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Learning modules

Activity 4: Patient-centred care planning

A plan of care is developed through contributions from all relevant disciplines and is based on a comprehensive assessment of the individual and family. The team works both autonomously and together with individuals, families and caregivers to clarify goals of care and develop a single, co-ordinated, needs-based palliative care plan. [123] Individual team members work within the evidence base for their specific profession. [4]

The care planning process may consider:

  • current disease status and past medical history, including all co-morbidities
  • physical and psychological symptoms
  • functional status
  • social, cultural, spiritual concerns
  • advance care planning preferences. [5]

Ideally, the multidisciplinary team communicates regularly (at least weekly, more often as required by the clinical situation) to review and evaluate the care plan. [35]  

Family meetings can be conducted to assist with aspects of care planning and provision. Family meetings can also have a significant role in meeting the education and information needs of the patient and caregiver. The Centre for Palliative Care Education and Research website includes an evidence-based resource Family meetings in palliative care:  multidisciplinary clinical practice guidelines to guide the planning and implementation of family meetings in palliative care. [6]

Thinking points


1. Meier, D.E., Beresford,L. (2008). The palliative care team. Journal of Palliative Medicine, 11(5), 677–681.

2. Baldwin, P. K., Wittenberg-Lyles, E., Oliver, D.P., Demiris, G. (2011). An Evaluation of Interdisciplinary Team Training in Hospice Care. Journal of Hospice & Palliative Nursing. 13 (3), 172-182, DOI: 10.1097/NJH.0b013e31820b5c16Article.

3. National Breast and Ovarian Cancer Centre. (2008). Multidisciplinary care principles for advanced disease: a guide for cancer health professionals. Surry Hills, NSW: National Breast and Ovarian Cancer Centre.

4. Palliative Care Australia. (2005). Standards for Providing Quality Palliative Care for all Australians. Retrieved 30 May 2011, from

5. National Consensus Project for Quality Palliative Care (2009). Clinical Practice Guidelines for Quality Palliative Care, Second Edition. Retrieved 30 May 2011, from

6. Hudson, P., Quinn, K., O’Hanlon, B., Aranda, S. (2008). Family meetings in palliative care:  multidisciplinary clinical practice guidelines. BMC Palliative Care, 7(1), 12. Retrieved 22 November 2016, from