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Transitional Care Planning (PDQ®)

Health Professional Version
Last Modified: 04/09/2014

Biopsychosocial Intervention and/or Options

  1. Places for care:
    • Institutional:
      • Hospital.
      • Rehabilitation unit.
      • Long-term acute care.
      • Skilled nursing facility.
      • Inpatient hospice unit.[1,2]

    • Residential:

  2. Possible team members for delivery of care:
    • Nurse, advance practice nurse (nurse practitioner, clinical nurse specialist, oncology, hospice, home care, rehabilitative, palliative care, radiation therapy).

    • Physician (oncologist, hospice, palliative care, primary care provider, general practitioner, internist, physiatrist [physician who specializes in physical medicine and rehabilitation]).

    • Dietitian.

    • Physical therapist.

    • Occupational therapist.

    • Medical social worker: assessment and referral for concrete services.[4][Level of evidence: II]

    • Mental health professional: psychiatric nurse, psychiatric social worker, psychologist, and psychiatrist.

    • Family minister, chaplain, priest, rabbi, or other clergy.

    • Companion.

    • Nursing assistants (may possibly be obtained through sectarian or nonsectarian family agencies for a minimal fee or free of charge, or may be obtained through proprietary home care agencies at patient and/or family expense).

  3. Programs offering a range of skills for delivery of care:
    • Home health agencies.
    • Hospice programs.
    • Palliative care (consultation) programs.
    • Community psychosocial support programs.
    • Home infusion agencies.
    • Bereavement programs.[5]

  4. Legal and/or advanced directives:
    • Physician.
    • Hospital social worker.
    • Family attorney.
    • Legal Aid Society.
    • Law school clinics.
    • Maintenance of written documentation regarding patient’s wishes.

  5. Pharmaceutical support:
    • Pain and symptom management (e.g., opioids, anxiolytics, antidepressants, antiemetics, and appetite stimulants).[2,6];[7][Level of evidence: II][8][Level of evidence: III] (Refer to the PDQ summary on Pain for more information.)

    • Chemotherapy.

    • Transfusions (blood products).

    • Antibiotics.

    • Growth factors.

    • Nutrition (enteral and total parenteral). (Refer to the PDQ summary on Nutrition in Cancer Care for more information.)

    • Respiratory therapy.

    • Wound and skin preparations.

  6. Nutrition:
    • Standard oral.

    • Supplemental:
      • Oral.
      • Enteral nutrition by nasogastric feeding, gastrointestinal, gastrojejunostomy, or percutaneous endoscopic gastrostomy tubes.
      • Parenteral nutrition (PN), central or peripheral.[9]

    • None (as an option).

    • Evaluation of nutritional status and home education.

    (Refer to the PDQ summary on Nutrition in Cancer Care for more information.)

  7. Special devices:
    • Ostomies/drainage devices:
      • Gastrostomy.
      • Colostomy.
      • Ileostomy.
      • Tracheostomy.
      • Pleural fluid drains (e.g., chest tube and Denver catheter).
      • Biliary drainage tube.
      • Abscess drainage devices.
      • Percutaneous nephrostomy tube.
      • Paracentesis draining devices.

    • Assistive devices:
      • Hospital bed.
      • Commode chair.
      • Wheelchair.
      • Wheelchair cushions.
      • Scooter.
      • Walker.
      • Cane.
      • Crutches.
      • Braces.
      • Prostheses.
      • Handheld shower.
      • Shower/tub chair.
      • Orthoses.
      • Specialized mattress or overlay.
      • Overbed trapeze.
      • Mechanical lifts.

    • Catheters:
      • Central venous access catheter.
      • Peripheral catheter (e.g., peripherally inserted central catheter).
      • Dialysis catheter.
      • Urinary catheter: condom catheter, indwelling catheter (Foley or suprapubic).
      • Epidural or intrathecal catheter.

    • Venous pumps (permanent or temporary):
      • Chemotherapy.
      • Opioids (subcutaneous infusions for opioids).
      • Pain medication. (Refer to the PDQ summary on Pain for more information.)

    • Suction equipment:
      • Nasogastric and endotracheal suctioning devices.
      • Yankur suction tube.

    • Respiratory:
      • Oxygen (portable, stationary).
      • Assisted ventilation (portable respirator, continuous positive airway pressure, bi-level positive airway pressure, Vapotherm humidification system).
      • Respiratory treatments (chest physiotherapy, intermittent positive pressure breathing inhalers, or nebulizer treatments).

  1. Plumb JD, Ogle KS: Hospice care. Prim Care 19 (4): 807-20, 1992.  [PUBMED Abstract]

  2. Ramsay A: Care of cancer patients in a home-based hospice program: a comparison of oncologists and primary care physicians. J Fam Pract 34 (2): 170-4, 1992.  [PUBMED Abstract]

  3. Jordhøy MS, Saltvedt I, Fayers P, et al.: Which cancer patients die in nursing homes? Quality of life, medical and sociodemographic characteristics. Palliat Med 17 (5): 433-44, 2003.  [PUBMED Abstract]

  4. Jones RV, Hansford J, Fiske J: Death from cancer at home: the carers' perspective. BMJ 306 (6872): 249-51, 1993.  [PUBMED Abstract]

  5. Whittam EH: Terminal care of the dying child. Psychosocial implications of care. Cancer 71 (10 Suppl): 3450-62, 1993.  [PUBMED Abstract]

  6. Wotring RA: Cancer pain management. Home Healthc Nurse 11 (5): 40-4, 1993 Sep-Oct.  [PUBMED Abstract]

  7. Herbst LH, Strause LG: Transdermal fentanyl use in hospice home-care patients with chronic cancer pain. J Pain Symptom Manage 7 (3 Suppl): S54-7, 1992.  [PUBMED Abstract]

  8. McCormack A, Hunter-Smith D, Piotrowski ZH, et al.: Analgesic use in home hospice cancer patients. J Fam Pract 34 (2): 160-4, 1992.  [PUBMED Abstract]

  9. Howard L: Home parenteral and enteral nutrition in cancer patients. Cancer 72 (11 Suppl): 3531-41, 1993.  [PUBMED Abstract]