Work Instruction for Management of Palliative Care

Date of Issue : --
Document No : MPC/HWC-SC/…../
16/10/2023--------
Effective Date: -
Version/Issue No: 01
21/10/2023--------

Work Instructions
on
PALLIATIVE CARE
at
ABHWC-HSCs

1
The signatures below certify that this procedure has been reviewed and approved, and
demonstrate that the Signatories are aware of all the requirements contained herein and are
committed to ensuring their provision.

Name Position Signature

Prepared By Ritu Baghel CHO

Approved By Dr Amrit lakra BMO

Amendment Note:

Page Context Revision Date

No

Note: Prior to use, ensure this document is the most recent issued
This procedure is reviewed to ensure its continuing relevance to the systems and process that
it describes. A record of contextual additions or omissions is given below:

2
Table of Contents

Palliative Care Services: Purpose and Scope..........................................................................................4

Service Delivery Framework (including Roles and Responsibilities)......................................................5
Activities to be undertaken...................................................................................................................8
Common Illness requiring Palliative Care............................................................................................12
Referral & Treatment Ensuring Continuum of Care at HWC-SHCs: -....................................................14
Medicine and Consumables: Home Care Kit........................................................................................15
ANNEXURES.........................................................................................................................................16

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Palliative Care Services: Purpose and Scope
Purpose: This work instruction manual will provide guidance on how to ensure services to
patients requiring primary level palliative care irrespective of whether the disease or
condition can be cured. Also, this will sensitise HWCs team and community level workers to
map, screen, sensitize, manage patients in need of palliative care through primary care
services at HWC SHCs and timely referred to higher level facilities in a systematic manner
and in turn will try to establish accountability of HCWs at community level

Scope: It applies to all the staffs who are involved in providing primary care services to the
patient requiring palliative care at the level of Health & Wellness Centre (HWC). Principally,
through the Health and Wellness Centre – Sub Health Centre Level, following palliative care
services will be provided as per the capacity of service providers:

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Service Delivery Framework (including Roles and Responsibilities)

Home-Based Palliative care Services: The Palliative Care team comprising of CHO, MPW,
ASHA and Volunteers should conduct Home-Based palliative Care Services to those in need
of ‘home-care’. Home Based care must be ably supported by a home visits by health care
professionals trained in palliative care and by linkages to day-care centres and or hospices to
manage situations that home visit to handle at home.
End-of-Life care Services: The Palliative Care team must be ready to provide ‘out-of-hours’
care to those experiencing the final days of their life (End-of-life-care). Each death has to be
duly reported to the HWC – PHC/UPHC through a sequence of reporting from ASHA to
CHO/MPW(F/M) to Medical Officer.
Drugs & Consumables: The Drugs and consumables such as catheters, air cushion, etc. will
be made available through the HWC-SHC.
Creating Patient Support Groups and Care givers Support Groups with community
volunteers. It is recommended that the group should be convened once in a month and the
meeting shall be presided by the CHO or the team led by CHO.
Health Promotion including the use of IEC for Behaviour Change Communication:
Collaborate with NGOs to act as technical advisory agencies for the process of community
awareness, mobilisation and empowerment in the field of palliative care programs.
These are few of the aspects of Palliative Care. To clear myths around Palliative Care,
remember following:
What palliative care is not What palliative care is not2
Needed from the time of the beginning of illness-
related
NOT restricted to end of life suffering, along with any disease-specific treatment.
NOT only for the end of life. All along the course of the disease
NOT only for cancer For any life-limiting illness
Provides realistic hope of achievable targets with
the treatment
of suffering, restoring dignity, and when the time
NOT the last option – when there is no comes, a
hope death as free of suffering as possible.
Filling life into remaining days, nurturing
NOT giving up relationships

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 The viable and humane alternative to euthanasia in
the vast
majority of instances. People demand euthanasia
because they
find their suffering to be unbearable. Through
palliative care,
we can significantly reduce the suffering and
thereby reduce
NOT euthanasia the number of people seeking to end their lives.
The scope of Palliative Care is better understood in light of this these myths and facts.
Service Delivery for Palliative Care will be broadly around the components described in the
figure below wherein, palliative care needs to be applied starting from the time of diagnosis
in chronic ailments like cancer. It is called as supportive care and needs to be incorporated
into disease specific treatment programmes. As the disease progresses and the curative
treatment decreases, the role of palliative care increases. At the end of life, palliative care will
be provided as terminal care extending as bereavement counselling and support for grieving
family after the patient’s death.

