1. No category

End of Life
Train the Trainer 1
Westin Wall Centre Hotel
December 9, 2010
1
Introduction
• Acknowledgements:
– BCHPCA Learning Centre for Palliative Care
– Fraser Health – Advance Care Planning
2
Session opening
Dr. Cathy Clelland
3
Session opening
• Introductions
• Agenda for today’s session
4
Case study: Mr. James Lee and his wife
5
Integrated primary and
community care: Towards
interdisciplinary End of Life
practice with GPs and MOAs
Katie Hill
6
Integrated care: Shifting the focus
Meeting the majority of people’s health care
needs by providing high quality, accessible,
community based health care and support
services
•
•
•
Built around attachment to a family physician and an
integrated health care team.
Stronger voice for the patient, family and local
community in the design and delivery of healthcare
services.
More focus on proactive management of health
conditions, supporting seniors and those with chronic
conditions to remain independent.
7
Working with population needs
8
BC End-of-Life care *statistics (2009)
•
•
•
•
•
29,744 persons died in total.
4,537 (15.3%) died in own home.
7,162 (24.1%) died in residential care.
3,291 (11.1%) died in hospices.
14,139 (47.5%) died in acute hospitals.
*Data source: Ministry of Health Services Quarter 4 2009 schema:
March 4, 2010 (ICD10: A00 to R99)
9
Why a population approach?
10
Who supports HPC End of Life care?
•
•
•
•
Primary care physicians and HPC Specialists
Home and Community Care palliative teams
Clients/patients and families/caregivers
Linking with...
– Acute care hospitals and tertiary ambulatory services
– Provincial services (BCCA, BC Renal, BC Children’s, HealthLink
BC)
– End of Life Care programs and services- regional and provincial
– Local Hospice Societies and other community services...
Produces patient-centred interdisciplinary practice
11
What will integrated care look like?
Aligns with EOL/HPC PSP Module - we’ll see...
• Community by community approach
• Divisions of Family Practice
– Family physicians - specialists
• Re-alignment of community health services to foster
inter-professional and client-centred practice
• Collaborative service committees
– Rethinking how we work together
• An iterative process
12
Inter-professional practice for EOLC
Interdisciplinary EOL care plans need to include:
• Medical and nursing care - goals of care aligned with
patient’s wishes.
• Care coordination of specialists, interdisciplinary team.
• Clinical support to assess and manage pain and other
symptoms.
• Functional supports to maintain quality and comfort.
• Family/caregiving support for emotional comfort
– Collaboratively built to improve quality of care.
– Involvement of patient and family to improve
experience.
13
Integrated community practice will enable
•
•
•
•
•
•
•
•
Clear roles and responsibilities for practitioners.
New service models, coordinated care.
A common language and standard pathways.
Capacity-building for proactive chronic disease
management.
Practice of the palliative approach across settings.
Consistent collaboration across service settings.
Involvement of patients and families.
Better care and improved health outcomes.
14
Questions?
15
Module aims
Dr. Cathy Clelland
16
Module aims
• To improve the care of patients and families
living with, suffering and dying from life-limiting
and chronic illnesses by:
– Identifying patients early who could benefit from a
palliative approach.
– Enhancing GP confidence and communication skills to
enable Advance Care Planning (ACP) conversations.
– Assessing patient and family needs from a palliative
perspective.
– Identifying and referring appropriate patients to specialty
palliative care and others for consultation and services.
17
Module aims (continued)
• Understanding provider needs, clarifying roles, tools
and resources for practice support and collaboration.
• Improving collaborative care planning, coordination and
communication with clients/caregivers and with other
local health care and community providers.
• Increasing physician knowledge of how they can
support their own emotional well being.
“Integration
in Action”
• Improving the experience of the patient, family,
physician, MOA and healthcare providers in End of
Life care.
• Improve physician confidence related to End of Life
care (e.g. care planning, forms, death certificates, etc.),
18
Patient/family’s voice
Brian Deakin
19
Palliative approach to
life-limiting illness
Dr. Doris Barwich
20
Type of deaths in Canada
21
Schematic depiction of comprehensive heart failure care
Copyright ©2009
Goodlin, S. J. J.A.C.C. 2009;54:386-396
22
Heart failure
High
Function
Terminal
Phase
Low
Begin to use hospital more
often, self-care more difficult
Death
Time ~ 2-5 years.
Death usually seems “sudden”
Modified from Lunney JR et al. JAMA 2003: 289: 2387.
23
Changing face of dying
• Living longer: by 2025: 30% >65.
• 33% increase in deaths over 2004.
• 2/3 will die with 2 or more chronic
diseases after months or years in
state of “vulnerable frailty”.
• Only 1/5 of us will die with a
recognizable terminal phase.
24
EOL trajectories
Cancer: Short period of decline
Organ failure (Heart, lung, kidney):
Slow decline with intermittent acute
episodes
Well
Unwell
Time
Frailty and dementia (prolonged dwindling) Joanne Lynn, “Living
Long in Fragile Health: The New Demographics Shape End of Life
Care” Improving End of Life Care: Why Has It Been So Difficult?
Hastings Center Special Report 35, no. 6 (2005): S14-S18.
25
Ambiguous dying
“There will not be a distinct terminal phase.
The week we die will start out like any other and
some unpredictable calamity will occur.
Amongst those of us with advanced heart failure,
we will have had a 50-50 chance to live for six months
on the day before we died”
Joanne Lynn:
Sick to Death and Not Going to Take it Anymore (2004)
26
Cannot wait for a ‘sign’ …
27
Table discussion
• Introduce yourself and how you are involved
with patients with chronic and life threatening
illness.
• Identify what you hope to get out of the session
today to improve the care of patients in relation
to considering palliative/supportive care needs.
