Eastern Counties Hospice Palliative and End-of-Life Care Network - Process of care


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PROCESS OF PROVIDING CARE

During each therapeutic encounter, the process for providing care involves six essential and several basic steps that guide the interaction between caregivers, and the patient and family. While these steps do not need to occur in any specific order, each one must be completed during each encounter.
1. Assessment History of active and potential issues, opportunities for growth, associated expectations, needs, hopes, fears Examine with assessment scales, physical examination, laboratory, radiology, procedures	2. Information sharing Confidentiality limits Desire and readiness for information Process for sharing information Translation Reactions to information Understanding Desire for additional information
3. Decision-making Capacity Goals for care Issue prioritization Therapeutic options with potential for benefit, risk, burden Treatment choices, consent Requests for: • Withholding, withdrawing therapy • Therapy with no potential for benefit • Hastened death Surrogate decisionmaking Advance directives Conflict resolution	4. Care Planning Setting of care Process to negotiate and develop plan of care that: Addresses issues and opportunities, delivers chosen therapies Includes plan for: • Dependents • Backup coverage • Respite care • Emergencies • Discharge planning • Bereavement care
5. Care Delivery Careteam • Composition • Leadership, coordination, facilitation • Education, training • Support Consultation Setting of care Essential services Patient, family, extended network support Therapy delivery • Process • Storage, handling, disposal • Infection control Errors	6. Confirmation Understanding Satisfaction Complexity Stress Concerns, other issues, questions Ability to participate in the plan of care

Ref: A Model to Guide Hospice Pallaitive Care, Canadian Hospice Palliative Care Association, Ottawa, Canada, 2002.

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