Service Delivery Framework for Palliative Care at HWC SHC level

Effective, timely & need based palliative care of elderly following activities will be ensured
through HWC-SHCs. Overall Service Delivery Framework at the level of HWCs can be
broadly divided into care at-
 Community Level
 SHC-HWC Level

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 Service Delivery framework of Palliative Care at HWC SHC level
Care at Community Level
Awareness generation and
community mobilization through
MPW, CHO & ASHAs
Create awareness about palliative
care, first level screening of
patient/families for potential
palliative care needs
Home visits to the patients and
provide psycho-social support to the
families/patient (ASHA, Community
volunteers)
Linkage with community platforms,
specific groups to raise awareness
about the needs of palliative care
patients and mobilize individual and
community level support
 Screening and Identification
Identification of bed ridden patients
and others needing palliative care
and refer to CHO.
Screening and Early Detection of the
identified individuals using
Palliative Care screening tool
Identification of community
volunteers.
Support family in identifying
behavioural changes and providing
care in elderly.
Identifying group of volunteers to be
trained in simple nursing skills.
Monthly report submission based on
the format of palliative care
services.
Care at SHC-HWC
Care and management through
Community Health Officer (CHO)
Support Home Based care
Provision of “Palliative care kit”
and ensuring
home based care for patients seeking
exclusive AYUSH treatment.
A list of hospices and trained
palliative care physicians in the
neighbourhood with their contact
details will be maintained and
shared with the community
Provision of services of Yoga trainer
and ICTC counsellor at the PHC-
HWC to enable supportive
supervision of the palliative care
team at the Sub Centre–HWC.
Providing “out of hours” care to
those experiencing the final days of
their life (End-of- life-care) and the
death is duly reported to the HWC –
PHC/ UPHC.
Provision of bereavement support
after the death of the patient.
Ensuring social support by availing
benefits from government and non-
governmental programs/schemes to
the eligible patients/ caregivers and
to be displayed at the HWC.
Creating Patient Support Groups
and Care givers Support Groups
with community volunteers and
ensuring to convene the meeting
once in a month presided by the
CHO.
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Activities to be undertaken
Detailed instructions related to activities under both the components:
Community/Individual/Family level:
 Identification: ASHAs will identify bed-ridden patients/individuals in need of palliative
care while mapping, population enumeration and empanelment process.
 Assessment: Then Multi-Purpose Worker (MPW)/Community Health Officer (CHO) will
visit the patients for a further assessment using the Palliative Care Screening Tool.
Assessment will be done using Annexure 1.
 Support: ASHAs and volunteers will undertake periodic home visits to the patients &
support the patient & family members.
 Assistance: Families will be assisted with routine home-based care, simple nursing skills
and accessing various services as needed including mobilization of local resources.
 Role of ASHA in palliative care:
o Create awareness and perform first level screening of patient/families for potential
palliative care needs.
o Identify & refer patients to the Community Health Officer (CHO), as required.
o Identify community volunteers for palliative care.
o Work with MPW to deliver basic patient management services.
o Provide general support to the families/patients.
o Escort the patient/family during initial visits to ensure better liaison between
beneficiary and service providers.
o ASHA will continue to visit the beneficiaries identified by her for Palliative care
services.
 Utilizing JAS/VHSNC/MAS: ASHA & MPW will utilize meetings of the Jan Arogya
Samiti/Village Health Nutrition and Sanitation Committee/Mahila Arogya Samiti
(VHSNC/MAS) to promote awareness about the needs of palliative care patients, and
mobilize individual and community level support, including accessing assistance
available through other government programmes.
 Community Health officer (CHO): He or She will undertake social & behaviour change
communication efforts in general community and specific groups (teachers, panchayat
members, NGOs, youth groups and women self-help groups) to recruit volunteers for
palliative care services in her/his HWC coverage area.
 Volunteer Groups:
o ASHA and MPW will identify a ‘group of volunteers’ in their service area.
Volunteers could be drawn from Youth Groups, Mahila Mandals, Co-operatives,
Non-Governmental Organizations, etc.
o CHO will train volunteers in social behaviour change communication.
o Willing volunteers shall also be trained in simple nursing skills.
o The list of trained volunteers to be displayed at prominent locations in the HWC
catchment area including the health facility, schools, anganwadis, ration shops,
panchayat office, etc. to enhance the credibility and pride in the volunteer.

