provided to the patient and their family. It’s developed by the interdisciplinary hospice team in collaboration with the patient, their family, and their physician. The plan guides everyone involved in the patient’s care, ensuring a coordinated and consistent approach.

How is the Plan Created?

The creation of the hospice plan of care is a collaborative and ongoing process that begins with a comprehensive assessment.

• Initial Assessment: When a patient is admitted to hospice, the hospice team conducts a thorough evaluation. This includes assessing the patient’s physical symptoms (pain, nausea, breathing difficulties, etc.), emotional and spiritual state, social needs, and practical concerns. The team also gathers information about the patient’s medical history, their understanding of their illness, and their values and preferences.
• Defining Goals of Care: A crucial part of the initial assessment is understanding the patient’s and family’s goals for care. What is most important to them during this time? Is it being free from pain, spending time with loved ones, remaining at home, or something else? These goals form the foundation of the care plan.
• Team Collaboration: The interdisciplinary team, which includes a physician, nurse, social worker, chaplain, and other specialists as needed, meets to discuss the assessment findings and develop a plan to address the patient’s identified needs and goals.
• Patient and Family Involvement: The patient and their family are central to this process. Their input is invaluable in shaping the plan and ensuring it reflects their wishes. They have the right to participate in the development of the plan and receive a written copy.
• Regular Review and Updates: The hospice plan of care is not static. It is reviewed and updated regularly by the hospice team, typically during team meetings and at each patient visit. As the patient’s condition and needs change, the plan is adjusted accordingly to ensure continued appropriate and effective care.

Why Does the Hospice Plan of Care Matter?

The personalised hospice plan of care is essential for several reasons:

• Ensures Patient-Centred Care: The plan is built around the individual patient, prioritising their comfort, dignity, and personal wishes.
• Guides the Care Team: It provides clear direction for all members of the interdisciplinary team, ensuring everyone is working together towards the same goals.
• Facilitates Communication: The written plan and the regular team meetings help ensure open and consistent communication among the care team, the patient, and the family.
• Coordinates Services: It outlines the specific services to be provided, such as nursing visits, therapy sessions, and access to equipment, ensuring these are coordinated effectively.
• Empowers Patients and Families: By involving patients and families in the planning process it gives them a sense of control and active participation in their care.
• Provides a Record of Care: The plan serves as a comprehensive record of the care provided, which is important for continuity and quality assurance.

The hospice plan of care is a dynamic tool that evolves with the patient’s journey. It is a testament to hospice care’s personalised and comprehensive support, focusing on living as fully and comfortably as possible. Reach out to us at https://angelwingshospice.org/contact-us/