TARGET AUDIENCE This guideline is intended for clinical staff, particularly medical and nursing staff, involved in early intervention palliative care discussions and patient support caring for someone with a life limiting illness PURPOSE The purpose of this document is to provide guidance for clinical staff in providing care to patients who are diagnosed with a life limiting illness and require social supports, either as an in patient or out-patient receiving care in the community. This includes symptom control, multi-disciplinary team member assessments, and communication with the patient and their family. GUIDELINE The goal is always to maintain the patient’s dignity and comfort from diagnosis inclusive of patient centred care that addresses the management of social issues DISCHARGE PLANNING FROM IN-PATIENT TO COMMUNITY Discharge planning from in-patient care can mean the difference between a smooth transition and a difficult one. Difficult transitions can place increased stress and anxiety on the patient and their family. Discharge planning includes ALL involved in someone’s care helping to ensure all necessary requirements are arranged at the time of discharge.