Palliative Care Toolbox

Adapted from Cancer Care Ontario's online Palliative Care Toolkit.

Palliative care aims to improve a person's quality of life through improved symptom management while addressing psychosocial, emotional and spiritual issues. It is care that is appropriate at all stages of a person's illness. An interdisciplinary care team may include your family physician, non palliative specialist physicians, palliative care physician or nurse practitioner, social workers, dietitians, nurses, spiritual care workers and other health professionals (Cancer Care Ontario, 2013).

This web page is designed with the primary care provider in mind, as a resource in navigating the provision of palliative care in the Missisauga Halton LHIN, with links to best practice tools and local resources. Tools are organized according to the 3-step model of best practice proposed by the Gold Standards Framework (GSF): Identify, Assess, and Plan.

STEP 1: IDENTIFY

Identify persons who may benefit from a palliative approach early in the illness trajectory, and flag this in their health record.

Triggers that suggest that patients could benefit from a palliative care approach include:

Surprise Question: “Would you be surprised if this person were to die in the next year?”
General indicators of decline: deterioration, advanced disease, decreased response to treatment, choice for no further disease modifying treatment
Disease specific indicators of decline

Specific details are described in the Early Identification and Prognostic Indicator Guide.pdf developed by the Mississauga LHIN. This tool has been adapted from the Gold Standards Framework (GSF) Prognostic Indicator Guidance Tool developed by the GSF Centre in the UK.

Once identified, consider a referral to the Mississauga Halton LHIN Palliative Care Program by using the following form: Mississauga Halton LHIN Palliative Services and NP Referral Form

STEP 2: ASSESS

Assess patient and family’s current and future needs across all domains of care (i.e. disease management, physical, psychosocial, spiritual, practical, grief/loss, goals of care, end of life care) using validated screening tools, and through an in depth history, physical exam and relevant laboratory/imaging tests. Type and timeliness of assessment will depend on severity, interference with life, urgency and complexity of issues identified.

1. Regularly screen for distress and other needs using validated screening tools. It is recommended to complete these tools with every encounter, if possible.

Palliative Performance Scales (PPS) - A reliable and valid tool to assess and quickly describe a patients functional performance, can be used to prognosticate, plan for care and communicate status to other providers.
Edmonton Symptom Assessment System (ESAS) - A valid and reliable assessment tool to screen for the intensity of nine common symptoms experienced by cancer patients: pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, wellbeing and shortness of breath. The score guides further focused assessment and your symptom management.
Patient Reported Functional Status (PRFS) - Functional status helps to assess the disease progression and how it may be affecting the daily living abilities of the patient.

2. Use the results of screening to prompt further discussions, including critical conversations about a person’s illness understanding, their values and beliefs, and their goals and wishes of future care. Be sure to record goals of care/advance care planning discussions in the medical record. These conversations are iterative and should be revisited regularly.

Advance Care Planning (Speak Up Campaign)
- Start the conversation (Just Ask: Booklet and Conversation Card)
- Encourage communication of goals and wishes (Ontario workbook - PDF (817 KB)
- Ontario Resources
Engaging in Illness Understanding and Goals of Care Conversations
- Article: Discussing Goals of Care
- Document the decision-making process
Obtaining Consent (to deliver, withhold or withdraw treatment)
- Health Care Consent and Advance Care Planning: The Basics - PDF (122 KB)
- Substitute Decision Makers (SDMs) in the Health Care Consent Act - PDF (128 KB)

STEP 3: PLAN

Plan and collaborate ongoing care to address needs identified during assessment, including prompt management of symptoms and coordination with other care providers.

Symptom Management Guides (SMGs):

Cancer Care Ontario's SMGs can help healthcare professionals assess and appropriately manage a patient's cancer-related symptoms based on their ESAS score severity. Please visit the Cancer Care Ontario website to view the online toolbox. Also available are downloadable pocket guides, algorithms for each symptom.
Hospice Palliative Care Symptom Guidelines (Fraser Health Authority)
Symptom Management Guides App

Collaborative Care Plans:

The following interdisciplinary Collaborative Care Plans (Cancer Care Ontario) were developed as a tool targeted at the generalist provider to improve the quality and consistency of patient care. They provide a detailed outline of the essential and basic steps during a therapeutic encounter for all domains of care.

Stable Collaborative Care Plan (PPS 70-100%)
Transitional Collaborative Care Plan (PPS 40-60%)
End-of-Life Collaborative Care Plan (PPS 0-30%)
Condensed Version - Collaborative Care Plan

The following expands on these collaborative care plans for increased local relevance:

Still Need Help?

As a primary care provider you will participate as a member of the primary level palliative care team. The majority of patient care can be manged by the primary level care team with specialist support as needed (See MH LHIN Model of Hospice Palliative Care). If patient/family needs are more complex or support is needed, consider the role of secondary level palliative care specialists (i.e. consultation, collaborative care/shared care, direct care).