Initial Palliative Care / Quality of Life Consultation form

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Select an option, TH, RIs, PLC, AC Service Only, Unsure

History

Physical Exam

Problem List

Assessment

Plan

Client Care Team or Palliative Care Nurse next steps:
<ul>
 <li>The palliative care nurses were instructed to send the following information sheets to the caregiver/s:
 <ul>
 <li>I.e. Canine Myxomatous Mitral Valve Disease</li>
 </ul>
 </li>

<li>The palliative care nurses were instructed on the following next steps:
 <ul>
 <li>I.e. Humane euthanasia was recommended within the following 7 days</li>
 </ul>
 </li>
</ul>

Psychosocial Plan and Caregiver Exercises:
<ul>

<li>Caregivers were provided with self-directed tasks to support decision-making and care planning. Where multiple caregivers are involved, each was encouraged to complete the activities independently over several days, then reconvene to discuss outcomes and work toward shared agreement.</li>

<li>Caregivers were advised to review the Comfort Care Pack prior to commencing the activities.</li>

<li>Caregivers were asked to clarify and document their individual goals, priorities, and boundaries relating to palliation and end-of-life care for their pet, and to place these where they can be regularly reviewed (e.g., visible household location or shared digital note). Integration of quality-of-life and pain considerations within these goals was encouraged. A priority list for emergency situations was discussed. If death is considered imminent, caregivers were encouraged to shift focus to a “bucket list” framework.</li>

<li>Caregivers were encouraged to commence daily quality-of-life scoring and record trends over time. They were also asked to identify 3–5 behaviours, habits, or characteristics that represent their pet’s emotional and social wellbeing, and to monitor whether these are consistently maintained. It was discussed that if fundamental welfare needs cannot be met (e.g., ability to urinate, adequate nutrition, pain control), humane euthanasia is likely indicated.</li>

<li>Caregivers were advised to begin incorporating the BEAP chronic pain scale into daily monitoring and to document the highest pain score each day. They were instructed to contact the Client Care Team if scores are consistently >5/10, as the patient will require in-person veterinary review for analgesia adjustment and/or consideration of humane euthanasia.</li>

<li>Caregivers were encouraged to begin open discussion regarding what a humane euthanasia appointment may look like for their family, to assist with emotional preparedness and reduce anticipatory anxiety.</li>

<li>Caregivers were advised to develop an emergency after-hours plan for humane euthanasia, including identifying where the patient will be taken if urgent care is required outside routine service hours.</li>

</ul>

Treatment

Updated Plan

Client Communication

<ul>
 <li>The limitations of telehealth consultations and of mobile veterinary services were discussed with the caregivers.</li>

<li>The patient’s condition was discussed based on information provided via telehealth consultation, intake documentation, and/or previous medical records. Caregivers acknowledged that, without a physical examination and/or diagnostics, clinical interpretation may be incomplete or inaccurate.</li>

<li>The likely disease trajectory was discussed, based on the assumption that the available information was accurate.</li>

<li>Caregivers’ goals, priorities, and concerns regarding palliation and end-of-life care were explored.</li>

<li>Caregivers were advised to contact the Rest Your Paws Client Care Team should they feel the patient requires an in-person quality-of-life assessment, palliative care consultation, or humane euthanasia appointment.</li>

<li>It was explained that if caregivers would like the Rest Your Paws team to assume ongoing care, a full in-person initial palliative care consultation will be required before specific medication or treatment advice can be provided.</li>
</ul>

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Home, Bev & Turned Euth

History

Physical Exam

Assessment

Treatment

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QoLs & PC

History

Physical Exam

<ul>
<li>Body weight is (approximately) __kgs, Body condition score: __/5</li>

<li>Muscle condition score is (normal./mildly decreased./moderately decreased./severely decreased.)</li>

<li>Demeanour is (bright, alert, responsive./quiet, alert, responsive./obtunded./stuporous./comatosed.)</li>

