Actively Dying or End-of-Life Care Note

Date and time of encounter: [Date and time]

Note type: [Actively Dying / End-of-Life Care Note]

Author and service: [Author name, credentials; service]

Patient location and level of care: [Setting and level of care]

Primary life-limiting diagnosis: [Diagnosis]

Hospice status: [enrolled (agency name) / not enrolled / unknown]

Code status: [DNR/DNI / Full Code / Limited Interventions / unknown—attempting to confirm] (Source: [orders / POLST / advance directive / unavailable])

Decision-maker/surrogate: [Name, relationship, how confirmed / unknown with plan to clarify]

Source of history: [patient / surrogate / family / staff / chart] (Note if patient unable to participate)

Situation Summary and Trajectory

[Reason for note today: loss of oral route / escalating symptoms / goals change / family meeting / route conversion / anticipatory medications needed]. Current phase: [actively dying with prognosis hours–days / end-of-life trajectory with prognosis days–weeks]. Overarching goal is [comfort-focused care]. Death [is / is not] expected in current setting; this [aligns / does not align] with patient/family preference.

[Objective basis for prognosis: intake status, level of consciousness, respiratory pattern, perfusion/mottling, urine output, functional decline as relevant]. [Brief timeline of decline with key milestones]. (Use probabilistic language. If no direct exam, label findings as "per bedside report.")

Goals of Care Discussion

Participants and setting: [Who participated and how: bedside / phone / video]. (If discussion attempted but incomplete, document why, what was shared, interim plan, and when reattempt will occur.)

Understanding and Prognostic Awareness: [What patient/family understands about illness and expected course]

Values and Priorities: [What matters most: comfort, time, family presence, preferred location of death, spiritual/cultural needs]. (Include brief direct quotes only if they capture core values.)

Treatment Decisions: [Decisions made today and specific limitations agreed upon]. (Differentiate patient/family preferences from clinician recommendations from final decisions reached. Document resulting order changes and transitions to comfort measures.)

Unresolved Issues: [Disagreements, outstanding questions, and plan to address] (Omit if none.)

Symptom Assessment

[Active symptoms with severity, whether by self-report or observation/proxy, current treatment, and response]. (If patient cannot self-report, state assessment is via observation and do not use "denies.")

Route feasibility: Oral route [reliable / unreliable / lost]. Aspiration risk [present / absent]. Available routes: [sublingual/buccal / subcutaneous / IV / transdermal / rectal]. [Renal/hepatic considerations affecting medication selection if relevant].

Plan

Comfort Regimen: [For each symptom requiring intervention: medication, dose, route, frequency, titration plan, and when to escalate]. [Route conversions from oral with equianalgesic adjustments]. [Non-pharmacologic measures: positioning, fan, mouth care, family presence, environment, spiritual support as relevant].

Interventions Discontinued or Deferred: [Treatments stopped or not pursued consistent with goals: labs, vitals frequency, telemetry, lines, nonessential medications].

Family/Caregiver Guidance: [Education provided on expected changes in dying process]. [How symptoms will be treated]. [Crisis instructions: what to try first, who to call and when, aligned with goals]. (If family not present, document outreach attempted and interim safety plan.)

Coordination: [Orders placed, team members notified, handoff to next clinician, equipment arranged, level-of-care changes]. [After-death planning if discussed: preferred location, funeral home, what to do at time of death, bereavement resources]. (Omit after-death content if not discussed.)

(Required elements must not be left blank: code status, surrogate, prognosis, comfort plan, and route feasibility. If unknown, document as such with plan to clarify.)