Planning and coordinating care

Ensuring palliative care is appropriate and timely

Ideally, palliative care involves an interdisciplinary team and planning that is person-centred. Often this means that it is provided across settings of care. Care coordination centres on ensuring that information is shared with the person and their family members and health professionals to inform care planning.

During end-of-life care, nursing care planning revolves around:

• controlling symptoms
• preventing or managing complications
• optimising quality of life
• helping the person, family, and carers prepare for death
• ensuring the preferences and wishes of the person and/or their family are met.

These elements of care are reflected in and guide comprehensive care assessment. Care planning in palliative care is person-centred. With guidance documents increasingly emphasising the importance of care personalisation, it is important that nurses understand the principles and related concepts.

The ACSQHC comprehensive care standard for end-of-life care (1.8MB pdf) includes advance care plans and goals of care plans as essential elements of discussing, planning, and delivering care.

Planning that anticipates or considers possible future needs can also be very useful at end of life when the illness trajectory is uncertain.

Personalisation of care planning can also be supported through:

• shared decision-making
• supported decision-making