title: Whole-patient assessment, goal planning, and inflection points: their role in achieving quality end-of-life care.
abstract: This article provides a framework for performing whole-patient assessment and goal planning. These clinical tasks involve a multidisciplinary, multidimensional, patient-centered approach to care and a deep appreciation for the complex interplay between the physical, psychological, social, and spiritual aspects of the human experience of dying. This article stresses the iterative nature of whole-patient assessment and goal planning, both of which should be conducted at certain important junctures in a patient's progression to manage effectively the evolving challenges faced by terminally ill persons and their families. This article also provides suggestions on successfully managing the communication challenges in caring for patients near the end of life and their family.
authors.affiliation: Department of Internal Medicine, Kaiser Permanente, Mid Atlantic States, INOVA Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22046, USA. Christopher.dellasantina@kp.org
authors.forename: Christopher
authors.initials: C
authors.lastname: Della Santina
authors.forename: Richard H
authors.initials: RH
authors.lastname: Bernstein
mesh_terms: D032722:Advance Care Planning; D000368:Aged; D005190:Family; D015577:Geriatric Assessment; D006040:Goals; D006801:Humans; D010166:Palliative Care; D018802:Patient-Centered Care; D011788:Quality of Life; D013727:Terminal Care