Standards › Standard 49 › Standard operating procedures (SOPs)
SOP · PAL-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 49.3
At a glance
- Palliative care needs are identified with a defined screening method at admission and at each change in condition.
- Symptoms are assessed and controlled using the symptom assessment chart (HSP-FRM-001) and pain reassessment (MNP-SOP-002).
- The patient and family are offered support, including bereavement follow-up (HSP-FRM-003).
- Palliative care is not withheld because of the diagnosis, setting or ability to pay.
- Stop and get help straight away if: a patient with a palliative need has no symptom plan or family support offer recorded.
1. Purpose
To make sure palliative needs are found by a defined method, and that symptoms and family needs are met (49.3).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Palliative care is needed for many patients long before the end of life. Identifying those needs with a defined method, and treating the symptoms, relieves suffering early.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Treating clinician | Screens for palliative needs and sets the symptom plan | Clinical lead |
| Nurse in charge | Reassesses symptoms at the set interval and offers family support | Clinical lead |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Screen.
- Screen each admitted patient for palliative needs with the defined method.
Key point: Screened.
Step 2. Control.
- Assess and control symptoms (HSP-FRM-001), and reassess pain (MNP-SOP-002).
Key point: Controlled.
Step 3. Support.
- Offer the patient and family support, and record the offer (HSP-FRM-003).
Key point: Supported.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Patients screened for palliative needs | 100% | Monthly | Clinical lead | Escalate to the hospital director |
| Patients with a symptom plan and a family support offer | 100% | Monthly | Clinical lead | Review the plan within 24 hours |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| HSP-POL-001 | Symptom assessment and control (existing, reused) | Policy |
| HSP-FRM-003 | Family support and bereavement follow-up record (existing, reused) | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
- End-of-Life & Palliative Care (LTC-06)
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)