It pays off to build your lifeboat before your ship is sinking. In the case of many illnesses, once in the end stage (for example memory disorders) or when facing an acute exacerbation (for example chronic obstructive pulmonary disease, brain tumour), it’s difficult for the patient to express their wishes. That’s why an advance care plan made ahead of time ensures that the patient gets the best possible treatment that takes their wishes into consideration. The plan includes an assessment of the kind of palliative care needed now and in the future. This creates a good basis for how to organise care.
Care planning in palliative care
In order to get your wishes heard and ensure the best possible treatment, it’s a good idea to plan ahead for the progression of illness and the end-of-life stage. In the case of a life-threatening or incurable illness, the plan should be made well in advance.
The contents of the care plan are unique to each individual, and depend on the patient and the illness. The plan should address physical, psychological, social, and existential needs.
The care plan includes
aims of treatment, in other words treatment intent
stage and likely progression of illness
the most severe symptoms and a plan for how to treat them
needs regarding existential, spiritual, and psychological support and a plan for how to respond to them
the patient’s wishes, concerns, and fears
living will, if one exists
family’s wishes, concerns, and needs for support
treatments refrained from at present or in the future (treatment limitations)
intended location for hospice care (for example home, inpatient ward, the nursing home where the patient lives)
preparations for hospice care (for example medication, persons responsible for care)
plan for how to act in the event of exacerbation leading to death.
The advance care plan is made as a collaborative process in a care meeting. The meeting involves the patient, the patient’s family or other people close to the patient (with the patient’s permission), the attending physician, and often the patient’s primary nurse or other members of the nursing staff.
Topics discussed in the care meeting include the progression and treatment of the illness as well as current and future care arrangements. The resulting care plan is recorded in the patient’s medical records, along with the contents of the discussion and the views and wishes of those involved. As a part of the care meeting, the patient can also make a living will in writing.
If needed, discussions regarding care continue throughout the progression of the illness, and the care plan is updated as the situation requires. The patient or their loved ones may also request a care meeting in order to make a care plan.
What’s in the care plan?
The contents of the care plan are unique to each individual, and depend on the patient and the illness. The plan should address physical, psychological, social, and existential needs.
The care plan includes
aims of treatment, in other words treatment intent
stage and likely progression of illness
the most severe symptoms and a plan for how to treat them
needs regarding existential, spiritual, and psychological support and a plan for how to respond to them
the patient’s wishes, concerns, and fears
living will, if one exists
family’s wishes, concerns, and needs for support
treatments refrained from at present or in the future (treatment limitations)
intended location for hospice care (for example home, inpatient ward, the nursing home where the patient lives)
preparations for hospice care (for example medication, persons responsible for care)
plan for how to act in the event of exacerbation leading to death.
How is the care plan made?
The advance care plan is made as a collaborative process in a care meeting. The meeting involves the patient, the patient’s family or other people close to the patient (with the patient’s permission), the attending physician, and often the patient’s primary nurse or other members of the nursing staff.
Topics discussed in the care meeting include the progression and treatment of the illness as well as current and future care arrangements. The resulting care plan is recorded in the patient’s medical records, along with the contents of the discussion and the views and wishes of those involved. As a part of the care meeting, the patient can also make a living will in writing.
If needed, discussions regarding care continue throughout the progression of the illness, and the care plan is updated as the situation requires. The patient or their loved ones may also request a care meeting in order to make a care plan.
Updated 27.3.2025