Patient and Hospice Agreement

PATIENT/HOSPICE AGREEMENT

Hospice of Charles County hereby agrees to provide the following services to Hospice patients. This agreement is made subsequent to the patient's request for consideration for hospice services, and the completion of Hospice assessments of the patient's needs. It is agreed that Hospice will:

 Accept and incorporate orders of attending physician in the Hospice Plan of Care.  Follow the wishes and desires of the patient in the Hospice Plan of Care.  Coordinate and maintain in writing an individual patient Plan of Care, incorporating the medical, social, emotional, and spiritual needs expressed by the patient, family and attending physician.  Provide in-home nursing care at any time needed by the patient or indicated by the Plan of Care.  Provide counseling, support, and relief to family members as needed or indicated in the Plan of Care.  Provide direct spiritual care counseling or assistance in obtaining such spiritual counseling as needed or indicated in the

Plan of Care.  Provide specific treatment as needed for palliation (to include speech, physical therapy, dietary counsel, and occupational therapy) or as needed or indicated in the Plan of Care.  Provide volunteer services for the comfort, company, occasional household duties of the patient and/or family as needed or indicated in the Plan of Care.  Provide drugs and biologicals necessary for palliative treatment of the patient's terminal illness as indicated by the Plan of Care.  Determine appropriate location for treatment in the event the patient's condition and Plan of Care requires inpatient care.

The patient and the patient's primary caregiver(s) agree to:

 Provide the Hospice team with complete medical history and information necessary for the planning and delivery of appropriate care.  Discuss needs and preferences with the Hospice team members.  Participate in the developing of a Plan of Care.  Report immediately to the Hospice staff any changes in the condition of the patient which will affect the Plan of Care. (Hospice staff may be contacted 24 hours a day.)  Notify Hospice staff immediately of any decision to seek or obtain treatment of services not included in the Hospice

Plan of Care.  Follow the policy and procedure of the Hospice in handling and caring for drugs and/or equipment supplied by the

Hospice. I understand that I may choose care other than Hospice at any time. Such a choice will relieve Hospice of any responsibility for further provision of care automatically.

The Hospice of Charles County's telephone (1-301-861-5317) is answered 24 hours a day, seven days a week.