End-of-Life Care Template

Consult Note
Patient Information: John Doe, 78-year-old male  
Reason for Visit: Routine palliative care follow-up  
Accompanying Person: Daughter, Jane Doe  
Medication Status  
Current medication status: Patient is on morphine for pain management, and lorazepam for anxiety.  
Recent changes or issues with medication: Increased morphine dosage due to escalating pain.  
Clinical Presentation  
Patient's current state and appearance: Appears frail, with noticeable weight loss.  
Level of alertness and coherence: Alert and oriented to person, place, and time.  
Signs of distress or discomfort: Occasional grimacing due to pain.  
Physical Examination  
Findings from physical examination: Cachectic appearance, pallor noted.  
Hydration status: Mildly dehydrated.  
Oral intake: Reduced appetite, minimal oral intake.  
Urinary output: Decreased urinary output.  
Bowel movements: Constipation reported.  
Symptom Management  
Current symptoms and management: Pain managed with morphine, constipation addressed with laxatives.  
Recommendations for symptom relief: Increase fluid intake, continue current pain management regimen.  
Nutritional status and appetite: Poor appetite, nutritional supplements recommended.  
Pain assessment: Pain score 7/10, primarily in lower back.  
Respiratory status: Mild dyspnea on exertion.  
Mobility and Equipment  
Current mobility status: Limited mobility, requires assistance for transfers.  
Assistive devices in use: Walker and wheelchair.  
Home equipment and supplies: Hospital bed and oxygen concentrator at home.  
Family Support  
Family members present: Daughter, Jane Doe  
Caregiver's capability and understanding: Daughter is primary caregiver, well-informed and capable.  
Support system in place: Family support available, hospice nurse visits twice a week.  
Patient Education  
Information provided to patient/family: Discussed pain management and end-of-life care options.  
Resources given: Provided pamphlets on palliative care and local support groups.  
Discussion of medication administration: Explained proper use of morphine and lorazepam.  
Medication Management  
Prescriptions provided: Morphine, lorazepam, and laxatives.  
Medication delivery details: Medications to be delivered by local pharmacy.  
Instructions for medication use: Detailed instructions provided to daughter.  
End-of-Life Planning  
Current prognosis: Prognosis is poor, with limited life expectancy.  
Discussion of end-of-life care: Discussed hospice care and comfort measures.  
Funeral arrangements: Preliminary discussions held, no formal arrangements yet.  
Follow-up Plan  
Next steps in care: Continue current management, follow-up in two weeks.  
Communication with other healthcare providers: Coordination with hospice team ongoing.  
Documentation  
Death certificate arrangements: Not applicable at this time.