28
Table discussion (continued)
Think about your self audit OR a recent death
of a non-cancer patient you were involved with`
• Were you satisfied with the experience?
– If so, what made it work?
– If NOT satisfied, why not?
• What were some of the gaps in clinical care?
• What could have been done differently?
29
Philosophy of care
Dr. Doris Barwich
30
Canadian Hospice Palliative Care
Association model of care (2002)
Disease-modifying therapy
Bereavement
Care
Palliative Approach to Care
Diagnosis of
life-limiting
illness
Death
Illness trajectory
31
Palliative care dimensions
Guided by person centered goals of care:
1. Pain and symptom management.
2. Psychosocial care for person.
3. Psychosocial care for family.
4. Spiritual care.
5. Disease management.
6. Preparing for and managing dying.
7. Bereavement.
(Canadian Hospice Palliative Care Association: Norms, 2002)
32
WHO definition of palliative care
Palliative care is an approach that improves the
quality of life of patients and their families facing
the problem associated with life-threatening
illness, through the prevention and relief of
suffering by means of early identification and
impeccable assessment and treatment of pain
and other problems, physical, psychosocial
and spiritual.
http://www.who.int/cancer/palliative/definition/en/
33
Goals
• Quality of living in the context of
a life-threatening illness.
• Quality of dying in the midst of
life.
34
Transitions in life-limiting illness
Early
Transitions
Disease
containment
Decompensation
Maintaining
function
Experiencing life
limiting illness
Transitions
Decline and
terminal
Dependency and
symptoms increase
Transitions
Transitions
Death and
bereavement
Transitions
Time of
Diagnosis
Time
McGregor and Porterfield 2009
35
Collaborative interdisciplinary approach
Palliative Care Australia
36
Best practice: Integrating the palliative approach
• Concurrent palliative and
disease modifying care.
• Elimination of the “terrible
choice”.
• Advance Care Planning and
patient centered decision
making.
• “Sick enough to die” rather
than “certain to die”.
Melanie Merriman PH.D. MBA
NHPCO Conference Fall 2003
37
Integrating the palliative approach to care
38
Improved quality of life
39
Improved survival
40
Outcomes of the palliative approach
• “Good death” in the most appropriate location.
• Better pain and symptom management.
• Better long term outcomes for bereaved
relatives.
• Improved experience of care.
• Better quality of care.
• Lower health care costs.
Zhang et al. Arch Intern Med Vol 169(5) Mar 9 2009:480-488
41
BC Guidelines.ca
42
Identification of patients who may
benefit from palliative care
Dr. Douglas McGregor
43
UK Gold Standard Framework
44
Identify patients:
Gold Standard Framework triggers
Three triggers for supportive/palliative care:
1.
The surprise question: “Would you be surprised if
this patient were to die in the next year?
2.
Choice/need: patient makes a choice for comfort
care only, or is in special need of
supportive/palliative care.
3.
Specific indicators: clinical indicators for each of 3
main EOL groups (cancer, organ failure, frail
elderly/dementia).
45
Identify: Sentinel events
46
Sentinel events questions/comments
• “Well, that was a close call. What were you
thinking about when this happened?”
• “What if things don’t go so well the next time?”
• “How did your family do during this time?”
47
Identify: Use prognostic indicators
General:
• Co-morbidity.
• Recent, multiple ER visits/hospital visits.
• Complications of recent hospital stay.
• Reducing performance status (ECOG/Karnofsky/PPS).
• Dependence in most activities of daily living (ADLs).
• Impaired nutritional status despite attempts to improve
– Serum albumin < 25 g/l.
– Weight loss 5-10% of body weight (last 6 months).
48
Identify: Use prognostic indicators (continued)
Examples of disease specific
Renal Disease
• Patients with Stage 5 kidney disease who are not seeking or
are discontinuing dialysis or renal treatment.
COPD
• Dyspnea after 100 meters or confined to house from
dyspnea.
• Recurrent infections, hospital admissions.
• Right heart failure.
• O2 criteria.
• Resting HR 100/min.
Heart Disease
• Symptoms despite optimal tolerated treatment.
• Dyspnea or chest pain at rest or minimal exertion.
• History of cardiac arrest.
• Hospital admissions.
49
Identify: Use prompts
• Is the patient’s function declining due to
progression of disease?
• Are the patient’s symptoms (such as pain)
responding inadequately to optimal
treatment?
• Does the patient need advance care
planning?
Ontario GAC Guideline
50
Spikes and empathy
• Iatrogenic suffering – what families remember.
• Breaking bad news.
SPIKES not YIKES!
• Empathy – even when you don’t think you can connect
easily.
51
Who would benefit from a palliative approach?
Practice approach to care
• Knowing your patient and family.
• Knowing what you plan to do with your
patient and family.
• Patient recognition / registry and material.
53
Identification: Table discussion
• At your table, start discussing the topics
covered:
– Identifying patients.
– How do you communicate and to whom.
– Consider who should be involved in your
community.
54
MOA role in identification
• Flag patients who may benefit from a “palliative
approach” based on triggers:
– “Surprise question”.
– Change in appearance.
– Missing appointments or unusual behavior e.g. change in gait.
– Repeated hospital admissions or polypharmacy issues.
– Admissions to Long-Term Care - “why” are they there, not just
the fact they are there.
– Decrease in ability to care for self.
– Family members phoning MOAs to inquire about patient.
– Changes in communication, e.g. family
calling instead of the patient.
– Gut feeling.
55
MOA role in identification (continued)
• When booking patients, MOAs are to ask them why
patients are coming in. Be aware of potential flags and
share concerns with physician.
• Support the creation of the patient registry (e.g. surprise
questions, clinical indicators).
• Help establish communication processes to share
concerns to physician.
• Flag caregivers of end-of-life patients that may be
distressed or burnt out.
