PALLIATIVE CARE

Patient Information

Name: __________________________ Most Responsible Physician: __________________

Diagnosis: __________________________ Resident: ____________________________________

Age at Diagnosis: _____________________ Specialists:___________________________________

Secondary Diagnosis: _________________ _____________________________________________

Home Care Contact:

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Caregiver: ____________________________________________________________

Next of Kin: __________________________________________________________

Surrogate Decision Maker: _____________________________________________

DNR:

• Yes
• No
• Not Sure

Details: ___________________________________

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Living Will:

• Done

Home Visits Needed:

• Yes Date: _____________________________

Psychosocial Issues___________________________________________________________

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Spirituality___________________________________________________________________