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Rural Palliative Care Resource Center - Implement

Addressing the holistic needs of the patient through a serious illness takes a skilled interdisciplinary team. Providing symptom management, continuity with support and care, and facilitating communication between providers while advocating for the patient’s and family’s wishes are key skills for the interdisciplinary team. These resources and tools support development of processes and workflow to start providing palliative care services.


Advanced care planning

Address Goals of Care. This VITALtalk resource presents the skills clinicians need to know to have discussions with patients and families about prognoses and treatments.

Disclose Serious News. A VITALtalk resource that covers the communications and listening skills clinicians must develop to convey difficult information to patients and families.

Locator Tool for Health Care Directives. Forms and language of health care directives vary state by state. Use this interactive map to locate a specific state’s directive.


Assessment Tools for Palliative Care Technical Brief. An overview of assessment tools for application in clinical care, as quality indicators or assessment of interventions. (145-page PDF)

Edmonton Symptom Assessment System. ESAS-r is the standard approach to clinical assessments in palliative care. (2-page PDF)

Edmonton Symptom Assessment System (ESAS-r). (45-minute webinar). Palliative care expert Lyn Ceronsky DNP, GNP, FPCN, provides an overview of clinical assessment using ESAS-r. Slides (20-page PDF)

Elements of Palliative Care Consultation. Consultation in palliative care must address assessment and management of pain and other physical and psychosocial symptoms, estimating prognosis, assisting in identifying goals of care, assessment of support system, coping abilities, and spiritual needs, and guidance for future decisions. (1-page PDF)

Palliative Care Referral Criteria. This scoring sheet outlines three methods by which care teams can evaluate whether or not palliative care is appropriate for a patient. (2-page PDF)

Referral Criteria Sheet. This extended scoring sheet includes general, neurological, and cancer criteria for evaluation of a patient’s need for palliative care. (2-page PDF)

Spiritual care and assessment

The Spiritual Assessment. Physicians can support patients by stressing empathetic listening, incorporating the precepts of patients' faith traditions into treatment plans, and encouraging patients to use the resources of their spiritual traditions and communities for overall wellness.

Whole Health: Change The Conversation. A resource that offers tools to take a spiritual history, help patients draw upon their strengths, provide compassionate care, and determine spiritual/religious beliefs that could affect the treatment choices. (5-page PDF)