56
Identification: Pearls
What have we learned?
1. Everyone can seek to identify.
2. Tools are available to support identification
–
–
–
Surprise question (intuitive awareness of
transition).
Choice (readiness of patient).
Clinical indicators (Functional/Prognostic signs).
3. Tools are available to support identification.
57
Break
58
Assessment
Dr. Doris Barwich
59
Assessment
60
Assess: Patient and their Illness experience
NEEDS and
PREFERENCES
DIAGNOSIS
SPREAD
DISEASE
OTHER
PROGNOSTIC
FACTORS
BENEFITS
TREATMENT
BURDENS
GOALS of
CARE
PATIENT
CULTURE
BACKGROUND
VALUES,
BELIEFS
EXPERIENCE
(SUFFERING)
61
Assess: Goals of care
Goals of care change over time and may include:
• Maintaining and improving function.
• Staying in control.
• Relief of suffering.
• Prolonging life for as long as possible or until a specific
event (time limited trials of care).
• Quality of life/ living well.
62
Assess: Goals of care (continued)
• Pain and symptom management.
• Relieving burden for family members.
• Strengthening relationships.
• Preferences for location of care.
• Preferences for location of death.
• Life closure/ dying well.
• Personal wishes for management of dying.
63
Assessment: Domains of care
1. Pain and symptom management.
2. Psychosocial care for person.
3. Psychosocial care for family.
4. Spiritual care.
5. Disease management.
6. Preparing for and managing dying.
7. Bereavement.
(Canadian Hospice Palliative Care Association)
64
“Distress screening”
Edmonton Symptom Assessment Scale (ESAS)
• Identifies key symptoms for
that person.
e.g. Dyspnea at rest, fatigue,
sleep, cough, pain
• Screen regularly for symptom
intensity and associated
distress.
• Monitor response to treatment.
65
Edmonton
Symptom
Assessment
System
66
Assess: OPQRSTUV and physical exam
Onset
Provoking/palliating factors
Quality
Region/Radiation
Severity
Treatment
Understanding/ Impact
Values /Goals of Care
67
Patient assessment: Pain and symptom diary
68
Symptom burden in chronic diseases
Symptom prevalence in Heart disease;
COPD; Renal; AIDS and Cancer
• Pain, breathlessness, and fatigue – found among
more than 50% of patients for all diseases.
• 11 symptoms as prevalent as in cancer.
• Common pathway for malignant and nonmalignant disease.
Salano, Gomes, Higginson, 2006
69
Functional assessment: Seniors Assessment Tool
• From Frail Elderly
Guidelines.
• To be completed by the
patient.
70
Performance
V2
PalliativePalliative
Performance
ScaleScale
(PPS)
PPS
Ambulation
Activity and
Evidence of Disease
Self-Care
Intake
Conscious
Level
Full
Normal activity and work
No evidence of disease
Full
Normal
Full
Full
Normal activity and work
Some evidence of disease
Full
Normal
Full
80%
Full
Normal activity with effort
Some evidence of disease
Full
Normal or
Reduced
Full
70%
Reduced
Unable to do normal job/work Full
Significant disease
Normal or
reduced
Full
60%
Reduced
Unable hobby/housework
Significant disease
Occasional
Normal or
assistance neces. reduced
Full
or confusion
Mainly sit/lie
Unable to do any work
Extensive disease
Considerable
Normal or
assistance req’d reduced
Full
or confusion
Mainly in bed
Unable to do most activity
Extensive disease
Mainly needs
assistance
Normal or
reduced
Full or drowsy
+/- confusion
30%
Totally bed
bound
Unable to do any activity
Extensive disease
Total care
Normal or
reduced
Full or drowsy
+/- confusion
20%
Totally bed
bound
Unable to do any activity
Extensive disease
Total care
Minimal to
sips
Full or drowsy
+/- confusion
10%
Totally bed
bound
Unable to do any activity
Extensive disease
Total care
Mouth
care only
Drowsy or coma
+/- confusion
100%
90%
50%
40%
0%
Death
x
x
x
x
71
Assess: Needs of the family/caregivers
72
Assess: Additional need for support/referral
•
? 24/7 support.
•
?Home Support ? Equipment or supplies.
•
Psychosocial care for person.
•
Psychosocial care for family.
•
Spiritual care.
•
Disease management (including risk of anticipated
crisis/ “emergency”).
•
Preparing for and managing dying.
•
Bereavement.
73
Assessment: Pearls
A good assessment:
• Acknowledges patient goals of care.
• Assesses the whole person and the “family” unit.
• Standardized tools can support practice and
provide information.
• Is proactive.
• Facilitates collaboration.
74
GP communication
Dr. Romayne Gallagher
75
Critical importance of communication
Six key components (in order):
1.
Talking with patients in an honest and straightforward
way.
2.
Willing to talk about dying: Not abandoning/avoiding
the dying patient.
3.
Giving bad news in a sensitive way: Balancing being
realistic with maintaining hope.
4.
Listening to patients.
5.
Encouraging questions.
6.
Sensitive to patients readiness to talk about death.
Weinrich et al. Communicating with dying patients within the spectrum of
medical care from terminal diagnosis.
AIM 2001; 161: 868-874; Curtis, J Gen Intern Med 2000; 16:41
76
Communication: Vital for EOL care
Patient experiences
• Being seen.
• Being heard.
• Being met.
Family and caregivers’ experience
• Support in transitions.
Establish partnership with clear goals
of care and a plan for the future.
77
Video of dying young mom
78
Communication: Assess readiness
Find out what is understood:
• “I know (…) has happened, so I wanted a chance to
talk with you about your health and illness.”
• “Can you tell me what you understand about your
current health? What are you expecting as your
illness changes?”
Assess coping and need for emotional support.
