Facilitating communication and collaboration across the continuum: a transportable plan of care

As the healthcare system becomes more complex and the need for communication and collaboration more critical, knowledge of hospice and palliative care, coupled with an easy-to-use tool that communicates a patient's wishes, becomes invaluable in preserving the dying patient's rights and wishes. Through this project, a stronger commitment and awareness of end-of-life issues and rights has been realized by those patients, families, and healthcare communities involved. The recipient of a National Hospice Organization Award of Excellence, the Plan of Care project is a model that can and should be adapted and incorporated into all healthcare settings to enhance continuity of care across settings and help to preserve the rights and wishes of all patients.