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Socio-cultural and technological advances have created a new paradigm of living and dying. Chronic disease, often multiple and complex, creates prolonged states of vulnerability and dependence on health professionals. This vulnerability comes from a set of listable, time-consuming and changeable needs. This renewed sense of medical professionalism is based on new methodologies for the chronic condition and complexity management. We discuss and prepare the concept of Individual and Integrated Care Plan as a reconciliation of multiple plans responding directly to specific needs. Planning is patient-centered, circumscribed to its intrinsic value as a human being of unrepeatable historical relevance, in its preferences and diversity, and projecting it into the future, where its anticipated needs are bridged by an interdisciplinary team. Implemented support is adjustable to patient / family status change. We consider this work tool to create a solid framework in approaching the frail and com-

Plano Individual e Integrado de Cuidados Como Objetivo da Relação Clínica