<li>Gait is (ambulatory and normal./ambulatory but weak./ambulatory but ataxic./ambulatory but lame __./non-ambulatory ___.)</li>

<li>Cursory musculoskeletal examination revealed (no significant findings./pain on palpation of the ____./and a reduced range of motion of the ____./a mass associated with ____./thickening of the ____./and crepitus associated with ____.)</li>

<li>Eyes are (unremarkable./unremarkable other than age related change./one eye (OD/OS) was enucleated./__.)</li>

<li>Ears are (unremarkable./unremarkable other than __./inflamed on the __./__.)</li>

<li>Nose is (clear, both nostrils were patent./abnormal, __.)</li>

<li>Thyroid (for cats)</li>

<li>Cervical assessment (is unremarkable./abnormal, __ i.e. pain on ventroflexion/dorsoflexion or to the left/right, cough elicited on tracheal palpation.)</li>

<li>Oral cavity is (unremarkable./unremarkable other than mild dental pathology, grade __/4 periodontal disease./abnormal, __.)</li>

<li>Integument is (unremarkable./abnormal, __.)</li>

<li>Peripheral lymph nodes (are within normal limits./are generally enlarged and non-painful./are normal except the ___ lymph nodes which are enlarged and non-painful./are generally enlarged and painful./are normal except the ___ lymph nodes which are enlarged and painful.)</li>

<li>Cardiovascular assessment
<ul>

<li>The mucous membranes are (pale,/pink,/injected,/cyanotic,/icteric,), (moist,/dry) and CRT is (<2 secs./prolonged at __ seconds./rapid at < 1 second.)</li>

<li>The heart rate is ___ bpm, with a (regular/regularly irregular/irregularly irregular) rhythm.</li>

<li>A heart murmur is (not present./auscultated as grade ___ of VI, _____.)</li>

<li>Femoral pulses are (strong and synchronous./weak and synchronous./strong but asynchronous ___./weak and asynchronous __./not present). There (is not a pulse deficit/is a pulse deficit of __).</li>

</ul>
</li>

<li>The respiratory rate is ___ bpm. Breathing effort (is normal./normal, yet panting was noted./is abnormal with inspiratory dyspnoea, __./is abnormal with expiratory dyspnoea, __./is abnormal with a restrictive breathing pattern, __.)</li>

<li>The upper airway is (unremarkable./stridorous./stertorous./unremarkable for a brachycephalic breed.)</li>

<li>Lung sounds are (unremarkable./abnormal, ___.)</li>

<li>Abdominal assessment 
<ul>

<li>Abdominal palpation is (unremarkable and non-painful./revealed ____.)</li>

<li>Gastrointestinal sounds (were not assessed./are present./are reduced ___./are absent ___.)</li>

</ul>
</li>

<li>Urogenital examination (was not assessed./is unremarkable./is unremarkable, testes palpated normally./is unremarkable, the uterus is not palpable. The last season was ___ ago./abnormal, __.)</li>

<li>Rectal examination (including anal sacs) (was not assessed./is normal./is abnormal, __.)</li>

<li>The prostate is (not palpated./not palpable./small and symmetrical./small but asymmetrical __./enlarged and symmetrical ___./enlarged and asymmetrical ___.)</li>

<li>Rectal temperature (was not assessed./is normal./is normal at ___ °C./is increased at ___ °C./is decreased at ___ °C.)</li>

</ul>

Problem List

Assessment

Procedure

Treatment

Plan

Client Care Team or Palliative Care Nurse Plan:
<ul>
<li>The palliative care nurses were instructed to send the following information sheets to the caregiver/s:
 <ul>
 <li>I.e. Canine Myxomatous Mitral Valve Disease</li>
 </ul>
</li>

<li>The palliative care nurses were instructed on the following next steps:
 <ul>
 <li>I.e. Humane euthanasia was recommended within the following 7 days</li>
 </ul>
</li>
</ul>

Psychosocial Plan and Caregiver Exercises:
<ul>

<li>Caregivers were provided with self-directed tasks to support decision-making and care planning. Where multiple caregivers are involved, each was encouraged to complete the activities independently over several days, then reconvene to discuss outcomes and work toward shared agreement.</li>

