Palliative Care Assessment &
Monitoring Checklist
A structured checklist for evaluating pain, respiratory distress, agitation, hydration, and comfort‑focused interventions in palliative care settings.
Palliative Care Assessment & Monitoring Checklist
A structured checklist for evaluating pain, respiratory distress, agitation, hydration, and comfort-focused interventions in palliative care settings.
Palliative care focuses on symptom relief, comfort, and quality of life for patients with serious or life-limiting illness. Standards require timely assessment, proactive symptom management, interdisciplinary communication, and ongoing monitoring as conditions evolve.
This tool helps attorneys evaluate whether palliative care teams met clinical expectations, responded appropriately to symptom escalation, and aligned care with the patient’s goals. Use during breach analysis, deposition preparation, and timeline reconstruction.
Initial Palliative Care Assessment
✔ Comprehensive Assessment Must Include
Pain: level, location, quality, pattern, and response history.
Respiratory: dyspnea/air hunger, O2 needs, work of breathing, secretion burden.
Mental Status: cognition, delirium indicators, distress, safety risks.
Psychological: anxiety, fear, coping, caregiver strain indicators.
Spiritual/Cultural: preferences impacting comfort care decisions.
Functional Status: mobility, ADLs, fall risk, fatigue, weakness trajectory.
Hydration/Nutrition: intake, nausea/vomiting, swallowing ability.
Skin Integrity: pressure risk, wounds, device-related skin concerns.
Medication Review: reconciliation, high-risk meds, interactions, symptom drivers.
Goals of Care: patient values, acceptable tradeoffs, symptom priorities.
✔ Required Documentation
Baseline Symptom Profile: pain/dyspnea/agitation scores and narrative descriptors.
Patient/Family Goals: documented priorities and decision-maker identification.
Advance Directives: code status, surrogate decision-maker, limitations of treatment.
POLST/MOST (if applicable): presence, accuracy, and consistency with stated goals.
Red Flags
Goals of CareNo documented goals-of-care discussion or unclear decision-maker identification.
Baseline MissingMissing baseline symptom assessment (no pain/dyspnea/agitation profile).
Medication SafetyNo medication reconciliation or inconsistent med list across records.
Litigation linkage: Initial palliative failures typically create downstream exposure — unmanaged symptoms, misaligned care intensity, and documentation gaps that destabilize the narrative under scrutiny.
Pain Assessment & Management
✔ Pain Assessment Requirements
Scale: numeric, faces, or behavioral pain scale (nonverbal patients).
Characterization: location, duration, quality, and severity pattern.
Modifiers: triggers and relieving factors (movement, care tasks, meds).
Function Impact: sleep disruption, mobility limitation, appetite decline, distress.
✔ Pain Management Standards
Timely Analgesia: administration aligned with severity and stated goals.
Opioid Titration: safe escalation with monitoring and documented rationale.
Non-Pharm: positioning, heat/cold if appropriate, calming techniques, massage, quiet environment.
Reassessment: documented follow-up after medication to confirm effect and next steps.
✔ Required Monitoring
Effectiveness: measurable relief and durability of response over time.
Sedation: level of consciousness changes and oversedation risk.
Respiratory: RR, work of breathing, O2 impact when opioids adjusted.
Side Effects: constipation prevention, nausea, delirium, hypotension.
Red Flags
Control FailureUncontrolled pain documented repeatedly without escalation or plan change.
No ReassessmentNo reassessment after opioids or PRNs (no documented effect).
Titration DelayDelayed titration despite persistent severe pain.
Litigation linkage: Pain cases often hinge on whether repeated complaints were treated as clinical triggers and whether reassessment documentation demonstrates responsible management.
Respiratory Distress Assessment
✔ Required Assessment
Objective: RR, O2 saturation (if used), work of breathing, accessory muscle use.
Subjective: anxiety/air hunger, distress cues, inability to speak in full sentences.
Contributors: cough, secretions, aspiration risk, fluid overload signs.
Trajectory: trend compared to baseline (worsening vs stable).
✔ Required Interventions
Dyspnea Opioids: opioids used appropriately for comfort-focused breathlessness.
Oxygen: if comfort-focused and consistent with goals of care.
Positioning: upright posture, fan/airflow, pacing, calm environment.
Secretions: anticholinergics, suctioning protocol if appropriate, mouth care.
✔ Required Monitoring
Response: documented effect of interventions and symptom relief.
Escalation: trigger recognition for med adjustment or higher-level support.
Distress Trend: signs of increased distress or new respiratory instability.
Red Flags
Non-ResponseDyspnea documented without comfort-focused intervention or escalation.
No ReassessmentNo reassessment after interventions (no effect documented).
Litigation linkage: Respiratory distress claims often center on preventable suffering — delays, under-treatment, and failure to adjust when symptoms escalate.
Agitation, Anxiety & Terminal Restlessness
✔ Required Assessment
Triggers: pain, dyspnea, urinary retention, constipation, noise/light, unmet needs.
Pain Contribution: agitation as pain expression in nonverbal patients.
