Palliative Care Transition of Care Summary

Patient name: [Patient full legal name]

DOB: [Date of birth]

MRN: [Medical record number]

Preferred name/pronouns: [Preferred name and pronouns / not documented]

Facility: [Hospital or facility name]

Unit: [Unit or ward]

Admission date: [Admission date]

Discharge/transfer date: [Discharge or transfer date]

Receiving setting: [hospice / SNF / outpatient palliative clinic / home with services / other]

Receiving agency/facility: [Agency or facility name / not yet determined]

Author: [Author name, credentials]

Service: [Palliative care service name]

Date/time signed: [Date and time]

Direct callback number: [Direct phone number for palliative service]

Transition Snapshot

• Primary serious illness and hospice-eligible conditions:
  • [Condition with stage/severity and key sites of involvement]
  • [Additional condition if it materially affects prognosis or eligibility]
• Current clinical status at transfer: [clinically stable / declining / rapidly declining / actively dying]
• Functional status: [PPS score / ECOG score / ADL dependence summary] — Ambulation: [status], Transfers: [status], Oral intake: [status], Continence: [status]
• Code status and treatment limits: [Code status order as of discharge] — [Specific limits such as no ICU escalation, no rehospitalization, comfort-focused only / unknown / not on file]
  Portable orders (POLST/MOLST): [present and sent with patient / not present / unknown]
• Surrogate decision-maker: [Name], [relationship], [phone] — Documentation on file: [yes / no / unknown]
  Primary day-to-day caregiver: [Name, relationship, phone / same as surrogate]
• Current symptom regimen summary: (Include only actively managed symptoms or those requiring anticipatory planning)
  • Pain: [Scheduled medication with dose/route/frequency] + PRN [medication with dose/route/frequency]
  • Dyspnea: [Medications, oxygen, non-pharmacologic measures]
  • Agitation/delirium: [Medications, environmental measures, safety notes]
  • Nausea: [Medications and triggers]
  • Bowel regimen: [Stimulant/osmotic regimen linked to opioid use]
• Top watch-outs and contingencies (first 24–72 hours):
  • [Watch-out with clear threshold for action and who to call]
  • [Watch-out with clear threshold for action and who to call]
  • [Bridging plan for after-hours symptom crises] (Only include if hospice start of care is pending)

Clinical Context

[Reason for palliative care consultation and dates of key involvement. One-sentence summary of clinical trajectory explaining current decisions. Primary diagnosis and major comorbidities affecting symptom management or disposition. Prognosis as discussed with patient and family with explicit attribution of understanding. Status of disease-directed therapy.] (If prognosis was not discussed, state "Prognosis discussion: not completed during this admission" with reason. Keep to 4–6 sentences focused on information necessary for safe, goal-concordant transitions.)

Goals of Care and Decision-Making

• Decision-making capacity: [present / lacks / fluctuating] — Supports used: [interpreter / assistive devices / communication aids / none needed]
• Decision-maker hierarchy: [Hierarchy summary] — Documentation: [healthcare proxy/POA on file / reported only / unknown]
• Preferences and priorities:
  • Location of care: [Preference and feasibility constraints]
  • Acceptable/unacceptable outcomes: [Summary of what matters most to patient/family]
  • Specific treatment preferences: ICU [accept / decline / time-limited / not discussed], Mechanical ventilation [accept / decline / time-limited / not discussed], Dialysis [accept / decline / time-limited / not discussed], Artificial nutrition [accept / decline / time-limited / not discussed]
• Hospice status: Discussed: [yes / no] — Elected: [yes / no / pending] — Agency: [name / not yet selected] — Start date: [date/time / pending] — Level of care: [routine / inpatient hospice / continuous care] (Use explicit "unknown" or "not on file" where uncertain)

Symptom Management Plan

(Organize by symptom in order of severity or likelihood to drive calls. Include: pain, dyspnea, anxiety, delirium/agitation, nausea/vomiting, constipation, terminal secretions, seizures, wound symptoms, bleeding risk as relevant.)