79
No CPR form
• Purpose: Legal physicians’ medical order, with
patient’s written consent, to allow paramedics and first
responders to withhold cardiopulmonary resuscitation if
patient has an arrest.
• Completed by: Physician and patient - community
use only - form not for use in acute care hospital
settings.
www.healthlinkbc.ca/no_cpr.stm
80
Video of patient with dementia
81
ACP: Process and intervention
A tool and a process to:
– Discuss, document, and review goals of care at
various transitions.
– Break “bad news” across all transition points.
– Include the family in the shared care process.
– Provide information for the patient/family to make
informed decisions throughout trajectory.
– Plan for acute episodic and crisis events,
declining function, and terminal phase
management.
82
Who makes your healthcare decisions?
1.
Capable adult (19 yrs).
2.
Committee of person (court ordered).
3.
Representative (representative agreement).
4.
Temporary Substitute Decision Maker* (TSDM).
a) Spouse (common law, including same sex)
b) Adult children (equally ranked)
c) Parent (equally ranked)
d) Brother or sister (equally ranked)
e) Another relative by birth or adoption
f) Another person appointed by PGT
*Capable, 19 years or older, no conflict, contact within 12
months, agrees to decide based on your wishes
83
Substitute Decision Makers (SDM)
• SDM represents values, beliefs, preferences of patient.
• SDM is a stressful role.
• Ask the right question:
“What would your father be thinking … ?”
“What would be important to your mother ..?”
84
Video of failing older man
85
When to hold ACP conversations
• Include in patient history form/intake assessment.
• Annual physicals for all adults: “I talk with all my patients
about this and we talked a little about this last year…”
• As part of chronic disease discussions: "This particular
illness can have a fairly predictable course…here are some
things you need to think about ahead of time…"
• Following emergency department/hospital admissions: “I
understand you have been in the hospital. What did the
doctors say?”
86
Patient wishes
• An Advance Care Plan ensures that the patient's
wishes would be listened to no matter who is present.
• http://www.fraserhealth.ca/media/MyVoiceWorkbookE
NG.pdf
• What if patient wishes are not medically appropriate?
87
Skills-based practice session
• Groups of 3
– Each scenario has 3 roles: patient, clinician, and
observer.
– Choose role you wish to play.
– Take 1-2 minutes to review your role.
– Clinician initiates the 5 minute conversation.
– Take 2 minutes to review the role play together.
88
Review skills-based exercise
• What feelings did you experience as you played the
role of the patient?
• What did you learn as you played the role of the
observer?
• In the clinician role, what surprised you?
• What 1 thing might you change about your ACP
conversations in the future?
89
Barriers to conversation
90
Health providers identified these barriers:
• Social and cultural.
• Afraid of patient reaction to the topic.
• Not within their role.
• Lack of confidence and comfort with the
conversation.
• Don’t want to take away hope.
• Time constraints.
91
Patients identified these barriers
• Too many medical problems.
• Doctor too busy.
• Perceiving ACP as irrelevant.
• Prefer to leave health in God’s hands.
• Information needs about health and choices.
• Nervous, sad, or too busy.
• Need help with “the form”.
92
Communication: Pearls
What have we learned?
All primary providers can:
• Initiate ACP conversations.
• Share information.
• Contribute to clarifying needs/preferences and
establishing goals of care.
• Support families to keep talking.
• Clinicians can be healers through listening, supportive
conversation and presence.
• The secret of caring for the patient is caring
about the patient.
– Peabody 1929
93
End of Life MOA role
Pat Porterfield, Josefa Kontogiannis
94
95
Getting started… what is the palliative approach?
• Expanded definition of the End of Life.
• Guided by an understanding of the illness
progression.
• Assists in understanding the transition of illness
from cure to symptom control.
• Improves quality of life in all life-limiting
illnesses.
96
End of Life Module: MOA Role
Identification
Care management
•
•
•
•
•
•
•
•
Flagging
Gut feeling
Surprise Question
Things you are noticing
Planning
Registry
Tools
“Paperwork”
Assessment
Office methodology
• Communication
• Tools: ESAS,
pain diaries etc.
• Huddles, pertaining to
overall plan
• Patient specific
huddles
• Processes
• Billing
Engaging family
Engaging community
97
Identification: Surprise question
Would you be surprised if this patient will die within
the next year??? This question will be the
physician’s “trigger”… how can you help?
• What are the signs to look for? What are the
questions to ask yourself?
• What are the steps to take when you start
answering “No” when thinking of certain patients?
98
Identification - what changes do you see?.....
Flagging
• Changes in appearance.
• Missing appointments.
• Admissions to Long Term
Care or multiple
hospital visits or even
frequent doctors visits.
• Family members
expressing concern,
wanting to talk to the
doctor about them.
• Changes in behaviour.
• Changes in gait.
• Decrease in ability to care
for themselves.
• Changes in
communication.
• Gut feeling.
99
Registry
What is it?
What types are there?
• A list
• A database
•
•
•
•
What is it used for?
Paper list
Excel spreadsheet
Binder
Flagged chart
• Tracking
• Maintaining
• Follow up
100
Care management: Tools for toolkit
• Care plan template.
• EOL care MOA flow sheet.
• My Voice (Advance Care Plan).
• No CPR form.
• BC Palliative Care Benefits Program form.
• Employment Insurance Compassionate Care Benefits
form.
• Notification of Expected Death in Home form.
• Death certificate.
101
Assessment
Using the assessment tools:
• Palliative Performance Scale (PPS)
•
ESAS: Screening for Distress
– When?
– How?
• Pain and Symptom Diary
• Seniors Assessment Tool
102
Engaging family
• Who are the primary contact people?
• Current contact information of all parties.
• Ensuring contact with family
– How is the family managing with caregiving?
– What can you say? What can’t you say?