Meds: side effects, withdrawal, paradoxical reactions.
Delirium: indicators, fluctuating awareness, hallucinations, sleep-wake reversal.
✔ Required Interventions
Comfort Meds: anxiolytics/antipsychotics as appropriate, aligned with goals.
Environment: reduce stimuli, calm setting, consistent caregiver presence when possible.
Family Support: coaching, reassurance, education about expected changes.
Reorientation: only if appropriate and not distressing; prioritize comfort.
✔ Required Monitoring
Effectiveness: symptom improvement after interventions.
Sedation: oversedation risk and functional impact.
Safety: fall risk, line/tube pulling, injury risk to patient/caregivers.
Red Flags
Unmanaged SymptomsPersistent or escalating agitation without adjustment or reassessment.
No AdjustmentNo medication adjustment despite worsening restlessness or distress.
Litigation linkage: The breach theme is typically failure to investigate drivers (pain, retention, constipation) and failure to adjust the comfort plan as escalation occurs.
Hydration & Nutrition Monitoring
✔ Required Assessment
Oral Intake: trends, tolerance, and barriers (fatigue, dysphagia, nausea).
Dehydration Signs: dry mouth, dizziness, reduced urine, lethargy (goal-aligned interpretation).
GI Symptoms: nausea/vomiting, constipation, aspiration risk.
Swallowing: ability, coughing/choking, need for texture changes.
✔ Required Interventions
Comfort Hydration: sips/ice chips, preferred fluids, assisted intake as tolerated.
Antiemetics: medications when nausea limits comfort.
Mouth Care: scheduled oral care for comfort regardless of intake.
Family Education: expected end-of-life intake changes and comfort-focused approach.
Red Flags
No AssessmentNo documented hydration status assessment or oral care plan.
Family CommunicationFamily not informed about expected intake decline and comfort goals.
Litigation linkage: The risk is often framed as “neglect.” Clear documentation of comfort-focused rationale and family education is a major defensibility anchor.
Mental Status & Cognition
✔ Required Assessment
Orientation: baseline vs current; ability to communicate needs.
Consciousness: arousal level and responsiveness trend.
Delirium: acute confusion indicators; fluctuating course; triggers.
Emotional Distress: fear, panic, grief response, caregiver impact.
✔ Required Monitoring
Trend Monitoring: changes in cognition and safety risks over time.
Medication Effects: sedation, paradoxical agitation, delirium contributors.
Reversible Causes: constipation, retention, infection, med toxicity when appropriate.
Red Flags
Unaddressed ChangeSudden confusion not assessed, trended, or escalated.
No EvaluationNo consideration/documentation of reversible contributors when clinically appropriate.
Interdisciplinary Team (IDT) Coordination
✔ Required IDT Involvement
Nursing: symptom assessment, medication response, escalation.
Palliative Physician/APP: prescribing, titration, goals alignment.
Social Work: family dynamics, resources, caregiver strain.
Chaplaincy: spiritual distress, cultural considerations.
Aides: daily comfort care, hygiene, skin monitoring observations.
Volunteers (if applicable): companionship, respite support (within scope).
✔ Required Communication
Symptom changes and escalation events.
Medication adjustments and response documentation.
Family concerns and education updates.
Care plan updates reflecting evolving condition.
Red Flags
IDT EvidenceNo IDT documentation or missing communication trail across disciplines.
Plan StagnationCare plan not updated despite clear clinical changes.
Visit Frequency & Ongoing Monitoring
✔ Visit Frequency Must Increase When
Symptoms worsen (pain, dyspnea, agitation).
Patient enters active decline or active dying phase.
Family requests increased support or reports crisis symptoms.
New medications are started or titrated.
✔ Required Monitoring
Symptom reassessment with documented trend comparison.
Medication effectiveness and side effects after changes.
Comfort level and distress cues (including nonverbal indicators).
Emotional needs and caregiver strain indicators.
Red Flags
Under-VisitingInfrequent visits during active dying or clear symptom escalation.
No ReassessmentNo reassessment after major changes, new meds, or escalating symptoms.
Common Breach Themes in Palliative Care
These themes are the strongest breach indicators in palliative care litigation and are most likely to appear in deposition testimony and documentation inconsistencies.
Uncontrolled pain or dyspnea
Delayed symptom management
Poor communication with family
Inadequate monitoring and reassessment
Medication errors or unsafe titration
Failure to align care with goals
Documentation gaps
Insufficient visit frequency during decline
Palliative Care Assessment & Monitoring Clarifies Symptom Control, Reassessment, and Oversight
Palliative care cases often hinge on whether symptoms were accurately assessed, reassessed at appropriate intervals, and addressed in alignment with patient goals and interdisciplinary care plans. The Palliative Care Assessment & Monitoring Checklist evaluates initial and ongoing symptom assessment, response to changes in condition, medication effectiveness, interdisciplinary communication, and documentation against accepted palliative care standards and regulatory expectations. Our clinical-legal team identifies missed assessments, delayed reassessments, inadequate monitoring, and documentation gaps that create regulatory exposure and liability risk.
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