Customizable Tear-off Pad

Image of the Conversations Matter Customizable Tear-Off Page

This tear-off pad provides health care providers with tips, resources, and answers to common questions about palliative care to help encourage interactive discussions with patients and their families or caregivers. It also includes customizable patient education sheets that can be filled out during patient visits.

Download your free copy in English or Spanish. This is a fillable PDF and can be used electronically.

NINR provides complimentary print copies of this tear-off pad. One pad contains 50 copies of patient education sheets. To order a print copy, please send an email specifying the language you prefer and your mailing address to or call 301-496-0207.

Who Can Use the Pad?

This tear-off pad was designed to help health care professionals from any discipline working in any setting engage in interactive palliative care discussions with pediatric patients and their families. You do not need to be a specialist in palliative care to use this tool. Additionally, you can use the pad even if your hospital does not have an existing pediatric palliative care team, by helping to identify palliative care resources and providers in your area that could assist patients and families.

How Do I Use the Tear-off Pad?

The tear-off pad was designed as a user friendly tool with tips and conversation starters to help health care providers maximize time with patients and their families.

The front cover of the tear-off pad includes instructions for health care providers explaining how to use the pad and providing general tips on palliative care conversations. The back cover contains four common questions families may ask about palliative care and suggested talking points to incorporate into the responses.

The 50, double-sided patient education sheets in the middle of the pad include basic information about palliative care and explain how it can work with ongoing curative care to help improve quality of life for the patient and family. The pages include sections to provide information on the patient’s care plan, members of the palliative care team, and resources in the community. Even if your hospital does not have an existing palliative care team, you can still offer support to pediatric patients and their families. These customizable pages can be filled out during discussions with individual patients and families. Once completed, the sheets can be torn off and sent home with the patient and family.

Where Can I Find Additional Information and Resources to Help Me Fill Out the Pad?

Effective palliative care can be successfully implemented even if resources are limited. It requires a broad multidisciplinary approach that includes the family and makes use of available community resources.

Developing a care plan

Work with the discharge planner, social worker, or care manager in your hospital or practice to develop a care plan for patients and their family or caregiver. They may be able to help think through recommendations and make arrangements for the patient and their caregiver’s special needs. Remember, a palliative care team can consist of any of the following:

  • Nursing Care
  • Social Services
  • Physician Services
  • Spiritual Support and Counseling
  • Home Health Aides and Homemaker Services
  • Trained Volunteer Support
  • Physical, Occupational, and Speech Therapies
  • Respite Care
  • Inpatient Care
  • Bereavement Support

Finding palliative care resources and providers

Even if your hospital or work setting does not have a built-in palliative care team, health care providers may still be able to help their patients and their families access these important services. Locate palliative care providers by state through the Get Palliative Care website or the National Hospice and Palliative Care Organization.

Paying for palliative care services

If costs are a concern for the family, ensure them most insurance plans cover all or part of the palliative care treatment, just as with other hospital and medical services. This is also true of Medicaid. However, each state might have different policies. Work with the discharge planner, social worker, care manager, or financial consultant in your hospital or practice to provide recommendations for a care plan and payment options. Visit the Centers for Medicare and Medicaid Services for additional information on Medicaid and the Children’s Health Insurance (CHIP) Program:

Tell us what you think of the tear-off pad. NINR would like to hear from you. Please send your feedback and comments about the campaign materials to:

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