<li>Caregivers were advised to review the Comfort Care Pack prior to commencing the activities.</li>

<li>Caregivers were asked to clarify and document their individual goals, priorities, and boundaries relating to palliation and end-of-life care for their pet, and to place these where they can be regularly reviewed (e.g., visible household location or shared digital note). Integration of quality-of-life and pain considerations within these goals was encouraged. A priority list for emergency situations was discussed. If death is considered imminent, caregivers were encouraged to shift focus to a “bucket list” framework.</li>

<li>Caregivers were encouraged to commence daily quality-of-life scoring and record trends over time. They were also asked to identify 3–5 behaviours, habits, or characteristics that represent their pet’s emotional and social wellbeing, and to monitor whether these are consistently maintained. It was discussed that if fundamental welfare needs cannot be met (e.g., ability to urinate, adequate nutrition, pain control), humane euthanasia is likely indicated.</li>

<li>Caregivers were advised to begin incorporating the BEAP chronic pain scale into daily monitoring and to document the highest pain score each day. They were instructed to contact the Client Care Team if scores are consistently >5/10, as the patient will require in-person veterinary review for analgesia adjustment and/or consideration of humane euthanasia.</li>

<li>Caregivers were encouraged to begin open discussion regarding what a humane euthanasia appointment may look like for their family, to assist with emotional preparedness and reduce anticipatory anxiety.</li>

<li>Caregivers were advised to develop an emergency after-hours plan for humane euthanasia, including identifying where the patient will be taken if urgent care is required outside routine service hours.</li>

</ul>

Environmental and Lifestyle Plan:
<ul>
<li> </li>
</ul>

Diagnostic Plan:
<ul>
<li> </li>
</ul>

Future Medical Plan:
<ul>
<li> </li>
</ul>

Emergency Plan:
<ul>
<li> </li>
</ul>

Client Communication

<ul>
<li>The inherent limitations of a mobile veterinary service were explained to the caregivers. It was emphasised that, without access to a fully equipped veterinary facility, assessment and management may be limited.</li>

<li>The patient’s condition was discussed based on intake documentation, physical examination findings in the mobile setting, and/or previous medical records and diagnostic results. Caregivers acknowledged that, in the absence of full hospital-based diagnostics, clinical interpretation may be incomplete, and the information provided may be subject to uncertainty.</li>

<li>The likely disease trajectory was discussed based on the assumption that the information available was accurate. It was noted that the actual progression may differ.</li>

<li>Caregivers’ goals, priorities, and concerns regarding palliation and end-of-life care were explored and documented.</li>

<li>Potential side effects of all prescribed and dispensed medications were explained, including common, expected, and serious adverse effects.</li>

<li>Caregivers were instructed to contact the Rest Your Paws Client Care Team in the event of:
 <ul>
 <li>Need for repeat assessment or consultation</li>
 <li>Questions regarding the medical plan</li>
 <li>Occurrence of side effects or adverse reactions to medications</li>
 <li>Any observed clinical decline in the patient</li>
 <li>Desire for a telehealth recheck consultation</li>
 <li>Consideration or scheduling of humane euthanasia</li>
 </ul>
</li>

<li>The emergency plan for urgent care and after-hours considerations was reviewed with the caregivers.</li>

<li>Caregivers were informed that, despite best efforts, the provision of palliative care cannot guarantee patient outcomes or a peaceful death, and that ongoing assessment and clinical judgment will guide decisions regarding interventions, analgesia, and euthanasia.</li>

</ul>

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Recheck Consults

History

Physical Exam

<ul>

<li>Body weight is (approximately) __kgs, Body condition score: __/5</li>

<li>Muscle condition score is (normal./mildly decreased./moderately decreased./severely decreased.)</li>

<li>Demeanour is (bright, alert, responsive./quiet, alert, responsive./obtunded./stuporous./comatosed.)</li>

