Appendix D Palliative care plan
| Patient name: | |||||
| Age and sex: | |||||
| Diagnosis: | |||||
Treatments received:
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Medical | Surgical | |||
| Current treatment: | |||||
Disease trajectory:
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Care category:
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| Prognosis: | Years | Months | Weeks | Days | Unsure |
Genogram:
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Team: | ||||
| Problem list | Action plan | Team member | Time frame |
|---|---|---|---|
| Body (Physical) | |||
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| Mind (Psychological) | |||
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| Spirit | |||
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| Family (Social) | |||
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