• Following patient’s death, contacting family
– What family needs to do after death?
– Family members that aren’t actual patients, how are
they seen or informed?
– Discuss your possible roles in
making bereavement calls or cards.
103
Engaging with community
• Identify resources available in the community and how to
contact them
– Home and Community Care - professional team and
HSW.
– Specialized palliative care services.
– Community supports: hospice societies, caregiver
support services, transport, meals, etc.
•
Create an information package for patients and families
– Work with community providers to develop a kit for
patients …identify written materials and on-line sites.
– Where are additional resources found: local
libraries, resource centers.
104
Websites to obtain important forms
• BC Palliative Care Benefits Program
application form
https://www.health.gov.bc.ca/exforms/pharmacare/349.pdf
• Employment Insurance Compassionate
Care Benefits
http://www.servicecanada.gc.ca/eng/ei/publications/compa
ssionate.pdf
• Notification of Expected Death
http://www.health.gov.bc.ca/hcc/pdf/expected_death.pdf
105
Office methodology: Things to ponder…..
• When will your
meetings be?
• What supports do
you need?
• Who fits “The
Surprise
Question”?
• What other tools
will help you?
• What will your
registry look like?
• Where will your
toolkit be kept?
• What else can you
add to your toolkit?
• What’s in your
community?
• What is your billing
process?
• Your comfort level,
how do you feel
about this?
106
Thanks and feedback
We would appreciate your contact
information so that we can keep in touch
with you and further support your
implementation of this work.
107
Planning: What needs to
happen next?
Dr. Doris Barwich
108
Planning: What needs to happen next?
109
A good care plan addresses: Whole person
DIAGNOSIS
GOALS of
CARE
SPREAD
DISEASE
OTHER
PROGNOSTIC
FACTORS
BENEFITS
TREATMENT
BURDENS
CARE PLAN
PATIENT
SYMPTOM
BURDEN
(ESAS)
FUNCTIONAL
STATUS (PPS)
EXPERIENCE
(SUFFERING)
110
Goals of care
• Maintaining and
improving function.
• Pain and symptom
management.
• Staying in control.
• Relieving burden for family
members.
• Relief of suffering.
• Prolonging life for as
long as possible or until
a specific event (time
limited trials of care).
• Living well.
• Strengthening
relationships.
• Preferences for location of
care/ location of death.
• Life closure / dying well.
• Quality of life.
111
Care plans
• Care plans: Directed by the goals of care
translated into concrete patient specific plans
– May mean reduction in aggressive tests, procedures,
medications. Not doing ‘too much’ or ‘too little.
– Focus on quality of life and life completion.
– Collaborative.
112
Plan: Acknowledge realities
• Assessment of prognosis.
• Approaching death.
• Suffering of patient and family.
– Some suffering is unavoidable

Existential issues of meaning, multiple losses,
functional decline.

Spiritual concerns.
– Avoidable

Iatrogenic
113
Plan: Address suffering
• Acknowledging patient/family distress and suffering is
powerful.
• Non-abandonment: “I will stick with you”; “I am here for
the duration of your journey.”
• Your presence is therapy.
114
GPAC guidelines: Palliative care: part 2
7 Sections: Brief overview, algorithm, medications
• Pain management
• Dyspnea
• Nausea and vomiting
• Constipation
• Delirium (includes section on palliative sedation)
• Fatigue and weakness
• Depression
115
Plan: Manage symptoms
Fraser Health symptom guidelines: > 20 topics covered
• Extensive literature and peer review (4th edition: April
2009).
• Being reviewed and revised as a provincial document (BC
Learning Centre for Palliative Care).
• http://www.fraserhealth.ca/professionals/hospice_palliative_
care
116
Common symptoms: Dyspnea
• Dyspnea present in 95% of
pts with COPD and 75% of
patients with advanced
disease of any cause.
• Despite a good evidence
base many people with
chronic disease do not
receive opioids for dyspnea
until they are dying.
117
Medical management: Opioids
• Meta-analysis:
OPIOIDS lead to statistically significant and clinically
consistent improvement.
• Drug of first choice in management of moderate to
severe dyspnea.
• Can be used for dyspnea in cancer, COPD, CHF,
neurological disorders (e.g. ALS).
• Relief occurs in the absence of significant changes in
blood gases, oxygen saturation.
Jennings: Meta-analysis Thorax 2002
118
Address issues related to functional decline
• Exercise.
• Equipment and supply needs.
• Falls prevention.
• Financial concerns.
• Caregiver burden and support needs.
119
BC Palliative Care Benefits Program
• Purpose: To support individuals of any age who have
reached the end stage of a life-threatening disease or illness
and who wish to receive palliative care at home.
• Eligibility - Canadian residents who meet all criteria:
– Living at home.
– Diagnosed with life-threatening illness with a life
expectancy of up to 6 months.
– PPS score of 50% or less (exceptions considered).
– Consent to palliative rather than treatment oriented care.
• Physician submits the signed BC Palliative
Care Benefits Program application on
patient’s behalf.
120
BC Palliative Care Benefits Program (cont'd)
• Approved Patients Receive:
– Palliative Care Drug Plan covers 100% of the cost of eligible
prescriptions (approval within 24 hours).
– Assessment by health authority to determine need for supplies
and equipment (e.g. PPS 50->30%) - a priority assessment.
– Clients reassessed monthly to confirm need and eligibility.
– Community Nurse will discuss with GP if patient no longer in need
of free palliative supplies and equipment.
• Drug Coverage:
– Some drugs not on PharmaCare’s Plan P formulary may be
considered benefits under Special Authority coverage if needed to
alleviate patient discomfort (#4.2.2 in Guide).
– Coverage continues as long as the client is diagnosed as
requiring palliative care.
