1. WRHA Palliative Care Program February 2013
Lori Embleton, Program Director
Mike Harlos, Medical Director

2. Palliative Care Program
Two streams of service delivery:
Registration on Program
Consultative Services

3. REGISTRATION ON PALLIATIVE CARE PROGRAM

4. Registration on Program
Patients can be “registered” on the Palliative Care Program if they meet program criteria:
Prognosis of less than 6 months
No longer receiving aggressive treatment which requires on-going monitoring for and treatment of serious complications
Have chosen a comfort-focused approach including a decision to decline attempted resuscitation

5. Registration on Program
Once registered with the program, patients are eligible for:
Case management through Palliative Care Coordinator
Access to Community Palliative Care Nursing 24/7
Palliative Care Nurses have access to Palliative Care Physician
Admission to Palliative Care Units (PCU) and Hospice – if bed available
Enrollment on Provincial Palliative Care Drug Access Program

6. When to Register a Patient on Palliative Care Program
Patients are considering going home from acute care
Need to plan for services to be in place
Patients being transferred to Long Term Care Setting

7. How to Register a Patient on PC Program
Complete the “Application for Registration” form
2 page form
“completed” forms can be processed more quickly
Completed forms are reviewed by PC coordinator
Accepts on to Program
Rejects application – all reviewed by Manager, Program Director or Medical Director

8. Acute Palliative Care Units (PCU)
Admission to PCU for symptom issues
Physical symptoms
Psycho-social distress
Caregiver distress
Admissions managed centrally by PC program staff
Bed management guidelines

9. Acute Palliative Care Units
St. Boniface Hospital
15 bed unit
Access to tertiary care services
Riverview Health Centre
30 bed unit (2 beds currently closed)
Long term care facility

10. Acute Palliative Care Units
Once symptoms are controlled, actively discharge to appropriate site
Approximately 75% of patients die on PC unit
Approximately 20% of patients are discharged home from Palliative Care Units
Lack of care options if home not possible
PCH
Chronic Care
Hospice

11. Hospice settings in WRHA
Grace Hospice
12 beds in stand alone facility near Grace hospital
RN staffing 24/7
Limitations in care that can be provided

12. Hospice settings in WRHA
Jocelyn House
4 beds in split-level home in St. Vital
RN staffing 4 hours a day – 5 days a week
HCA provide care 24/7

13. Hospice Hospice is appropriate when: Symptoms well controlled
Care needs are not complex
Prognosis of 1 – 3 months
Patients cannot or do not wish to be cared for in the community

14. Care at Home
Majority of patients on Palliative Care program are in the community
Palliative patients in community have same service limitations as all Home Care clients
HCA and PSW services provided by Home Care Program
Families/caregivers must be very involved in providing care

15. Community Teams:
Community Nurses
CNS MD
Coordinator
Psychosocial

16. Inter-professional Community Model
Implementing EMR
Will allow all members of Palliative Care team in community to chart on one charting system
Will improve information sharing and communication between primary care providers (using EMR) and palliative care providers

17. CONSULTATION SERVICES

18. Consultative Services
Available to anyone with a life limiting illness in any care setting for symptom management, psycho-social support or assistance with discharge planning
Consultation services are provided by inter-professional team members including:
Palliative Care Physician
Palliative Care Clinical Nurse Specialist
Psycho-social Support Specialist

19. When should Palliative Care be consulted?
Assistance with symptom issues
Managing Physical symptoms
MD to MD consults for advice 24/7
Psycho-social
Assistance with care planning
What might care team expect as patient nears end of life?
Will oral route be available?
Could symptoms escalate?

20. When should Palliative Care be consulted?
Goals of care are not clear
Discrepancy between patient, family and/or members of care team with plan of care
Discharge to community or LTC is anticipated
Does patient need to be or are they currently “registered” on Palliative Care program?
Would it be appropriate for Palliative Care nurse to see the patient in the community?

21. What information is needed on consult?
Main reason for consult
What is the main symptom issue?
Urgency of consult
Is the physician aware of the consult?

22. How to contact Palliative Care Program
One number to call if you have questions or need a consultation during business hours:
Do not page Palliative Care team members directly or leave messages regarding consults on their office phones.

23. How to contact Palliative Care Program
Physician to physician consultation available 24 hours a day – 7 days a week:
204 –

24. Community Palliative Nursing
Consult Service
Community Palliative Nursing
Case Coordinator
Admission Eligibility
Medication Coverage
comfort-focused
prognosis “6 mo. or less”
some treatment limitations (DNAR, no TPN, no chemoTx with high adverse effects
aggressive, often toxic treatment focused on cure or life-prolonging disease modification
Diagnosis of
Life-Limiting
Illness
Transitioning
to Palliative
Palliative

25. Increase capacity through education, advocacy,
Formal
Program
Palliative Care as a
philosophy of care
Resources
Increase capacity through education, advocacy,
partnerships