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Rural Palliative Care - Clinical Resources

The following resources can assist health care providers with setting clinical guidelines and developing clinical tools that support delivery of palliative care services.

Care delivery

Agency for Healthcare Research and Quality (AHRQ) Health Care Innovations Exchange. This website includes palliative care innovation case studies and offers links to quality tools.

CAPCconnect palliative care discussion forum. Resource for health care professionals who want to share information, exchange ideas, and get advice from their colleagues on operational issues affecting their palliative care programs. Search previous forum messages. Member login required to post or respond to messages. Center to Advance Palliative Care (CAPC)

Center to Advance Palliative Care tools. This curriculum catalogue has clinical tools including pain management, communication skills, symptom management, relief of suffering and whole-person care. Available to CAPC members only.

Choosing Wisely. A national campaign started by the American Board of Internal Medicine Foundation.  The campaign aims to promote conversations between physicians and patients by helping patients choose care that is:

  • Supported by evidence
  • Not duplicative of other tests or procedures already received
  • Free from harm
  • Truly necessary

Through the campaign national organizations representing medical specialists have been asked to “choose wisely” by identifying five tests or procedures commonly used in their field, whose necessity should be questioned and discussed. This has resulted in more than 30 lists of “Five Things Physicians and Patients Should Question.”  Additional lists are expected to be added as more specialty groups start to participate. Consumer Reports, is also participating in the campaign by helping disseminate patient education materials.

Edmonton Symptom Assessment System (ESAS-r). Instructions and strategies. Presented by Lyn Ceronsky, DNP, GNP, CHPCA, FPCN, system director, M Health Fairview Palliative Care Program. (45-minute webinar, 12/11/18), slides (20-page PDF)

Ethnic-Specific Geriatric Care in the United States. Educational modules on the health and health care of 13 ethnicities of older adults in the U.S. Modules include general history and demographics, culturally-appropriate care, access and utilization, and instructional strategies including case studies. eCampus Geriatrics of Stanford School of Medicine

Faith Leaders - Palliative Care Resource Paper for Rural Faith Leaders. A faith leader's partnership with a palliative team is vital, given their knowledge of the patient's history, relationship with the patient, and shared faith-specific values. They can recognize or converse about whether and how patients might be suffering. (4-page PDF)

Healthcare Equipment Recycling Organizations. Project HERO collects and redistributes donated health care materials to benefit those in need. This program can be used to help patients find equipment they need, for a small handling fee.

Information about Palliative Care Consultation. Provides an outline of what a palliative care consultation addresses and gives an example of a palliative care case. (1-page Word doc)

Pain Management. Strategies for pain management Presented by Dr. Barry Baines, MD, chief medical officer, UCare. (60-minute audio file. 4/16/09) Handout (16-page PDF)

Palliative Care Symptom Management Guidelines. Example from LifeCare Medical Center, Roseau (4-page Word doc)

Pathway Comfort Care. Example from Lake Winona Manor (2-page Word doc)

Screening tool. Gives three methods to identify patients appropriate for palliative care. Example from  Fairview Health Services (1-page Word doc)

The Silent Scream of Delirium: Improving Prevention, Diagnosis, and Management in Palliative Care. This webinar is presented by Sandra Gordon-Kolb, MD, CPE, MMM, Medical Director, Palliative Care Services, UMMC – Fairview. (55-minute webinar)

Social Workers and Spiritual Providers. Presented by Dot Landis, clinical social worker, University of Minnesota Medical Center Palliative Care Program, and Paul Galchutt, chaplain, University of Minnesota Medical Center Palliative Care Program. (60-minute webinar. 1/25/11) Handout (8-page PDF)

Social work assessment. Use as part of the palliative care consult, covers levels of cognitive and emotional functioning, patient/family coping and communication skills, family support system, and psychosocial assessment. Example from Fairview Health Services (2-page Word doc)

Spiritual assessment. Includes six components of a spiritual care assessment for palliative care patients and examples of questions to begin a dialogue about the patient's spirituality. Example from Fairview Health Services (1-page Word doc)

Traveling Care Plan. The Granite Falls Community uses a three-ring binder traveling care plan for their high risk patients—those that have multiple diagnoses or with multiple readmissions. The patient and family are instructed to bring this binder with them when they visit their health care provider, transition to another care setting or need to return to the emergency department. (1-page Word doc)

We Honor Veterans. This project assists organizations caring for veterans at end of life to learn how to accompany and guide America's veterans and their families through their life stories toward a more peaceful ending. Sponsored by the National Hospice and Palliative Care Organization in collaboration with the Department of Veterans Affairs. See also Palliative Care Rural Initiative Dissemination Model and Implementation Guide.

