1. Discussion of illness limitations and prognosis. |
2. Recommendations for conducting a whole patient assessment including the patient’s physical, social, psychological, and spiritual issues, their family and community setting. |
3. Recommendations for when to make these assessments |
4. Recommendations on when PC should be integrated-referral criteria. |
5. Assessment of the patient’s goals for care. |
6. Continuous goal adjustment as the illness and the person’s disease progresses. |
7. Palliative care interventions to reduce suffering as needed. |
8. Advance care planning. |
9. Recommendation of involving a PC team. |
10. Recommendations on care during the last hours of living. |
11. Recommendations on grief and bereavement care. |