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Palliative Care Policies & Forms

Policy #TitleRationaleDateSummaryLink
CLI.5910.SG.006.SD.03Promoting High Quality Palliative CareTo outline the process for Palliative Care access for patients to Acute Care/Transitional care beds; either through ED or by prioritized admission.Jan 5, 2026
CLI.5910.SG.006.SD.02Palliative Care Process Map Admissions to Transitional Care or Acute CareTo outline the process for Palliative Care access for patients to Acute Care/Transitional care beds; either through ED or by prioritized admission.Jan 5, 2026
CLI.5910.SG.006.SD.01Palliative Care Patient Flowchart EDTo outline the process for Palliative Care access for patients to Acute Care/Transitional care beds; either through ED or by prioritized admission.Jan 5, 2026
CLI.5910.SG.006Palliative Care Patient Flow Regional Admission ProcessTo outline the process for Palliative Care access for patients to Acute Care/Transitional care beds; either through ED or by prioritized admission.Jan 5, 2026
CLI.5910.SG.005.FORM.01Palliative Care Week On Call LogForm was revised to decrease the manual calculations and errors required by scheduling/payroll when nurses are on callOct 6, 2025
CLI.5910.PL.008.FORM.01Advance Care Planning Goals Of Care Formformatting changes to signature linesApr 14, 2025
CLI.5910.PL.008Advance Care Planning Goals of Care PolicyAdded language about next of kinApr 7, 2025
CLI.5910.PL.008.SD.01Advance Care Planning Sharing Your WishesAdded language about next of kinApr 7, 2025
CLI.5910.PL.007.FORM.01Palliative Care Standard Orders FormSep 22, 2024
CLI.5910.PL.001.FORM.01Palliative Care Referral FormJun 1, 2024
CLI.5910.PL.001.FORM.01.FPalliative Care Referral Form FrenchJun 1, 2024
Medication CardApr 12, 2024
Medication PRN ChartingApr 12, 2024
CLI.5910.SG.004.FORM.01Discharge Planning Checklist for Patients Receiving Palliative CareMay 3, 2022
CLI.5910.SG.004Discharge Planning for Palliative Care Patients from Hospital to CommunityMay 3, 2022
CLI.5910.PL.005.SD.001Anticipated Death at Home Information for Family Caregiver BilingualNov 8, 2021
CLI.5910.PL.005.FORM.01Notification of Anticipated Death at HomeNov 2, 2021
CLI.5910.SG.005Palliative Care Telephone ConsultationNov 2, 2021
CLI.5910.PL.005Anticipated Death at HomeOct 31, 2021
CLI.5910.PL.010.FORM.01Palliative Care Social Work Referral FormJun 6, 2021
CLI.5910.PL.010Palliative Care Social Work ReferralJun 6, 2021
CLI.5910.PR.001.SD.01Bereavement Support to Caregivers BilingualOct 25, 2019
CLI.5910.PR.001.FORM.01Grief Snapshot FormOct 25, 2019
CLI.5910.PR.001Grief Snapshot ProcedureOct 25, 2019
CLI.5910.PL.009Thoracentesis Catheter Intermittent Drainage of Pleural Fluid and Care of Long TermSep 27, 2019
CPCP Consult RequestSep 20, 2019
CLI.5910.SG.001.FORM.02Edmonton Symptom Assessment System Revised GraphFeb 8, 2019
CLI.5910.SG.003.SD.02Richmond Agitation-Sedation Scale: Palliative VersionOct 16, 2017
CLI.5910.SG.003.SD.01Sedation for Palliative Purposes Resources for Decision MakingOct 16, 2017
CLI.5910.SG.03Sedation for Palliative PurposesOct 16, 2017
CLI.5910.PL.003.SD.01Palliative Care Drug Access Program – Drug Product ListingJul 25, 2017
CLI.5910.SG.001.FORM.01Edmonton Symptom Assessment System RevisedJul 21, 2017
CLI.5910.SG.001.FORM.01.FEdmonton Symptom Assessment System Revised FrenchJul 21, 2017
CLI.5910.SG.002.FORM.01Palliative Performance Scale Version 2Jun 2, 2017
CLI.5910.SG.002Palliative Performance ScaleJun 2, 2017
CLI.5910.PL.006.FORM.01Ambulatory Subcutaneous Infusion Pump Order FormJan 26, 2017
CLI.5910.PL.006.FORM.03Ambulatory Subcutaneous Infusion Pump Flow FormJan 26, 2017
CLI.5910.PL.006.FORM.02Ambulatory Subcutaneous Infusion Pump Client Statistical Information FormJan 26, 2017
CLI.5910.PL.006.SD.01Ambulatory Subcutaneous Infusion Pump Set Up Continuous TherapyJan 26, 2017
CLI.5910.PL.006.SD.03Ambulatory Subcutaneous Infusion Pump Set Up PCA TherapyJan 26, 2017
CLI.5910.PL.006.SD.02Ambulatory Subcutaneous Infusion Pump Set Up Intermittent TherapyJan 26, 2017
CLI.5910.PL.006Ambulatory Subcutaneous Infusion PumpJan 26, 2017
CLI.5910.PL.003.FORM.01.FPalliative Care Drug Access Program Application FrenchJan 25, 2017
CLI.5910.PL.003.FORM.01Palliative Care Drug Access Program ApplicationJan 25, 2017
CLI.5910.PL.003Palliative Care Drug Access ProgramJan 25, 2017
CLI.5910.PL.002.SD.01Palliative Care Emergency Symptom Management Kit Contents ListJan 25, 2017
CLI.5910.PL.002.FORM.03Palliative Care Emergency Symptom Management Kit Medication Count Sheet FormJan 25, 2017
CLI.5910.PL.002.FORM.04Palliative Care Emergency Symptom Management Kit Narcotics And Controlled Drug Count FormJan 25, 2017
CLI.5910.PL.001Palliative Care ReferralJan 25, 2017
CLI.5910.PL.002Palliative Care Emergency Symptom Management KitJan 25, 2017
CLI.5910.PL.002.FORM.01Palliative Care Emergency Symptom Management Kit Signature FormJan 25, 2017
CLI.5910.PL.002.FORM.02Palliative Care Emergency Symptom Management Kit Release And Prescription Authorization FormJan 25, 2017
CLI.5910.PL.007Palliative Care Standard OrdersJan 25, 2017
CLI.5910.PL.006.SD.06Ambulatory Subcutaneous Infusion Pump Patient Guide PCA TherapyNov 7, 2016
CLI.5910.PL.006.SD.05Ambulatory Subcutaneous Infusion Pump Patient Guide Intermittent TherapyNov 7, 2016
CLI.5910.PL.006.SD.04Ambulatory Subcutaneous Infusion Pump Patient Guide Continuous TherapyNov 7, 2016
CLI.5910.PL.006.FORM.04Ambulatory Subcutaneous Infusion Pump Patient Caregiver Teaching FormJan 25, 2016

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