Policies and guidelines

Palliative Care Guideline. This guideline will assist primary and specialty care providers in identifying and caring for adult patients with a potentially life-limiting, life-threatening or chronic, progressive illness who may benefit from palliative care. It outlines key considerations for creating a plan of care to meet patient, family and other caregivers' needs throughout the continuum of care. Institute for Clinical Systems Improvement (ICSI)

Rural Palliative Care Networking GroupEducational session: ICSI Palliative Care Guidelines. This interactive session discussed the use the Palliative Care Guideline as a tool in providing palliative care services to patients with a serious illness, described the six domains of palliative care as annotated in the guideline, and discussed the importance of early identification and assessment of patients who would benefit from palliative care. Presented by Linda Setterlund, Clinical Systems Improvement Facilitator, Institute for Clinical Systems Improvement. See the Palliative Care Guideline to follow along. (Recorded November 30, 2011) (61-minute podcast)

Directions for Use of Symptom Management Guidelines. Example from LifeCare Medical Center, Roseau (5-page Word doc)

Guidelines for Using Symptom Assessment Scale. Example from LifeCare Medical Center, Roseau (1-page Word doc)


H.O.P.E Spiritual Assessment. Example from Lakewood Health System, Staples (1-page Word doc)

Palliative Care Score for Patients/Residents with Instructions. Example from Lakewood Health System, Staples (1-page Word doc)

Palliative Care Screen Tool. Example from Winona Health (2-page Word doc)

Patient Family Care Conference Record. Example from LifeCare Medical Center, Roseau (2-page Word doc)

Patient Family Informed Consent. Example from Lakewood Health System, Staples (1-page Word doc)

Symptom Assessment Scale. Example from LifeCare Medical Center, Roseau (3-page Word doc)

Sample order sets

Order Set - draft. Example from Ridgeview Medical Center, Waconia (4-page Word doc)

Palliative Care End of Life Order Set. Comfort Measures/Symptom Relief. Example from Rice Memorial Hospital, Willmar (2-page PDF)

Palliative Care Order Set. Sample palliative care order set. Example from Fairview Health Services (3-page PDF)

Palliative Care Order Set. Sample palliative care order set provided by the Institute for Clinical Systems Improvement (49-page PDF)

Palliative Care Standing Orders. Example from Lakewood Health System, Staples (4-page Word doc)

Advanced care planning

Provider Orders for Life-Sustaining Treatment (POLST). Presented by Ed Ratner, MD, internist and geriatrician, associate professor of medicine, University of Minnesota, and geriatrician, Minneapolis Veterans Administration Medical Center. (60-minute webinar)

Advanced Care Planning Using the Honoring Choices Minnesota Model. Presented by Katie Snow, Honoring Choices Minnesota, Jessica Hinkley, Fairview Red Wing Health Services, and Trudi Paulson, Partners in Aging Program, Fairview Red Wing Health Services. (60-minute webinar, 4/5/11)

National Healthcare Decisions Day. This annual grassroots effort promotes advance care planning and health care decision making. All Americans are encouraged to voice their wishes and take steps to ensure that their choices are known and protected. April 16 is the day marked for awareness raising and call to action

Health Care Directive Form. This form is completed as part of an advance care planning discussion. It helps people examine and document their values, beliefs, and desires to assist them in making the choices that are right for them at end of life and to ensure those choices are documented. Developed by Honoring Choices Minnesota, a metro-wide community approach to fostering increased use of advance care planning.

POLST Form - Minnesota. The Provider Orders for Life Sustaining Treatment (POLST) Form is a signed medical order form that communicates the patient's end-of-life health care wishes to other health care providers during an emergency. (2-page PDF)

Sample advance advance care planning tool

Advanced Care Planning Tools. Allina Web page