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 Documentation: Format for the documentation of Palliative Care Services is provided
for ASHA at Annexure 2. She will submit the same at the Sub Centre as part of her
monthly report.
 Additional Support:
o MPW will also assess patients and undertake basic nursing tasks like dressing of
the foul-smelling wound, bladder catheter change, etc.
o Caregivers (family) will also be equipped to perform simple nursing tasks.
 ANM/MPW to refer those in need of more thorough assessment to the CHO.
 CHO to conduct home visit and assess the patient/family utilizing Annexure 3.

Health and Wellness Centre – Sub Centre Level:

 Home-Based Palliative care Services: Home-based palliative care is considered the
backbone of palliative care services. The Palliative Care team comprising of CHO, MPW,
ASHA and Volunteers will conduct Home-Based palliative Care Services to those in need
of ‘home-care’. Although the visit is need based, the team will follow a fixed schedule for
visits to different patients to assure continuum of care-
o As general rule, CHO will categorize patients into High, Middle and Low
priorities depending on their Palliative Care needs. The High priority patients are
visited once/ twice or more often every week. Middle priority patients are visited
once a fortnight. Low priority patients are visited once a month. These priorities
are changed as and when required.
o Higher priority for regular homebased care visits is given to patients based
on-
 Accessibility: Homecare priority is given to patients with limited
accessibility. The limited accessibility could be due to physical constraints,
financial constraints and geographic constraints.
 Unsettled problems: Patients with poor symptom control and end of life
symptoms will require frequent homecare visits.
 Patients who require procedures (like catheter change)
o Home Based care will be supported through a home visits by health care worker
trained in palliative care and by linkages to day-care centres and or hospices to
manage situations that are difficult to handle at home.
o The CHO will utilise the ‘palliative-care kit’ containing necessary drugs and
consumables. (Kit listed ahead in this module)
o Home-based care should also be provided to those patients seeking exclusive
AYUSH treatment. The CHO and ASHA Facilitator will do basic physiotherapy
to educate patients/caregivers.
o CHO will list hospices and trained palliative care physicians in the neighbourhood
and up to the district with all contact details. The same will be provided to the MO
and Kept at HWC-SHCs and when possible be made available to community.
o Services of the Yoga trainer shall be coopted through HWC-SHCs in ensuring
holistic care of the patient.
o Services of the ICTC counsellor at the PHC-HWC wherever available shall be
made available at regular intervals for supportive supervision of the palliative care
team at the Sub Centre – HWC and counselling of the patient and his/her family.
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  End-of-Life care: HWC team will provide ‘out-of-hours’ care to those in need of End-
of-life-care. Each death has to be duly reported to the MO. Team would also provide
Bereavement post death of the patient. VHSNC/JAS/MAS/RWA has a key role in
bereavement support
 Drugs and Consumables: CHO Must ensure that the Drugs & Consumables such as
catheters, air cushion, etc. are available at the HWC-SHC. The CHO will refer patients
with high pain score (pain score of 6 and above) to the PHC-HWC for pain management.
Note:

 Prescription and dispensing of Oral Morphine for pain management can only be done by a
Medical Officer trained in Pain and Palliative Care.
 Oral Morphine to be stocked and dispensed at the PHC-HWC as per The Narcotics Drugs and
Psychotropic Substances Rules.
 It will be backed by proper scrutiny and record keeping to ensure that the opioids are used
properly.

