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People with identified palliative care needs collaborate with their primary care provider and other health care professionals to develop an individualized, person-centred care plan that is reviewed and updated regularly.
Creating and documenting an individualized, person-centred care plan improves the quality and efficiency of care. Care plans place the patient at the focal point and guide the care that is provided. The use of care plans promotes communication, continuity of care, and coordination of care. The care plan should include the person’s goals and wishes, treatment decisions and consents to treatments or plan of treatment, preferred care setting, current and anticipated care needs, and the resources required to meet those needs. The care plan is documented in the medical record so that all team members have access to the information. The care plan is shared with the patient or their substitute decision-maker. The person’s ability to be involved in making decisions may change as their condition changes, and the care plan should be updated accordingly.
Your care team should work with you to create a care plan that fits your values, wishes, and goals. Your care team should use this plan to provide palliative care that meets your needs. This care plan should be updated as often as you need.
Collaborate with people with identified palliative care needs to create and document a care plan that reflects their individual values, wishes, and goals of care. This plan should be created at the start of their care and then reviewed and updated as needed.
Ensure that all health care settings have the tools, systems, processes, and resources in place for health care professionals and people with identified palliative care needs to create, document, and share individualized, person-centred care plans.
Percentage of people with identified palliative care needs (or their caregivers) who state that they worked together with their health care provider to develop a care plan
Percentage of people with identified palliative care needs (or their caregivers) who state that they have had the opportunity to review and update their care plan when they wanted to do so
Percentage of people with identified palliative care needs who have a documented care plan in their medical record
Individualized, person-centred care consists of care and treatment that is customized for each person based on their values, wishes, goals, and unique health needs. The person with the progressive, life-limiting illness drives the care provided; a person-centred approach involves a partnership between patients and their health care professionals.
A care plan is a written document that describes a person’s health needs and goals and the care that will be provided to meet them. A care plan is not the same as having a discussion about goals of care. Nor is it a decision or consent for treatments. A care plan is broader and different than a plan of treatment. A plan of treatment is associated with a health care decision and requires informed consent from the patient or substitute decision-maker.
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