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Appendix D Palliative care plan

Patient name:
Age and sex:
Diagnosis:

Treatments received:

 

 

Medical Surgical
Current treatment:

Disease trajectory:

 

Care category:

 

Prognosis: Years Months Weeks Days Unsure

Genogram:

 

 

Team:
Problem list Action plan Team member Time frame
Body (Physical)

 

 

Mind (Psychological)

 

 

Spirit

 

 

Family (Social)