Pain/symptom assessment |
Are there distressing physical or psychological symptoms? |
Social/spiritual assessment |
Are there significant social or spiritual concerns affecting daily life? |
Understanding of illness/prognosis and treatment options |
Does the patient/family/surrogate understand the current illness, prognostic trajectory, and treatment options? |
Identification of patient-centered goals of care |
What are the goals for care, as identified by the patient/family/surrogate? |
Are treatment options matched to informed patient-centered goals? |
Has the patient participated in an advance care planning process? |
Has the patient completed an advance care planning document? |
Transition of care post-discharge |
What are the key considerations for a safe and sustainable transition from one setting to another? |