<li>Gait is (ambulatory and normal./ambulatory but weak./ambulatory but ataxic./ambulatory but lame __./non-ambulatory ___.)</li>

<li>Cursory musculoskeletal examination revealed (no significant findings./pain on palpation of the ____./and a reduced range of motion of the ____./a mass associated with ____./thickening of the ___./and crepitus associated with ___.)</li>

<li>Eyes are (unremarkable./unremarkable other than age related change./one eye (OD/OS) was enucleated./__.)</li>

<li>Ears are (unremarkable./unremarkable other than __./inflamed on the __./__.)</li>

<li>Nose is (clear, both nostrils were patent./abnormal, __.)</li>

<li>Thyroid (for cats)</li>

<li>Cervical assessment (is unremarkable./abnormal, __ i.e. pain on ventroflexion/dorsoflexion or to the left/right, cough elicited on tracheal palpation.)</li>

<li>Oral cavity is (unremarkable./unremarkable other than mild dental pathology, grade __/4 periodontal disease./abnormal, __.)</li>

<li>Integument is (unremarkable./abnormal, __.)</li>

<li>Peripheral lymph nodes (are within normal limits./are generally enlarged and non-painful./are normal except the ___ lymph nodes which are enlarged and non-painful./are generally enlarged and painful./are normal except the ___ lymph nodes, which are enlarged and painful.)</li>

<li>Cardiovascular assessment
 <ul>
 <li>The mucous membranes are (pale,/pink,/injected,/cyanotic,/icteric,), (moist,/dry) and CRT is (<2 secs./prolonged at __ seconds./rapid at < 1 second.)</li>

<li>The heart rate is ___ bpm, with a (regular/regularly irregular/irregularly irregular) rhythm.</li>

<li>A heart murmur is (not present./auscultated as grade ___ of VI, _____.)</li>

<li>Femoral pulses are (strong and synchronous./weak and synchronous./strong but asynchronous ___./weak and asynchronous __./not present). There (is not a pulse deficit/is a pulse deficit of __).</li>
 </ul>
</li>

<li>The respiratory rate is ___ bpm. Breathing effort (is normal./normal, yet panting was noted./is abnormal with inspiratory dyspnoea, __./is abnormal with expiratory dyspnoea, __./is abnormal with a restrictive breathing pattern, __.)</li>

<li>The upper airway is (unremarkable./stridorous./stertorous./unremarkable for a brachycephalic breed.)</li>

<li>Lung sounds are (unremarkable./abnormal, ___.)</li>

<li>Abdominal assessment
 <ul>
 <li>Abdominal palpation is (unremarkable and non-painful./revealed ____.)</li>
 <li>Gastrointestinal sounds (were not assessed./are present./are reduced ___./are absent ___.)</li>
 </ul>
</li>

<li>Urogenital examination (was not assessed./is unremarkable./is unremarkable, testes palpated normally./is unremarkable, the uterus is not palpable. The last season was ___ ago./abnormal, __.)</li>

<li>Rectal examination (including anal sacs) (was not assessed./is normal./is abnormal, __.)</li>

<li>The prostate is (not palpated./not palpable./small and symmetrical./small but asymmetrical __./enlarged and symmetrical ___./enlarged and asymmetrical ___.)</li>

<li>Rectal temperature (was not assessed./is normal./is normal at ___ °C./is increased at ___ °C./is decreased at ___ °C.)</li>

</ul>

Updated Problem List

Updated Assessment

Treatment

Updated Plan

Client Communication

<ul>
 <li>The inherent limitations of a mobile veterinary service were explained to the caregivers. It was emphasised that, without access to a fully equipped veterinary facility, assessment and management may be limited.</li>

<li>The patient’s condition was discussed based on intake documentation, physical examination findings in the mobile setting, and/or previous medical records and diagnostic results. Caregivers acknowledged that, in the absence of full hospital-based diagnostics, clinical interpretation may be incomplete, and the information provided may be subject to uncertainty.</li>