121
Compassionate Care Benefits Form
• Provide Employment Insurance (EI) benefits to those
who have to be away from work temporarily to provide
care or support to a family member who is gravely ill and
who has a significant risk of death within 26 weeks (six
months).
• A maximum of six weeks of compassionate care benefits
may be paid to eligible people.
122
Use the End of Life Care Plan
Refer to:
• End of Life Care Plan Template.
• Track interventions.
• Track response to treatment.
• Other providers involved and plan of care.
123
Supports to team-based care
• Establish reliable methods of message leaving and
retrieving messages.
• Establish how patient visits and referral between team
members should be made.
• Advise others on what information is useful on referral.
• Agree how and when communication between
professionals will occur.
• GPs learn how to bill for palliative care in CD (reference
in package).
124
Getting the help you need from
the team
Della Roberts
125
Team players
•
•
•
•
Patient, family and informal network
Family physician
Community pharmacist
Home Health / Community Care –
– Nurses/rehab/home support
•
•
•
•
Nurse practitioners, community RT
Acute care discharge nurses
Disease specific specialists / services
Hospice palliative care consult teams
126
Transitions in life-limiting illness
Early
Transitions
Disease
containment
Decompensation
Maintaining
function
Experiencing life
limiting illness
Transitions
Decline and
terminal
Dependency and
symptoms increase
Transitions
Transitions
Death and
bereavement
Transitions
Time of
diagnosis
Time
McGregor and Porterfield 2009
127
Spectrum of collaboration
– Parallel practice
– Consultation/referral
– Co-provision of care
128
Transition 1
Advancing disease
Referral - Home and community care.
Chronic disease clinics
– Identify main contact in community and ensure
information exchange.
– Discussion with patient family of goals, wishes and
plans as illness advances and acute changes occur.
Plan for health changes.
– Tools – advance care planning; guidance for advancing
illness, goals and wishes, identification of substitute
decision maker.
129
Transition 2
Decompensation
Prognosis months versus more than a year;
cancer – PPS 50%
– Referral to Home care for Palliative services nursing/rehab/home support/equipment




Tools - Palliative benefits ; GP letter from HH - needs
response.
Coordination of care conversation between GP and HCN.
Enable ready access to achieve co-provision of care vs
parallel practice.
Discuss pt/family goals and wishes as illness advances put plans in place.
130
Consultation with hospice palliative care
across transitions
• HPC specialists available
in each health authority but specific access
different.
• HPC team and structure
in your community:
Physician, nursing,
psychosocial support.
• Describe the support for
after hours and
weekends.
131
Indicators of referral HPC specialist
• Complex patient / family specific
needs and anticipated illness
course.
• Patient / family distress with
symptoms or coping remains after
providing care
– No resolution within 2-3
interventions.
– Distress continuing.
– Complex family dynamics and
indications of total pain.
• Self reflection - knowledge, skill and
ability of involved team in relation to
patient/family needs.
132
Criteria for hospice palliative care/home
care/BC benefits
• Criteria is both prognosis and needs based
– Last months of life.
– Accepting of palliative services.
– Need home based services.
133
Transition 3
Dependency and symptoms
• Increased frequency of team communication.
• HCN and GP connecting via fax and phone anticipating
changes, responding to acuity, preparing patient and family
for changes and death.
• Identify goal and backup – home death or hospice/hospital.
• GP home visit – ideal in conjunction with HCN; plan for 24 hr
access to support for patient/family.
• May consult with HPC for complexity of symptoms – reference
to symptom guidelines.
• Tools – palliative care planning conference; No CPR order;
preparation for time of death; may complete
Notification of Death form.
134
Transition 4
Last days
• Responsiveness / plan required – anticipating dying – may
be change in plan for home death.
• Nurse and physician: Reinforce family preparation what to
expect prior to death and at time of death.
• Anticipate route changes, meds for active dying.
• Clear plan who to call for what 24/7.
• Complexity – HPC consult.
• Tools – medication kits;
– Notification of Expected Death
135
Table discussion
Think about your practice in relation to the
palliative approach:
• How can you more effectively work as a team
with these patients?
• How can you support one another?
• What could you do differently to maximize
the roles and time of all primary providers?
136
Collaborative practice: Table discussion
Identify one aspect of
care that you will do
differently in your
practice and when
137
How to support patient
and family
Dr. Douglas McGregor
138
What we know about GPs doing this work
• They find it immensely fulfilling.
• They get more comfortable at it the longer they are
in practice.
• A personal contact with a supportive palliative care
physician greatly enables this.
• Historically, it was very badly taught at medical school.
• It makes a huge impact on the patient and surviving family.
139
What equips GPs to give quality care in the
last days of life?
• Strong relationships with Community Nurses and local
palliative care teams.
• Good access to these resources.
• Shared clinical practice guidelines.
• Adequate remuneration for the time intensive nature of
the work.
• Availability and familiarity with local “medication kits” or
pharmacy arrangements.
140
Is this a good death? Who decides?
US Institute of Medicine (1997): “One that is free
from avoidable suffering for patients, families, and
caregivers; in general accord with patients’ and
families wishes; and reasonably consistent with
clinical, cultural, and ethical standards.”
141
Patient perspectives: A “good death”
• Pain and symptom management.
• No prolongation of dying.
• Sense of control:
– Clear approach to decisions and roles.
• Strengthening relationships:
– “Doing for others”; not a burden.
• Continuity of self:
– Before, during, and after illness.
• Meaning and completion.
• Life review, purpose and meaning.
142
Challenges of ensuring high
quality care at the end stages
What might some of the
“issues” be in relation to
the patient?
143
Challenges of ensuring high quality care at
the end stages
What might some of the family’s issues be?
144
Identifying and balancing the goals of care –
takes leadership and teamwork
• The biggest role here is guidance and leadership, after
clarifying the patient / family’s goals and wishes and
beliefs.
