A Community of Exceptional Nurses
University of Medicine & Dentistry of New Jersey: SICU Palliative Care Assessment
A single page palliative care assessment form completed by a member of the Family
Support Team after interviewing the nurse, resident or attending physician, within
24 hours of the patience admittance to the Intensive Care Unit.
Clinical Care Tools - Clinical Assessment Tool
University of Medicine and Dentistry of New Jersey
150 Bergen Street
Newark, New Jersey 07103-4300
Anne Mosenthal, M.D.
How the grantee used this instrument:
The palliative care assessment form is to be filled out within 24 hours of admittance.
It evaluates the patient in the area of family involvement, pain assessment, and
symptom assessment by the nurse and the physician.
care plan, pain assessment, symptom management, health status, protocols, continuity
of care, advance directives
To use this tool:
You may print and copy for your own use from this site. Please credit the source.
Developed specifically for this project by the project team.
To view this tool:
Comprehensive SICU Plan > 1page PDF
(Viewing PDF files requires downloading and installation of the free
Adobe Acrobat Reader.)
Posted: July 2006
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Promoting Excellence in End-of-Life Care was a national program of the Robert Wood Johnson Foundation
dedicated to long-term changes in health care institutions to substantially improve
care for dying people and their families.
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