<li>Potential side effects of all prescribed and dispensed medications were explained, including common, expected, and serious adverse effects.</li>

<li>Caregivers were instructed to contact the Rest Your Paws Client Care Team in the event of:
 <ul>
 <li>Need for repeat assessment or consultation</li>
 <li>Questions regarding the medical plan</li>
 <li>Occurrence of side effects or adverse reactions to medications</li>
 <li>Any observed clinical decline in the patient</li>
 <li>Desire for a telehealth recheck consultation</li>
 <li>Consideration or scheduling of humane euthanasia</li>
 </ul>
 </li>

<li>The emergency plan for urgent care and after-hours considerations was reviewed with the caregivers.</li>

<li>Caregivers were informed that, despite best efforts, the provision of palliative care cannot guarantee patient outcomes or a peaceful death, and that ongoing assessment and clinical judgment will guide decisions regarding interventions, analgesia, and euthanasia.</li>

</ul>

Medications used for Sedation

Pre-Appointment Oral

Oral sedation given by vet at appointment*

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Dormosedan

(ml) of sedation given for Dormosedan 10mg/ml*

Route of Administration for Dormosedan 10mg/ml*

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Butorphanol

(ml) of sedation given for Butorphanol 10mg/ml*

Route of Administration for Butorphanol 10mg/ml*

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Ketamine

(ml) of sedation given for Ketamine 100mg/ml*

Route of Administration for Ketamine 100mg/ml*

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Zoletil

(ml) of sedation given for Zoletil 100mg/ml*

Route of Administration for Zoletil 100mg/ml*

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Acepromazine

(ml) of sedation given for Acepromazine 10mg/ml*

Route of Administration for Acepromazine 10mg/ml*

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Section Break

Other Oral Sedation*

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Section Break

Injectable sedation given by vet at appointment*

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Butorphanol

(ml) of sedation given for Butorphanol 10mg/ml*

Route of Administration for Butorphanol 10mg/ml*

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Acepromazine

(ml) of sedation given for Acepromazine 10mg/ml*

Route of Administration for Acepromazine 10mg/ml*

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Zoletil

(ml) of sedation given for Zoletil 100mg/ml*

Route of Administration for Zoletil 100mg/ml*

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Xylazine

(ml) of sedation given for Xylazine 100mg/ml*

Route of Administration for Xylazine 100mg/ml*

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Ketamine

(ml) of sedation given for Ketamine 100mg/ml*

Route of Administration for Ketamine 100mg/ml*

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Dormosedan

(ml) of sedation given for Dormosedan 10mg/ml*

Route of Administration for Dormosedan 10mg/ml*

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Midazolam

(ml) of sedation given for Midazolam 5mg/ml*

Route of Administration for Midazolam 5mg/ml*

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Alfaxan

(ml) of sedation given for Alfaxan 10mg/ml*

Route of Administration for Alfaxan 10mg/ml*

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Other Injectable Sedation Section

Other Injectable Sedation*

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Section Break

Were any other medications administered? Ignore this question if not applicable

How was Pentobarbitone administered?

(ml) of Pentobarbitone used?

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Section Break

Treatment

Medical Regimen

Rehabilitation or Physiotherapy Tx

Crisis Kit

Plan

Social Plan

Environmental / Enrichment

Diagnostic Plan

Medical Plan

Emergency / Crisis Plan

Initial Palliative Care / Quality of Life Consultation form

Owner Details

Pet's Details

Species isn't "Other"

Species is "Other"

Appointment Notes

Select an option, TH, RIs, PLC, AC Service Only, Unsure

Home, Bev & Turned Euth

QoLs & PC

Recheck Consults

Medications used for Sedation

Dormosedan

Butorphanol

Ketamine

Zoletil

Acepromazine

Section Break

Section Break

Butorphanol

Acepromazine

Zoletil

Xylazine

Ketamine

Dormosedan

Midazolam

Alfaxan

Other Injectable Sedation Section

Section Break

Section Break

Treatment

Plan

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