Palliative Care Service Plan

---
name: palliative-care-service-plan
description: |
  Design a realistic, measurable service plan for people with life-limiting illness and their families as a palliative care nurse and doctor.
  TRIGGERS - Use when a palliative care nurse and doctor needs a service plan design for people with life-limiting illness and their families in hospices, hospitals and homes.
category: Palliative Care
license: MIT
version: 1.0
---
# Service Plan Design — Palliative Care

Design a realistic, measurable service plan for people with life-limiting illness and their families as a palliative care nurse and doctor. The deliverable is a written plan with goals, actions, owners, timelines and review dates.
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 written plan with goals, actions, owners, timelines and review dates.
- 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** - Start from the assessment findings and agree goals with people with life-limiting illness and their families — specific enough to measure against symptom control scores
2. **Step 2** - Break each goal into actions sequenced for hospices, hospitals and homes, naming who does what and by when
3. **Step 3** - Build the plan around symptom assessments so progress, changes and decisions are recorded in one place
4. **Step 4** - Price or resource the plan honestly: time, symptom control equipment and materials, with contingencies for uncontrolled symptoms
5. **Step 5** - Set the review date and the trigger points that would change the plan, and confirm the plan with all parties

## 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 written plan with goals, actions, owners, timelines and review dates, 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.)