Palliative Care Follow Up Maintenance

---
name: palliative-care-follow-up-maintenance
description: |
  Plan follow-up and maintenance so gains for people with life-limiting illness and their families are checked and sustained.
  TRIGGERS - Use when a palliative care nurse and doctor needs a follow-up & maintenance schedule for people with life-limiting illness and their families in hospices, hospitals and homes.
category: Palliative Care
license: MIT
version: 1.0
---
# Follow-Up & Maintenance Schedule — Palliative Care

Plan follow-up and maintenance so gains for people with life-limiting illness and their families are checked and sustained. The deliverable is a follow-up schedule with intervals, checks and escalation triggers.
This skill is written for a palliative care nurse and doctor working with people with life-limiting illness and their families in hospices, hospitals and homes.

## When to use
- You are a palliative care nurse and doctor preparing, delivering or reviewing this part of your work in hospices, hospitals and homes.
- You need a defensible, repeatable approach that produces a follow-up schedule with intervals, checks and escalation triggers.
- A colleague, auditor or client asks how this was done and what evidence supports it.

## Key Concepts
| Term | Meaning |
|------|---------|
| Advance care planning | recording wishes for future care |
| Syringe driver | a pump delivering continuous medication under the skin |
| Hospice | specialist care for people approaching the end of life |

## Workflow
1. **Step 1** - Set follow-up intervals from the plan and from how symptom control scores is expected to move over time
2. **Step 2** - Define what is checked at each contact, using symptom control equipment where measurement is needed, and record it in symptom assessments
3. **Step 3** - Give people with life-limiting illness and their families clear guidance for the interval: what to do, what to watch for, when to make contact sooner
4. **Step 4** - Act early on warning signs — deterioration linked to uncontrolled symptoms shortens the interval, never lengthens it
5. **Step 5** - Close the follow-up cycle formally when goals are met, with a summary and re-entry route if needs return

## Profession-Specific Components
| Component | Details for Palliative Care |
|-----------|-------------------------------|
| Core documentation | symptom assessments; advance care plans; medication charts; bereavement records |
| Core tools & equipment | symptom control equipment; syringe drivers; pressure care equipment; communication tools |
| People involved | people with life-limiting illness and their families; the palliative care nurse and doctor; colleagues and other services in hospices, hospitals and homes |
| Primary record | symptom assessments — keep it current, dated and attributable |

## Output Format
**Context:** [Situation in hospices, hospitals and homes] | **Objective:** [What this must achieve] | **Audience:** [people with life-limiting illness and their families and other stakeholders]

The finished output is a follow-up schedule with intervals, checks and escalation triggers, structured as:
1. Summary of position and evidence
2. Detail, following the workflow above
3. Decisions, actions, owners and dates
4. Review point and escalation route

### Action Plan
1. **Immediate:** Confirm scope, consent and the evidence available in symptom assessments.
2. **Short-term:** Complete the workflow steps and record outcomes against symptom control scores.
3. **Medium-term:** Review results, close actions, and update local procedures in hospices, hospitals and homes.

## Success Metrics
| Metric | Target | Method |
|--------|--------|--------|
| symptom control scores | Agree a local target and track the trend | Measured from symptom assessments and reviewed on a set cycle |
| preferred place of care achieved | Agree a local target and track the trend | Measured from symptom assessments and reviewed on a set cycle |
| family feedback | Agree a local target and track the trend | Measured from symptom assessments and reviewed on a set cycle |
| response times to crises | Agree a local target and track the trend | Measured from symptom assessments and reviewed on a set cycle |

## Guardrails & Quality Checks
- Never let this happen: uncontrolled symptoms.
- Never let this happen: advance wishes not recorded.
- Never let this happen: family distress unsupported.
- Work only within the competence and authority of a palliative care nurse and doctor; escalate or refer anything beyond it.
- Record facts and observations, not speculation, and keep records confidential to hospices, hospitals and homes's rules.
- Verify names, dates, figures and measurements twice before anything is issued or signed off.
- Use only real, verified information from the case in hand — never invent results, credentials or evidence.

## Example (illustrative)
A palliative care nurse and doctor in hospices, hospitals and homes applies this workflow for people with life-limiting illness and their families: they open
symptom assessments, work through the five steps using symptom control equipment, and close by recording
the outcome against symptom control scores and agreeing the next review date. (Illustrative example only —
replace with the real details of the case in hand.)