 Social support:
o VHSNC/JAS/MAS/RWA will ensure availability of benefits from various
governments and non-governmental programs/ schemes to the eligible patients/
caregivers.
o CHO will take the leadership in creating Patient Support Groups and Care givers.
Support Groups with community volunteers.
o The group should be convened once in a month and the meeting will be presided
by the CHO.

Although, HWC team’s broad responsibilities are provided above. Their specific roles
responsibilities of community level health workers will be as provided below-
Specific Roles and Responsibilities of ‘Community Level Primary Health Care Work-force’
Sl.No
. Palliative Care Provider Components of essential service package
• Awareness for Palliative care and the importance of
volunteers for Psycho-social economic-spiritual support
• Help families with routine home care
• Help in accessing various service as needed including
mobilization of local resources
1 JAS/VHSNC/MAS/RWA • Bereavement support
• Identifying patients/families for palliative care needs
• Help families with routine home care
• Help in accessing various service as needed
• Networking to assure community support
• Referral services
2 ASHA • Encourage VHSNC/JAS/MAS/RWA to provide bereavement
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Sl.No
. Palliative Care Provider Components of essential service package
support
• Assessment of patient/families by home visits
• Perform basic nursing procedures
• Supporting – caregivers/ ASHA/Volunteers
• Compassionate communication and Counselling
• Provide basic medications as per instructions from Staff
Nurse/MO
• Referral services
3 MPW/ANM • Bereavement support

• Detailed assessment of patient/families by home visits

• Perform basic nursing procedures
• Training of the caregivers/ASHA/Volunteers/ANM.
• Dispense medication as per the prescription of MO to
palliative care patients excluding Narcotic Drugs.
• Conduct weekly outpatient clinics in HWC
• Referral & Linkage services for complex cases
• Data management for entire HWC
• IEC activities
4 CHO at HWC-SHC • Compassionate communication and Counselling

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Common Illness requiring Palliative Care

Palliative care is more often required for-

 Cancer
 HIV / AIDS
 Dementia
 Progressive neurological disorders: Parkinson's disease, Multiple sclerosis, Motor neuron
disease, Stroke
 Progressive systemic diseases: COPD, ILD
 Heart diseases
 Liver and kidney dysfunctions due to various causes
 Old age and other degenerative disorders

All these diseases and/or associated symptoms require specific treatment in consultation with
Medical officer and CHO/MPW need to ensure that appropriate assessment, treatment,
counselling and community level support is provide to the patient in need of Palliative care
for the specific disease, inline the Service Delivery framework and following the suitable
treatment and referral pathways.

Since, Home-based palliative care is considered the backbone of palliative care services.
There are many diseases that require Home-Based Palliative Care during the later course of
the disease like, Alzheimer's and other dementias, Cancer, Cardio-Vascular Diseases
(excluding sudden deaths), Cirrhosis of the Liver, Chronic Obstructive Pulmonary Diseases
(COPD), Diabetes, HIV/AIDS, Chronic Kidney Diseases (CKD), Multiple Sclerosis,
Parkinson's Disease, Rheumatoid Arthritis, Drug-resistant tuberculosis (DR-TB), Advanced
age, Spinal-cord injuries, Mental Retardation, Congenital anomalies and patients whose
mobility is limited due to various reasons.
Home care request can be accepted from the patient, Family caregivers, Neighbour/Friend,
Community caregivers, Field staff, Hospitals, Health care professionals, Other palliative care
centres, Governmental/non-governmental organization.
But, when the home care request is accepted from a non-family member, the Palliative-
Home-Care team will call the patient/family and confirm the registration.

PAIN is often the most important or only symptom reported by the patient for Palliative care
to be provided. It is essential to ascertain the cause of pain.

