| Progressive Changes: | Generally patient is ambulatory and coherent Some side effects from curative measures and/or medications Initial stages of grief, anger and denial |
| Medical Director: | Initial examination of patient Certification for hospice care Develop plan of care Orders |
| RN Case Manager: | Assessment for hospice conference with family Confer with physician Develop plan of care Order medications Order DME (Durable Medical Equipment) Train and instruct primary caregiver(s) |
| Home Health Aides: | Start person care program Instruct primary caregiver(s) |
| Social Service Workers: | Assess patient and family psychosocial/bereavement needs to develop plan of care Establish trusting relationships with patient and family |
| Chaplain: | Spiritual assessment Confer with other team members for development of plan of care |
| Volunteers: | Conference with hospice team for direction Learn interests of patient Initial visitations |
| Progressive Changes: | Some weight loss, weakness, symptoms manifested Signs of stress Growing acceptance of terminal state Fear, depression |
| Medical Director: | Monitor and assess plan of care ICC meeting Orders Evaluate symptoms Manage pain |
| RN Case Manager: | Follow plan of care and direct team members Provide direct care Report observations Establish rapport with patient and family |
| Home Health Aides: |
Establish supportive, loving, trusting relationship with patient and family |
| Social Service Workers: | Monitor and implement approved plan of care Determine need for referral to other community resources Identify dysfunctional patient/family problems Make recommendations |
| Chaplain: | Implement plan of care conference with patient/family who desire spiritual support Assess other needs requiring psychosocial intervention |
| Volunteers: | Establish supportive, trusting relationship via ongoing visit and contact |
| Progressive Changes: | Continuing weight loss, decreasing appetite Physical manifestation Symptoms more pronounced Grief work, planning, and resolving |
| Medical Director: | Monitor and assess plan of care ICC Meeting Orders Evaluate symptoms Manage pain |
| RN Case Manager: | Monitor ongoing implementation of approved plan of care Increased need for symptom management and pain control Evaluate psychosocial needs of family and patient with other team members |
| Home Health Aides: | Assist with personal care needs Identify and report special needs to Case Manager |
| Social Service Workers: | Continued monitoring of plan of care Ongoing assessment of patient/family abilities to cope with terminal diagnosis and its impact on daily living |
| Chaplain: | Implement plan of care as appropriate Contact spiritual support person of denomination of patient/family choice |
| Volunteers: | Assist with letter writing, telephoning, reading, music Provide emotional support to patient and family Respite for family |
| Progressive Changes: | Physical deterioration apparent Symptomatology and pain increase Beginning of withdrawal Acceptance of terminal disease |
| Medical Director: | Reassessment for new benefit period Monitor and assess plan of care ICC meeting Orders Evaluate symptoms Manage pain |
| RN Case Manager: | Monitor ongoing implementation of approved plan of care Increasing need for order changes to manage symptoms and control pain Continued coordination of patient, family and team |
| Home Health Aides: | Continued assistance with personal care needs Identify and report special needs to Case Manager |
| Social Service Workers: |
Evaluate patient/family coping abilities and assess appropriateness of respite care |
| Chaplain: | Implement plan of care as appropriate Encourage family to continue observance and rituals that provide meaning and support to them |
| Volunteers: | Arrange for personal preferences of patient: food, visitation, special interests Respite for family |
| Progressive Changes: | Progressive physical deterioration Symptoms increase Pain management primary May be bedridden Increasing withdrawal Resolution and closure |
| Medical Director: | Monitor and assess plan of care ICC Meeting Orders Evaluate symptoms Manage pain |
| RN Case Manager: | Monitor more closely Increase visits, as needed Implementation of approved plan of care Daily review of symptom management and pain control Increase family support Coordination of psychosocial plan of care |
| Home Health Aides: | Provide bathing, dressing and other personal care needs, as necessary Provide comfort measures Report needs to Case Manager |
| Social Service Workers: | Continued monitoring of approved plan of care Assess patient and family for signs of dysfunctional grieving and provide appropriate intervention Facilitate support systems |
| Chaplain: | Implement plan of care Provide spiritual support as appropriate to patient and family wishes Assist with final arrangements as requested |
| Volunteers: | Provide respite periods for family Assist with visitation and personal needs |
| Progressive Changes: | End-stage - pronounced withdrawal Requires total care Intensive management of symptoms and pain No appetite |
| Medical Director: | Monitor and assess plan of care ICC Meeting Increased need for medication changes to manage symptoms and control pain Support family |
| RN Case Manager: | Daily monitoring of end-stage process Monitor side effects of medications, symptoms manifested and pain management Coordinate preparation for death with other team members Increase patient/family support |
| Home Health Aides: | Increase contact with patient and family for direct care Assure all personal care needs are met Provide comfort measures |
| Social Service Workers: | Continued monitoring of approved plan of care Assist patient and family in resolution and closure Ensure final arrangements Facilitate support systems |
| Chaplain: | Implement plan of care Provide support to patient and family, as well as hospice staff in preparing for separation Assist with final arrangements as requested |
| Volunteers: | Provide respite periods for family Provide patient with emotional support |
| Medical Director: | May have further communication with the family |
| RN Case Manager: | Call and/or visit family Assess special bereavement needs May attend funeral Complete discharge charting |
| Home Health Aides: | May attend funeral |
| Social Service Workers: | Call and/or visit family May attend funeral Begin bereavement follow-up Identify dysfunctional grieving and initiate appropriate intervention |
| Chaplain: | May visit family Instruct family regarding bereavement groups and memorial service Provide grief/bereavement support |
| Volunteers: | Provide bereavement support to family and significant others Maintain regular contact for up to 12 months |
Compiled by the Lincoln/Greater Nebraska Chapter of the Alzheimer's Association, 1999.