Patient

• Who is patient? – social context
• What is wrong? – illness, where in course of illness
• Is patient “clear-headed” – What does patient understand?
• What are Goals of Care?
  • Prolong survival
  • Optimize function
  • Optimized comfort
• What are consequences – How are you coping?
  • Physical/psychological/social/existential
• What are deeper thoughts/future problems

Family

• Who is family? – social context
• What is physical/psychological well-being of family?
• Coping?
• What are deeper thoughts/future problems/other losses in past?

HCP

• Who is involved?
• ? expertise/experience/understanding of illness

Care Plan

• Medical condition/Goals of care
• Patient/family issues
  • Physical
  • Psychological
  • Spiritual/existential
  • Social
  • Communication/decision-making
  • Understanding
• HCP issues
  • Staffing
  • Training
  • Resources
  • Emotional coping
• Coping assessment
  • Patient
  • Family
  • NCP
• Contingency planning