Causes of Pain:
Causes of Pain
Due to cancer
At the spot where the disease first started
At the spot where the disease had spread
Radiation, chemotherapy, surgery.
Cancer-related conditions
Constipation, bedsores, emaciation
Things to be remembered!
Factors that enhance pain
Exhaustion, loss of sleep
Anxiety, Despair, Despondency
Anger
Feeling of isolation
Loneliness, Fear

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 Unrelated to Cancer Factors contributing to relief
Disc prolapse Adequate sleep and rest
Fracture Relief from other ailments
Burns Hope - The feeling that there are people to
Stress help.
Gastritis The opportunity to open up one's mind

CHO/Palliative Care team at SHC-HWC will ensure ‘PAIN MANAGEMENT’ based on

following principles:
Principles of Pain Management
1. Consider the 'whole patient'. Symptoms are never purely physical or purely
psychological, and all symptoms and treatments will have an impact on the patient, their
family and friends. So, assess and document the pain location of pain, intensity,
characteristics, mechanisms, expressions and functions, assessment of the psychosocial
factors and the current analgesic treatment if any and response to the same.
2. Evaluate symptoms thoroughly. Consider potential causes and remember to consider
reasons other than cancer. Consider the impact of the symptom on the patient's quality of
life.
3. Communicate effectively. Explain in simple terms and avoid medical jargon. Discuss
treatment options with patients and their families, and involve them in the management
plan.
4. Correct the correctable, as long as the treatment is practical and not overly burdensome.
Remember nondrug treatments, e.g. palliative radiotherapy for metastatic bone pain.
5. Simplify Drug Treatment. When using drug treatments for persistent symptoms, give
regularly and also 'as needed'. Keep drug treatment as simple as possible.
6. Review regularly and adjust treatment in consultation with the MO/Specialist.
7. Consider non-pharmacological strategies to help relieve symptoms, e.g. simple
repositioning, or the use of a TENS machine may help the pain; complementary therapies
may help psychological distress. Although the evidence base for such treatments is not
robust, some patients find them helpful.
8. Plan in advance. Good communication is essential in establishing patients' wishes for
their future care and treatment.
9. Keep other staff informed.
10. Ask for help from Medical Officer or Staff, as necessary.

NOTE:

Work instructions are restricted to this minimal information with respect to specific
responsibilities for Palliative care in a Particular Disease condition. CHO/MPW(M/F)/ASHA will
provide treatment, support, counselling, out-patient care/Home-Based Care as per their training.
To have deeper understanding and ascertain appropriate Palliative Care, the Training Modules for
CHO/ASHA/MPW will be referred by the respective Community Health Worker.

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Referral & Treatment Ensuring Continuum of Care at HWC-SHCs: -
HWC Team with their individual responsibilities must ensure following things for effective
referral. The usual sequence of events will be:
 ASHA/ Volunteers will identify the patient/family in need of palliative care based on
the Community Based Assessment Checklist (CBAC).
 MPW along with ASHA would assess the patient/family using assessment form and
identify those in need of urgent medical and/or nursing attention. Caregivers (family)
can also be equipped by her to perform simple nursing tasks.
 ANM/MPW to refer those needing a more detailed assessment through CHO to
Medical officer in PHC/UPHC.
 Community Health Officer/Staff Nurse to conduct home visit and assess the
patient/family
 The Medical Officer in the PHC-HWC could refer the patient to suitable higher centre
[District Hospital / Palliative Care Centre] for specialized management including
inpatient care of variable duration as per Standard Operating Protocol of continuum of
care.
 The referrals from Community level/HWC-SHCs level will be accompanied by a
referral slip, providing in brief key problem identified, plan of treatment or treatment
so far and reasons for referral.

Referral Pathway for patients in need of Palliative care

Community level identification of patient through:

 ASHA/MPW/volunteers/CHO
 Screening based on palliative care screening tool

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Home based care PHC: Palliative care at least
through HWC-SHC once a week
Continuum of care

