Section 2: Clinician Guidelines

Palliative care is the comprehensive care and management of the physical, psychological, emotional and spiritual needs of patients and their families with chronic, serious or life-threatening illness. Palliative care may be complementary to curative or life-prolonging therapies that are being used to meet patient-defined goals of care.

The palliative care team may include some or all of the following: physician, advanced practice nurse, nurses, pastoral and/or spiritual care, social work, case management, dietician, pharmacist, physical therapist, speech therapist, occupational therapist and respiratory therapist.

The palliative care team will:

  • Assist the patient/family in defining goals of care
  • Address symptoms relating to disease and treatment
  • Promote the highest quality of life for patient and family
  • Coordinate care among providers
  • Educate the patient and family on disease and expected course of the illness
  • Establish an environment that is comforting and healing
  • Plan for discharge to the appropriate level of care and appropriate services.

Initiating a Palliative Care Consultation

A referral to palliative care services may come from many sources such as physicians, nurses, patient, family members, social work and clergy. If the referral for palliative care services comes from anyone other than the attending physician, a member of the palliative care team will notify the primary care physician of the referral and request permission to provide a consultation. The requirement for permission from the primary care physician will vary by organization.

Educating Patients and Families about Palliative Care

The palliative care team will provide education to the patient, family and caregiver. The most commonly provided education is:

  • Pain and symptom management
  • Advance care planning and advance directives
  • Appropriate healthcare services
  • What to expect through the course of the disease.

As educational needs are defined, they are incorporated into the plan of care.


The palliative care team strives to understand and treat the patient's physical and emotional symptoms. This includes but is not limited to pain, nausea, dypsnea, anxiety, depression, constipation, anorexia and fatigue. One way the team accomplishes this is through a comprehensive patient assessment.

The comprehensive assessment identifies:

  • Diagnosis
  • Presenting problems
  • Current treatments, medications and side effects
  • Pain level
  • Symptom inventory
  • Patient, family/caregiver concerns and preferences
  • Spiritual and cultural beliefs or concerns.

Once the assessment is completed, the palliative care team creates a comprehensive treatment plan with the patient and family/caregiver. Once the plan is finalized the palliative care team works with the clinical team to ensure the implementation and monitoring of the treatment plan. The treatment plan is modified based on ongoing assessment.

Goals of Care

Palliative care specialists often address many of the difficult and painful conversations that need to take place with patients and their families. The palliative care team specializes in such communication where the patient and family goals are addressed and a feasible, evidence-based plan is offered, thereby helping guide patients through a complex health system.

When developing the goals of care, we need to ask the question: what are we trying to achieve?
Consider asking the patient:

  • What are your hopes for the future?
  • How do you define quality of life?
  • Is there a special event that you wish to attend (wedding, birthday, graduation)?
  • What activities do you want to continue or what activities do you wish to be involved in?