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 illnesses. Standards require timely assessment, proactive symptom management, interdisciplinary communication, and ongoing monitoring as conditions evolve.
This checklist helps attorneys evaluate whether palliative care teams met clinical expectations, responded appropriately to symptoms, and aligned care with the patient’s goals.
Use this tool during breach analysis, deposition preparation, and timeline reconstruction.
INITIAL PALLIATIVE CARE ASSESSMENT
✔ Comprehensive Assessment Must Include
• Pain level and characteristics
• Respiratory status
• Mental status and cognition
• Emotional and psychological needs
• Spiritual or cultural considerations
• Functional status
• Hydration and nutrition
• Skin integrity
• Medication review
• Goals of care discussion
✔ Required Documentation
• Baseline symptom profile
• Patient/family goals
• Advance directives
• POLST/MOST forms (if applicable)
Red Flags
• No documented goals of care
• Missing baseline symptom assessment
• No medication reconciliation
PAIN ASSESSMENT & MANAGEMENT
✔ Pain Assessment Requirements
• Numeric or behavioral pain scale
• Location, duration, quality
• Triggers and relieving factors
• Impact on function
✔ Pain Management Standards
• Timely administration of analgesics
• Safe titration of opioids
• Non‑pharmacologic interventions
• Reassessment after medication
✔ Required Monitoring
• Pain relief effectiveness
• Sedation level
• Respiratory status
• Side effect
Red Flags
• Uncontrolled pain
• No reassessment after opioids
• Delayed titration
RESPIRATORY DISTRESS ASSESSMENT
✔ Required Assessment
• Respiratory rate
• Work of breathing
• Oxygen saturation
• Anxiety or air hunger
• Cough, secretions
✔ Required Interventions
• Opioids for dyspnea
• Oxygen (if comfort‑focused)
• Positioning
• Secretion management
✔ Required Monitoring
• Response to interventions
• Increased distress
• Need for medication adjustment
Red Flags
• Dyspnea not addressed
• No reassessment after interventions
AGITATION, ANXIETY & TERMINAL RESTLESSNESS
✔ Required Assessment
• Triggers
• Pain contribution
• Medication side effects
• Delirium indicators
• Environmental factors
✔ Required Interventions
• Comfort‑focused medications
• Environmental modifications
• Family support
• Reorientation (if appropriate)
✔ Required Monitoring
• Effectiveness of interventions
• Sedation level
• Safety
Red Flags
• Unmanaged agitation
• No medication adjustment despite worsening symptoms
HYDRATION & NUTRITION MONITORING
✔ Required Assessment
• Oral intake
• Signs of dehydration
• Nausea/vomiting
• Swallowing ability
• Weight trends (if relevant)
✔ Required Interventions
• Comfort‑focused hydration strategies
• Anti‑nausea medications
• Mouth care
• Family education
Red Flags
• No assessment of hydration status
• Family not informed about expected changes
MENTAL STATUS & COGNITION
✔ Required Assessment
• Orientation
• Level of consciousness
• Delirium indicators
• Emotional distress
✔ Required Monitoring
• Changes in cognition
• Medication effects
• Safety risks
Red Flags
• Sudden confusion not addressed
• No evaluation for reversible causes
INTERDISCIPLINARY TEAM (IDT) COORDINATION
✔ Required IDT Involvement
• Nursing
• Palliative physician
• Social work
• Chaplaincy
• Aides
• Volunteers (if applicable)
✔ Required Communication
• Symptom changes
• Medication adjustments
• Family concerns
• Care plan updates
Red Flags
• No IDT documentation
• Care plan not updated despite changes
VISIT FREQUENCY & MONITORING
✔ Visit Frequency Must Increase When:
• Symptoms worsen
• Patient enters active decline
• Family requests support
• New medications are started
✔ Required Monitoring
• Symptom reassessment
• Medication effectiveness
• Comfort level
• Emotional needs
Red Flags
• Infrequent visits during active dying
• No reassessment after major changes
COMMON BREACH THEMES IN PALLIATIVE CARE
• Uncontrolled pain or dyspnea
• Delayed symptom management
• Poor communication with family
• Inadequate monitoring
• Medication errors or unsafe titration
• Failure to align care with goals
• Documentation gaps
• Insufficient visit frequency
These are the strongest breach indicators in palliative care litigation.