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Palliative Care Clinical Resources
Palliative Collaborative Care Plans
- What are Collaborative Care Plans?
- Why are Collaborative Care Plans created?
- Who should use Collaborative Care Plans?
- Generic Collaborative Care Plans: Stable, Transitional & End-of-Life
- Pain Collaborative Care Plan
- Dyspnea Collaborative Care Plan
- Fatigue Collaborative Care Plan
- Collaborative Care Plans Condensed Version
NOTE: Used in conjunction with Collaborative Care Plans, the Symptom Management Guidelines are password protected and available for use to practitioners that have received education about PCIP and the management symptoms experienced by palliative patients. To receive education about PCIP, please contact the Pain & Symptom Management Consultation Service.
What are Collaborative Care Plans?
Collaborative Care Planning provides care teams with the opportunity to examine, understand and improve care for a specific patient population. An interdisciplinary plan of care for patients with a particular diagnosis or procedure is developed through this process.
Collaborative Care Plans (CCPs) define activities, interventions and outcomes that should occur within a specific stage or time frame.
Why are Collaborative Care Plans created?
Collaborative Care Plans (CCPs) are designed to place the patient at the focal point of care. They are evidence based and reflect the best practice patterns of all disciplines. Teams develop CCPs to:
- guide the care of typical patient
- promote the critical review of care processes
- promote quality patient care
- promote interdisciplinary collaborative practice
- promote patient satisfaction
Who should use Collaborative Care Plans?
Nurses are responsible for initiating the Collaborative Care Plans (CCPs), using the plan to guide care, and assessing a patient’s progress. CCPs help to:
- optimize the timing of interdisciplinary events
- minimize delays and unnecessary variations in care
- define expected patient outcomes
- improve communication between staff and to patients and families
- promote patient satisfaction and interdisciplinary collaborative practice
Generic Collaborative Care Plans: Stable, Transitional & End-of-Life
These Collaborative Care Plans (CCPs) build on the work of the Kingston Frontenac Leeds and Addington Palliative Care Integration Project and align with the Canadian Hospice Palliative Care Association’s (CHPCA) Model for Hospice Palliative Care. These revised CCPs were developed by a provincial working group that was tasked with developing a tool targeted at the generalist provider that would improve the quality of patient care by increasing consistency across providers and settings.
The Stable CCP should be used for paients who score between 70% and 100% on the Palliative Performance Scale (PPSv2).
- Generic CCPs: Stable - Click here
The Transitional CCP should be used for paients who score between 40% and 60% on the Palliative Performance Scale (PPSv2).
- Generic CCPs: Transitional - Click here
The End-of-Life CCP should be used for paients who score between 0% and 30% on the Palliative Performance Scale (PPSv2).
- Generic CCPs: End-of-Life - Click here
Pain Collaborative Care Plan
The Pain Collaborative Care Plan guides the management of pain often experienced by palliative patients. Pain is measured using the Edmonton Symptom Assessment Scale (ESAS). The Pain CCP information is applicable to all levels of pain severity. Reassessment of pain at regular, appropriate intervals is essential.
- Pain Collaborative Care Plan - Click here
Dyspnea Collaborative Care Plan
The Dyspnea Collaborative Care Plan guides the management of shortness of breath that is often experienced by palliative patients. This Dyspnea CCP is divided according to the Edmonton Symptom Assessment Scale (ESAS) measurement of dyspnea severity. Review all information included in the CCP when completing an assessment and intervention.
- Dyspnea Collaborative Care Plan - Click here
Fatigue Collaborative Care Plan
The Fatigue Collaborative Care Plan guides the management of fatigue, a symptom often experienced by palliative patients. The patient’s own description of fatigue is the most reliable indicator of severity. Fatigue severity should be screened daily using the tiredness scale on the Edmonton Symptom Assessment Scale (ESAS).
- Fatigue Collaborative Care Plan - Click here
Collaborative Care Plans Condensed Version
The Collaborative Care Plans Condensed Version has been developed as a resource for Handheld computers or for printing.
- Collaborative Care Plans "Lite" Version for Handheld computers or for Print - Click here