[Symptom]

• Current pattern and severity: [Numeric scale or descriptive pattern]
• Current regimen: Scheduled: [medication with dose/route/frequency]; PRN: [medication with dose/route/frequency]; Non-pharmacologic: [measures]
• Response and adverse effects: [Effectiveness and any side effects]
• Titration and contingencies: [Stepwise plan with thresholds and maximum dosing; when to call and whom]
• Route-change plan: [Alternative route if swallowing declines]

(Repeat for each active symptom. If no uncontrolled symptoms at discharge, state this briefly and reference anticipatory plans below.)

Anticipatory/Comfort Kit

• [Medication]: [dose, route, frequency] — Indication: [symptom] — Initiation instruction by: [hospice nurse / caregiver teaching completed]

Discharge Medications

• [Medication (generic)] — [Dose] — [Route] — [Frequency] — Indication: [indication] — [continue / new / changed / discontinue] (Add taper plan, max daily dose, or renal notes as needed)

Opioid summary: Total scheduled daily dose: [dose in OME] — Breakthrough: [dose and frequency] — Conversion notes: [if rotation occurred]

Deprescribing: [Medications stopped with rationale: burden exceeds benefit / no longer goal-concordant / swallowing difficulty]

Pharmacy: [Pharmacy name and contact] — Controlled substances: [sent and filled / pending / backup plan if not available]

Devices and Equipment

(Omit section if no devices or equipment are relevant)

• Lines/tubes/drains: [Device with management plan and whether removal is planned]
• Oxygen: [Flow rate, delivery method, goals]
• Feeding/nutrition: [Plan and alignment with goals]
• DME: [Hospital bed, commode, suction, wound supplies ordered or needed]
• Therapy: [PT/OT/SLP recommendations if applicable]

Psychosocial and Caregiver Considerations

(Include for hospice and SNF transitions)

• Living situation and barriers: [Home layout, stairs, bathroom access, safety concerns]
• Caregiver availability: [Who is available, capacity, teaching completed] (If uncertain, note contingency placement plan)
• Communication needs: [Language, interpreter, health literacy]
• Financial/insurance constraints: [Coverage considerations affecting medications, equipment, or services]
• Spiritual support: [Needs identified and chaplain involvement]

Pending Items and Follow-up

Pending tests/results

• [Test] — Expected: [timeframe] — Owner: [Hospice physician / SNF clinician / Outpatient palliative / PCP / Specialist name]

(Do not leave ownership ambiguous. If owner cannot be assigned, document escalation instructions.)

Unresolved decisions

• [Decision topic] — Discussed: [summary] — Remains undecided: [what] — Decision-makers: [names/roles] — Timeline: [target]

Follow-up appointments

• [Clinic/service] — [Date, time, location] — [Contact info]
• [If not scheduled: Who will schedule, by when, contact number]

Discharging palliative service: [Contact info]

Receiving clinician/service: [Contact info]

Contingency Plans

• Who to call first: [Hospice 24/7 line / SNF on-call / Palliative clinic / 911] (Specify based on patient's treatment preferences; do not imply alternatives to 911 unless goals explicitly support this)
• Pain crisis: [Rescue medication and max frequency] — Call [whom] if not controlled after [threshold]
• Acute dyspnea: [Rescue steps including medications, oxygen, positioning] — Rehospitalization: [desired / not desired per goals] — Call [whom] if not controlled
• Severe agitation/delirium: [Rescue medications and safety measures] — Call [whom] for further direction
• Refractory nausea/vomiting: [Rescue medications] — Hydration: [approach if consistent with goals] — Call [whom] if persistent
• Constipation with abdominal pain: [Laxative escalation plan and red flags] — Call [whom] if concern for obstruction
• Seizures: [Rescue medication and route] — Call [EMS / hospice per goals] (Include only if at risk)
• Catastrophic bleeding: [Comfort priorities, dark towels, sedation plan] — Rehospitalization: [desired / not desired] — Call [whom] (Include only if risk identified)
• Location-of-care fallback: [If home plan fails: respite, inpatient hospice, SNF placement options with case management contacts]

(If any critical element—code status, surrogate, hospice election, pending test ownership—is unknown or not documented, state this explicitly rather than omitting. This document supplements but does not replace the primary hospital discharge summary.)