Assisting patients in creating a Quality-of-Life Care Plan

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Assisting patients in creating a Quality-of-Life Care Plan

< 1 minute read

The Cancer Center at Presbyterian Hospital initiated quality-of-life care planning to improve the patient care transition experience.

The Issue

Being informed of the “bad news” may be the most stressful period a patient experiences during the course of treatment for a life-threatening medical diagnosis. The fact that a patient has entered the end stage of their illness also is a difficult time for staff. The task of delivering difficult information is one of the most challenging responsibilities a doctor has to perform. Recognizing the limitation put on doctors by time constraints and lack of counseling training, physicians are increasing advocating for staff who are trained in transitioning patients from curative treatment modalities to quality-of-life care planning and lending supportive care counseling.


Location- Albuquerque, New Mexico.

Type- Acute care hospital.

Number of Beds- 453 beds.

Setting- Urban.

Payer Mix- A mix of Medicare, Medicaid, commercial insurance and Indian Health Service.

Population Served- A diverse population with multiple languages spoken including Spanish, Navaho and English.

The cancer center provides medical oncology, hematology, radiation therapy and high-risk cancer care services, offering a wide range of comprehensive rehabilitation and support care programs when active treatment is no longer effective. The cancer center provides transitional care with referrals to palliative or hospice care service teams.

What We Tried

In an effort to support our end-of-life care patients, the cancer center initiated quality-of-life care planning in 2011. From this initiative, we developed the Advanced Care Planning Readiness Assessment Tool. This tool sought to assess the patient and family’s readiness to transition from active treatment to palliative or hospice care. Additionally, the tool captured the need for emotional support and concrete services available to a dying patient and their family members.

The tool consisted of a three-part questionnaire: the National Comprehensive Cancer Network distress thermometer, the Quality of Life Navigator Intake form, and three advanced care planning readiness questions (See attachments below). The tool’s primary function was to capture the patient’s awareness of their end stage status, the needs of the family such as financial considerations, needs of school-aged children and overall support of loved ones. The instrument and the assessment process included the entire oncology staff. The staff consisted of physicians, nurses, social workers, dietitians and rehabilitation specialists. After the deployment of the tool, there was consultation with the entire patient care team to develop the end of life care plan.


Patients and families accepted advanced care planning, though difficult for most staff to implement. Care for the Caregiver was found to be beneficial for staff in assisting them in the separation and loss issues they experienced during their work with terminally ill patients. There were initial difficulties in developing smooth transition plans between oncology service and palliative care teams and hospice service. Most patients welcomed assistance with completing medical advanced directives.


Create positions for staff trained in end life care and quality-of-life navigation. Offer support to staff who work with end stage patients and family members.

Organizational Background

Organization Name: Presbyterian Hospital

Location: 1100 Central Ave SE, Albuquerque, NM 87106

Organization Type: Hospital

Organization Model: Not Set