Preparing Your Plan of Care: What Your Team Needs to Know
When you receive end-of-life care, you’re the center of attention – part of a Plan of Care.
A plan of care is required for all patients receiving formal end-of-life care. It discusses everything from which medication is needed and how often it is to be taken, to what is explained to the caregiver during the process. It’s in place so everyone clearly understands what needs to be done to give the patient the most compassionate and comfortable time they can.
The interdisciplinary group
The patient, if possible, is part of the group that develops the plan of care. Their representative or designated caregivers are in the group, too. If they have their own physician, the doctor is included as well.
On Centrica Care Navigators’ side, the hospice physician and the interdisciplinary group (IDG) help create the plan of care. The IDG includes a supervising physician, nurse, social worker, chaplain, and sometimes other staff, depending on the patient’s needs. Together they identify the patient’s condition when starting care, the patient’s goals for care, and the problems they may face along the way, along with potential solutions.
Every patient’s situation is unique, and so is each plan of care. A log of medications and basic supplies like wheelchairs might be part of the plan. A to-do list of personal care tasks that should be performed a few days a week could be included. And maybe the patient wants a pastor, priest, rabbi, or another figure to discuss spiritual matters.
What’s in a plan of care?
The plan of care records what the patient and/or a caregiver understands about care. If the plan of care states that a nurse will visit twice a week, for example, then a nurse must visit twice a week, and document the visits.
A plan of care, fundamentally, is the same as almost every other kind of plan: it identifies what needs to be done (like “compassionate care”), what roadblocks the patient and the IDG might encounter (like “lack of energy”), and presents ways to handle those obstacles and why that’s important.
The better prepared the IDG is, the better time the patient is likely to have. If problems do arise, possible solutions have already been discussed, and changes in the plan of care can be made quickly.
Beyond the basics
Once a plan is in place, that’s not the end. Plans of care are regularly updated as the patient’s situation changes. What might work for a patient in the first days of hospice may be too intense closer to the end of life. It’s the IDG’s responsibility to keep the plan accurate to the treatment the patient is currently receiving. The plan also needs to be kept current.
There are always goals in a plan of care, too, beyond providing the compassionate and comprehensive end-of-life care that’s expected for any Centrica Care Navigators patient. Education is vital; the patient, family members, and other caregivers need to understand what receiving hospice care really means.
Some research may be needed to meet the patient’s spiritual and cultural needs. This could be a note on what should be done to properly prepare them for death, emotionally and socially – or more simply, maybe a mention that the patient doesn’t want shoes worn indoors.
Every single patient who receives service with Centrica Care Navigators has a plan of care. Find out more about what goes into a plan and how you can help make yours the best it can be by contacting us at 269.345.0273.
Our Mission is to guide and support individuals and their caregivers coping with illness, aging, dying, and loss by providing compassionate medical, emotional, spiritual, and personal care.