A plan of care is developed through contributions from all relevant disciplines and is based on a comprehensive assessment of the individual and family. The team works both autonomously and together with individuals, families and carers to clarify goals of care and develop a single, coordinated, needs-based palliative care plan. [1-3] Individual team members work within the evidence base for their specific profession. 
The care planning process may consider:
- Current disease status and past medical history, including all comorbidities
- Physical and psychological symptoms
- Functional status
- Social, cultural, spiritual concerns
- Advance care planning preferences. 
Ideally, the multidisciplinary team communicates regularly (at least weekly, more often as required by the clinical situation) to review and evaluate the care plan. [3, 5]
Family meetings can be conducted to assist with aspects of care planning and provision. Family meetings can also have a significant role in meeting the education and information needs of the patient and caregiver. The evidence-based resource Family meetings in palliative care: multidisciplinary clinical practice guidelines can guide the planning and implementation of family meetings in palliative care. 
- When and how can patient and carer input be facilitated in the care planning process?
- What strategies can be used to ensure the contribution of a range of different service providers is optimised when planning multidisciplinary care?
- Meier, D.E., Beresford,L. (2008). The palliative care team. Journal of Palliative Medicine, 11(5), 677–681.
- Baldwin, P. K., Wittenberg-Lyles, E., Oliver, D.P., Demiris, G. (2011). An Evaluation of Interdisciplinary Team Training in Hospice Care. Journal of Hospice & Palliative Nursing. 13 (3), 172-182, DOI: 10.1097/NJH.0b013e31820b5c16Article.
- National Breast and Ovarian Cancer Centre. (2008). Multidisciplinary care principles for advanced disease: a guide for cancer health professionals. Surry Hills, NSW: National Breast and Ovarian Cancer Centre.
- Palliative Care Australia. (2005). Standards for Providing Quality Palliative Care for all Australians. Retrieved 30 May 2011, from http://palliativecare.org.au/national-standards-assessment-program/
- National Consensus Project for Quality Palliative Care (2009). Clinical Practice Guidelines for Quality Palliative Care, Second Edition. Retrieved 30 May 2011, from www.nationalconsensusproject.org
- Hudson, P., Quinn, K., O’Hanlon, B., Aranda, S. (2008). Family meetings in palliative care: multidisciplinary clinical practice guidelines. BMC Palliative Care, 7(1), 12. Retrieved 22 November 2016, from https://bmcpalliatcare.biomedcentral.com/articles/10.1186/1472-684X-7-12