My Palliative Care Plan

Step 1) Talk to your doctor

The first step is to talk to your own doctor. If your doctor is not already a palliative care giver, then you should ask for a palliative care referral and begin to build your palliative team. Your team may include other doctors, pharmacists, therapists, social workers, and nurses who can help you whether you are in the hospital or at home.

What to discuss:

  • Tell your doctor you are considering palliative care and want more information
  • Ask what palliative services are available in your area.
  • Be clear that you want a plan to control the quality of your life. That you know that the illness that you have may have many long-term symptoms that can cause pain and other discomforts. That it is your wish to create a palliative care plan so you can have some control over what happens.
  • If you have an advanced health care directive be sure to provide your doctor with copies of all documents.
  • Be sure your doctor is aware of any personal, religious, or cultural beliefs, values, or practices that are important to consider in your care and treatment decisions.
  • Explain to your doctor what quality of life means to you. This may include being able to spend time with loved ones, how you would like pain and other distressing symptoms aggressively treated, the ability to make your own decisions for care and your preferred location of treatments (home vs. in the hospital).
  • Physicaian Order for Life-Sustaining Teatment (POLST) Form

    Step 2) Fill out a POLST Form with your doctor

    The POLST Form, or Physician Order for Life-Sustaining Treatment (POLST) Form, will define and direct all health care personnel who may be called in to help you. You may fill out the form with the help of a nurse, social worker, clergy, or family. It MUST be signed by your doctor. You will want to keep it (or copies of it) posted in obvious places in your home (by your bed, on the refrigerator) so that emergency personnel or other family members will have access to it.

    The California POLST form is bright pink and printed on heavy card stock, it is made this way to be quickly recognizable by any health care professional. If your doctor does not have this form - POLST forms are online in several languages and for specific states within the United States.

    What to discuss:

  • Tell your doctor what treatments you may or may not want and have him complete a POLST form with, which will define your instructions for resuscitation if your heart were to stop, being placed on a mechanical ventilator if your lungs were to fail, undergoing dialysis if your kidneys were to fail, and artificial nutrition by a feeding tube if you were unable to eat, and so forth.