• Need to repeatedly check in with patient, family /
caregivers, and professionals about what is developing
or changing.
• Anticipation is essential.
• “Active listening” is critical.
145
Markers of the dying phase
• Patient withdrawing from world around them.
• Refusing tablets, food and drink or basic nursing
care (need to exclude obvious clinical depression).
• Decreased appetite, decreased oral intake.
• Decreased circulation, mottling, tachycardia.
• Changes in breathing patterns with respiratory.
congestion (trapped secretions) or periods of apnea.
• Changes in level of consciousness.
• Occasionally confusion, agitation, delirium.
• Changes in perception: Awareness of “other”.
146
End of Life care check list
• Points to consider when patients enter the dying phase:
– Review a patient's goals of care, preferred place of
care, what to do in an emergency.
– Refer to home nursing if not already arranged.
– Ensure that required forms are completed (No CPR
and/or Planned Home Death).
– Discontinue non-essential medications.
147
End of Life care check list (continued)
• Arrange for subcutaneous (SC) / transdermal
medication administration or a drug kit to be placed in
the home when a patient is no longer able to take
medications by mouth.
• Arrange for a hospital bed +/- pressure relief mattress.
• Arrange for a Foley catheter as needed.
• Leave an order for a SC anti-secretion medication
(e.g., atropine, glycopyrrolate).
148
Can the family do this?
• Practically?
– Elderly couple.
– Singles.
– Confusion/ incontinence/costs.
• Psychologically?
– Mental health or addiction issues.
– Out of keeping with family’s expected role or
usual activity.
149
Preparations for death
• Education and support for caregivers/family.
• You may need to prepare, guide, and
interpret the experience.
• Dialogue about dying and
preparations that need to be made.
• People who need to visit (and
those who don’t).
• Issue of “unfinished business”.
• Funeral plans/wills.
• Exploration of preferences for location of
death (home, hospice, hospital).
150
Preparations for death: Referral to hospice:
• May differ in each Health Authority but will require
involvement of palliative care team and clarification of
goals of care (No CPR; No dialysis; prognosis < 3
months; no IVs; no further acute interventions).
• Per diem cost (~ $30/day).
• More stable re symptom management.
• Private rooms and support for families.
• Do you need a back-up plan?
151
Preparations for death
When a home death is preferred:
• Access your local Home Health service/palliative care
providers and discuss an urgent referral. Information:
http://www.health.gov.bc.ca/hcc/pdf/expected_home_death.pdf
• Identify supports available:
– Will need caregivers who can provide hands-on care.
• Medications: Training in Subcutaneous medication
administration
152
Preparations for death (continued)
When a home death is preferred:
• Completion of community based No CPR form:
Includes
– Room to document plan for time of death (No 911).
https://www.health.gov.bc.ca/exforms/bcas/302.1fil.pdf
• Completion of the Notification of Expected Death form
to clarify pronouncement of death and final disposition.
http://www.health.gov.bc.ca/hcc/pdf/expected_death.pdf
153
Preparations for death (continued)
• Every family is different: Explore preferences for time of
death: Keeping vigil; who to call.
• Other arrangements: Spiritual support?
• Timing varies:
– Some die quickly, others more slowly.
– Some seem to “choose” to die alone, others
someone present.
– May require “permission” of family.
154
Preparations for death (continued)
?Oral intake Feeding? ?IV fluids.
Decreased oral intake is normal
and does not represent
starvation.
Parenteral or oral feeding does
not prolong life or improve
symptom control.
Need to re-direct caring -> mouth
care and ice chips.
155
At the time of death
• Acceptance of dying as a normal process.
• Patient/family as the unit of care.
• Shared decision making/Advance Care Planning:
– Information about prognosis and options for care with
appropriate time for reflection and discussion.
• Effective communication: Hope and support.
• Anticipatory planning.
• Management of symptoms.
• Management of transitions.
• Effective team work and support.
156
Supporting grief and
bereavement
157
Definitions
• Bereavement: the loss of a significant person and also
the period of adjustment for the bereaved after the loss.
• Grief: the normal response to the loss of someone or
something precious.
• Mourning: the social expression of grief after a death,
associated with rituals and behaviours within the
appropriate religious and cultural context.
158
Classes of grief
• Typical (Normal)
• Anticipatory
• Complicated
• Disenfranchised
• Unresolved
159
What are the patient/family cultural traditions?
• Do you understand how they have
developed over centuries?
• Are they important to you?
• Are they important to your siblings?
• Are they important to your children?
• What other traditions have you witnessed?
160
161
Understanding normal grief and how to support it
• 85% of grief experiences follow a normal pathway - it’s
not about fixing it.
• In the context of a death, grief is a complex lifelong
process that involves transforming a relationship rather
than detaching from it.
• We all grieve differently - allow for diversity.
• It often gets worse before it gets better.
• You can’t prevent grief, but you can try to develop
elements of resilience.
162
Resilience
“The capacity to bounce back, to withstand harm
to yourself”
• Insight
• Independence
• Relationships
• Initiative
• Creativity
• Humour
• Morality
163
Understanding normal grief and how to support it
• Bad News – SPIKES
• Lifestyle Management
– What is helpful for them
– “Homework”
• Education
–
–
–
–
–
–
–
Normalize the process not “going crazy”
What to expect
What is helpful
Giving hope
Key phrases
Clichés to avoid
Resources
• Pharmacology
164
Key phrases
• Use the deceased’s name.
• Acknowledge the death – “I am sorry James is gone”.
• Talk about the deceased and memories, ask about
“What are you remembering about James today?”
• Bring closure to the death “Do you have questions
about James’ final illness or treatment?”
• Talk about grief feelings: “How has James’ death
affected you?”