Outpatient/ and or secondary level case at

FRU (CHC or Taluk hospitals)
Fe
ed
ba
ck
14 M
Tertiary level care at district or Sub divisional ec
hospital/PMJAY empaneled continuum of care unit ha
at DH nis
m
Medicine and Consumables: Home Care Kit
For effective delivery of home-based palliative care services, the home care team will be
provided a home care kit. The kit will be located in Sub Health Centre-Health & Wellness
Centre. CHO will be responsible for maintaining the home care kit. PHC will ensure an
uninterrupted supply the contents of the kit. The contents of the kit will be procured
through existing state specific procedures. The funds for the same will be provided as part
of NPCDCS budget. The suggested composition of home care kit would be as follows:
Supplies Medicines
Equipment Pain Control
1. Stethoscope 1. Paracetamol
2. BP Apparatus 2. Ibuprofen
3. Light weight foldable stool 3. Diclofenac
4. Torch 4. Tramadol
5. Thermometer 5. Dexamethasone (as adjuvant)
6. Tongue Depressors
7. Forceps
8. Glucometer
Supplies Wound Management
1. Dressing Supplies 1. Betadine Lotion and Ointment
2. Cotton 2. Metrogyl Gel
3. Scissors 3. Hydrogen Peroxide
4. Gauze Pieces 4. Turpentine oil
5. Gauze bandages
6. Dressing Trays
7. Gloves
8. Micropore Tapes
9. Syringes and Needles
10. Condom Catheters
11. Urine Bags
12. Feeding Tubes
13. Foley’s Catheter
Gastrointestinal Symptom Management Antibiotics and Antifungals
1. Domperidone 1. Ciprofloxacin
2. Bisacodyl 2. Metronidazole
3. Loperamide 3. Amoxycillin
4. Oral Rehydration Salts 4. Fluconazole
5. Ranitidine
6. Metoclopramide
7. Dicyclomine+
8. Hyoscine Butyl Bromide
Psychological Symptom Management Nutritional Supplements
1. Lorazepam 1. Iron, Vitamin and Mineral Supplements
2. Amitriptyline Other Miscellaneous:
1. Spirit
2. Lignocaine Gel
3. Ethamsylate
4. Deriphylline
5. Cough Preparations
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ANNEXURES
Annexure 1: Suggested Palliative Care Screening Tool for MPW/Community Health
Officer/Staff Nurse/Medical Officer
Name of ASHA Village Part
Name of ANM Sub Centre
PHC Date
Name Dependent (financially): Yes / No
Number of earning members in the household: Any Identifier
Number of children (under the age of 18 years): (Aadhar Card, UID, Voter ID)

Age RSBY beneficiary: (Y/ N )

Sex Telephone/ Mobile No.

Address : Undergoing treatment from:

Date of diagnosis: …./…./…….. Diagnosis:

Screening Items Points

1 Nature of serious health related suffering including diagnosis (India 2
SHS screening tool – see below)
2 Functional status score, according to ECOG/WHO performance status
score 0
 Normal & Asymptomatic 1
 Symptomatic, able to do Normal Work as pre-diseased 2
 Symptomatic, able to do activities of Daily life without assistance
3
 Needs assistance with ADL, Limited Mobility
 Bed ridden, Totally dependent on others for ADL 4
3 Presence of one or more serious comorbid diseases also associated with 1
poor prognosis (eg, moderate-severe COPD or CHF, dementia, AIDS,
end stage renal failure, end stage liver cirrhosis)
4 Presence of palliative care problems
 Symptoms uncontrolled by standard approaches** 1
 Moderate to severe distress in patient or family, related to cancer 1
diagnosis or therapy
 Patient/family concerns about course of disease and decision making 1
 Patient/family requests palliative care consult 1
Total score (0-13)
Cut off of 4 or more will be considered for referral for palliative care services
** To be assessed by a trained Medical Officer

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 NCG – SHS Tool for Field Testing
Not at all A little A lot
Domains of Health-related Suffering Score 0 Score 1 Score 2
Associated with your health, do you suffer physically? With
pain/ breathing difficulty/ vomiting/ constipation/ weakness /
feeding/loose motion/ bleeding/ itching/ wounds
/difficulty with senses (see, hear, smell, touch, taste) / difficulty
moving/ other issues
Associated with your health, do you suffer emotionally?
Feeling sad/ unloved / worried/ angry/ lonely/ difficulty sleeping/
confused/ poor memory / other issues
Associated with your health, do you suffer due to issues with
family/ relationships/ friends/ community/ feeling isolated/
difficulty at work/ difficulty with hospital visits/ difficulty
communicating/ other issues
Associated with your health, do you suffer due to feeling
punished/ fearful/ shame / guilty / angry with God / no meaning to
life/ disconnected/ other issues
Associated with your health, do you suffer due to lost job/
stopped studies/ stopped working/ loan / debt/ sold property/ sold
assets / migrated out / other issues

