| Date of initial consultation: |
| Referring provider: |
| Reason for consultation: |
| Pain control |
| Non-pain symptom management |
| Psychosocial/spiritual support |
| Establishing goals of care |
| Interfamily conflict |
| Family-clinician negotiation |
| Withdrawal of life-sustaining treatment |
| Terminal care |
| Inpatient hospice referral |
| Disposition |
| Other: |
| History of the present illness: |
| Palliative review of symptoms (may include standardized numerical [eg, Likert] or categorical recording method) |
| Performance status |
| ECOG |
| 0 - Fully active |
| 1 - Restricted strenuous activity |
| 2 - Ambulatory, unable to work |
| 3 - Limited self-care, bed- chair >50 waking hours/week |
| 4 - Bed/chair confined, no self-care |
| Pain |
| Pain description: |
| Pain intensity [0 to 10]: |
| Dyspnea: |
| Cough: |
| Nutritional status (weight change, appetite, taste disturbance): |
| Oral symptoms (xerostomia, dysphagia, odynophagia): |
| Nausea/vomiting: |
| Constipation/diarrhea: |
| Urination problems: |
| Sleep: |
| Fatigue: |
| Sedation: |
| Cognitive/memory problems: |
| Anxiety: |
| Depression: |
| Concerns/worries: |
| Other: |
| Goals of care |
| Information-sharing preferences |
| Patient's understanding of medical condition and prognosis: |
| Knows diagnosis: Yes/No |
| Knows prognosis |
| Terminal |
| Life-threatening |
| Serious |
| Not life-threatening |
| Not serious |
| Not discussed |
| Patient's preference about sharing medical information: |
| Patient alone should receive all information |
| Patient and family may receive information |
| Only family or specific family member(s) should receive information |
| Patient declines information sharing |
| Unsure |
| Family's or surrogate's awareness of illness: |
| Decision-making preferences |
| Patient's decision-making preferences: |
| Fully involved |
| Speak to family |
| Leave to clinician |
| Unsure |
| Patient understanding of illness and prognosis |
| Hopes and concerns |
| Previous experiences with end-of-life decisions |
| Attitudes about diminished functional states and use of "aggressive" life-sustaining care |
| Unacceptable states (eg, unable to think or communicate or live independently) |
| Advance directives |
| Health care proxy: |
| Name: |
| Address: |
| Telephone: |
| Location of proxy document: |
| Limitations on life-sustaining treatments (should conform to orders) |
| Full Code, discussed with patient or surrogate |
| Full Code, default, discussion not possible/appropriate presently |
| Limitation of life-sustaining treatment: |
| No cardiopulmonary resuscitation |
| No endotracheal intubation or mechanical ventilation |
| No noninvasive ventilatory support (BiPAP, CPAP) |
| Other instructions: |
| Comfort care form or POLST: Yes/No |
| End of life plans |
| Patient preference for place of death: Home ____ Hospital ____ Other ____ |
| Funeral arrangements/wishes: |
| PMHx: |
| Hospitalizations: |
| Operations: |
| Other serious illnesses: |
| Allergies, adverse reactions: |
| Current medications and complementary therapies: |
| Social history |
| Place of birth: |
| Education: |
| Marital status: Single ____ Married ____ Divorced ____ |
| Children: |
| Work: |
| Hobbies/joys: |
| Habits: |
| Patient coping: |
| Support system: |
| Family support: |
| Family coping: |
| Financial issues: |
| Cultural issues: |
| Spiritual history |
| Religious/spiritual orientation: |
| Involvement in a spiritual community: |
| Desire for further chaplaincy support: Yes/No |
| Family history: |
| Physical examination: |
| Laboratory studies: |
| Impression/problems: |
| 1. |
| 2. |
| 3. |
| Suggestions/plans: |
| 1. |
| 2. |
| 3. |