Total Score Total

>/= 2 Score < 2
Is there Presence of Health-related Suffering? YES NO
If YES: Is the health-related suffering Serious?
Has this suffering limited you from doing what you need to do, for >/= 14 days over the last 30
days? e.g. self-care (feed, bathe, dress, walk, toilet); care for others; communicate; learn /
think/perform duties; sleep / rest?
YES. (SHS)
1. Document as ‘Patient has screened positive for Serious
Health-related Suffering on the case file, notify and activate
further evaluation by the primary treating team
2. Ask the patient – Do you seek more help for your concerns? NO. ( SHS)
NO, I do not seek more help The screening for SHS is
Educate patient/family on how to continued at quarterly intervals.
YES, I seek help seek additional support in case
Activate further evaluation and they feel the need for it and
care-pathways to respond to empower with the necessary
SHS1 information

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Annexure 2: Suggested format for documentation of Palliative Care Services

Patients with palliative care needs

Sr. Name Age/Sex Diagnosis Functional Screening Referral
No. Diagnosis* score Yes/ No
1
2
3
4
5
Home care visits
Sr. Name Age/Sex Diagnosis Functional Accompanied Main
No. Diagnosis* by interventions
1
2
3
Sensitization/ IEC activities
Sr. No. of Venue Resource Type of Method used
No. Beneficiaries person Beneficiaries
1
2
3
* With respect to Activities of Daily Living (ADL) – Independent/ Minimal support required/ Bed ridden

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Annexure 3: Home visit case sheet ( To be attached to screening form)
Name of the patient: Age: Sex:
Education status: Marital status:
Date:

Type of visit: Routine /Emergency

Diagnosis:
ECOG performance status: 0 / 1 / 2 / 3 / 4;

General condition Fairly good / Poor / Debilitated / Very weak / Drowsy / Unconscious/
Terminal state
Communication Easy / Occasionally / Withdrawn /Non – communicative
Ambulation/ Normal activities / Limited activities (needs support) / Needs
Activity assistance for ADL/ Bed bound
Main concerns

Sleep Normal /Disturbed /Wakeful nights (reason)

Urination Normal / Hesitancy/ Increased frequency / Incontinence / on catheter
Bowel Normal /Diarrhoea / Constipation /Stoma
Malodour Due to incontinence/ Infected ulcer
Appetite Good / Fair / Poor / None
Present symptoms: (by patient / informant)

Pain Sore mouth Itching

Nausea Swelling Delirium
Vomiting Ulcer/ Wound Breathlessness
Swallowing difficulty Bleeding Tiredness
Heart burn Lymphoedema Drowsiness
Cough Pressure sores Others (List)
Constipation *

*Blank spaces for any other symptoms

Most distressing symptoms: Distress

level:

Ongoing Medicines:
Mental Status: (tick appropriately)
Normal; Anxious; Sad/No Interest: Irritable: Withdrawn: Fearful: Body Image: Suicidal
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Socio-economic issues:
Care Giver – Name ; Age Sex: Relationship with the patient:
Contact No:
No of dependents:
Social Entitlements: Ration Card: Yes/No; Aadhar Card: Yes/No; Old age pension: Yes/no; Widow
pension – Yes/No; Disability Pension – Yes/No; Education support for children: yes/no
Etc (based on state specific entitlements); Bank Account – Yes/No;
Emotional concerns:
Spiritual concerns:
Pain Assessment:
Patient has no pain.

Effectiveness of present pain medicine: Good / Fair /Poor / not on any pain medication

Site Intensity Duration Type Character (Aching/ Cause* Provoking/

(0-10) (Constant/ Throbbing / Burning / Palliating
Intermittent) Pricking/ Lanciating) factor
A
B
C
D
Systemic Examination:

Treatment advised (Pharmacological &

Non-pharmacological):

End of the Document

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