165
Key phrases (continued)
• “I am sorry”
• “It must be hard for you”
• “What would be most useful right now?”
• “Do you want to talk about it?”
• “Do you have someone you would like me to call?”
• “What do you miss most about James?”
• “What would you like me to do for you?”
• “What are your supports?”
166
Clichés to avoid
• “ I understand” or “ It’s for the best”
• “There was a reason” or “ It’s God’s will”
• “I know how you feel”
• “Time heals”
• “You will get over it”
• Avoid giving examples of those who are “worse off”
• Disallowing patient's feelings “ You should be getting
over this by now”
• Giving early advice
167
Resources
• Every member of staff should know how to access.
• Handouts / leaflets.
• BC Bereavement Helpline and other counseling/ grief
support resources.
• Local hospice society.
• Legal issues/ custody issues / public guardian and
trustee
• Specialist areas – children, teenagers, mental health
and addictions.
168
Complicated grief
• Need to recognize early because:
– Symptoms of complicated grief post loss are highly
predictive of impairment and complications at 13
and 24 months post loss.
– Rate of depression is 15-35% during the first year
after loss of a spouse.
– Suicide risk especially after loss of a child, loss of a
spouse (older men) and sudden traumatic loss.
– Higher rates of morbidity, mortality, health care
utilization, alcohol, tobacco, sedatives and impaired
immune function.
169
Practical tips for the office
• An immediate phone call to family/ caregiver.
• Inform and debrief with all staff in the office.
• Send a card – some staff may want to write
something too.
• Ensure all appointments are cancelled.
• Phone CHNs to thank and debrief.
• A follow up visit at 4 - 6 weeks.
• Another at 6 months.
170
Grief versus depression
Feeling
Grief
Depression
Mood states
Greater range, quick shifts in a day,
variability in mood, activity,
appetite, sexual interest in one
week
Mood and feelings static-consistent
sense of depletion, psychomotor
retardation,anorexia,sexual interest
Anger
Open, externally directed
Absence of external anger,
Internally directed
Sadness
weeping
Difficulty weeping or controlling
weeping
Self concept
Guilt associated with specific
aspects of the loss – preoccupation
with loss - world seems empty
Loss confirms they are bad or unworthy – punitive thoughts – global
guilt. Preoccupation with self
Responsiveness
Periodic – want solitude but
respond to warmth and
involvement
Static – fear of being alone and yet
unresponsiveness to others
Pleasure
Periodic – responds to warmth and
involvement
All pleasure restricted – loss of sense
of humour
171
Our circle of care
• Non – negotiable in this context of healthcare.
• Team meetings not just technical reviews but
remembering spaces.
• Awareness of early “burnout”.
• Awareness of staff supports available.
• Memorials are for the staff as well.
172
Acknowledging our own grief
For individual patients
• Individual “closure” rituals.
• Group “moment of silence”
or reflection on what we
learned from this person
about death.
• Photos or characteristic
items as transitions.
• Place for “thank you“ letters
for staff to see.
173
Acknowledging our own grief (continued)
• For cumulative deaths
– Personal philosophy of life, death, medicine

Certainty, control, responsibility.

Emotional distance, flexibility, conflict.
– Resources for avoiding stress, burnout

Balance personal, professional life.
– Rewards for this aspect of medicine

Sense of connection, accomplishment,
success.
174
Physician Health Program
Dr. Andrew Clarke
175
176
177
Break
178
Evaluation
Dr. Marcus Hollander
179
Billing criteria for new
incentive payments
Dr. Cathy Clelland
180
Case study – Mr. James Lee
• Mr. James Lee is a 74 yr old retired electrician.
• Has a history of COPD, hypertension and was diagnosed
with Prostate cancer 6 yrs ago (at age 68 yrs).
• Followed by both an urologist and a radiation oncologist
and maintained on hormone therapy.
• His COPD has been managed in a shared care manner
with a respirologist.
• Every fall you have undertaken a review of his COPD
Action plan and this has kept him fairly stable.
14053 COPD CDM
181
Office visit
• Last year, (5 yrs after the original diagnosis) James
indicated that he was having pain in his back and
shoulder.
• The radiation oncologist organized radiation for pain
relief and coordinated changes in hormone therapy;
the radiation relieved the pain initially.
17100 Office Visit
182
Community patient conferencing
• Fax your request to the oncologist and he calls the next
day re: some interim management and development of
a plan to manage his symptoms.
• Communicate this info to James by phone.
• Total GP time for conferencing 20 minutes.
14016 Community Patient Conferencing
Example for specialist:
10002 Oncologist billing code (non-urgent up
to 1 week)
183
Counseling visit for patient
• At the next appointment, you discuss the Advance
Care Plan and undertake counseling James on the
outlook of his prognosis and his related anxieties – 25
min counseling visit.
17120 Office Counselling
184
Urgent advice
• James is feeling quite poorly. You decide to urgently
consult his respirologist on options for management in the
community
• Respirologist calls you within 20 minutes and you discuss
James’ current status
17100 Office Visit
14018 Urgent (<2hr) Telephone advice from
Spec/GP with spec training
10001 Respirologist billing code for the
urgent telephone advice
185
Office counseling for family members
• You arrange a meeting with the daughter to
discuss her concerns. You undertake
counseling with her that takes 30 minutes.
00120 Office Counselling (for daughter)
186
Daily MRP care, discharge planning fee
• When you are not on call, there is a decline: hospital in
respiratory failure.
• He is seen by the respirologist on call in consultation.
• James remains in hospital 5 days.
• A 30 minute discharge planning care conference.
• You providing MRP care daily and he is first patient
seen each day; respirologist support.
13008 Hospital acute care visit X 5 (Daily
MRP care)
13338 First visit bonus X 5 days
14017 Discharge Planning care
conference X 2 units
187
Palliative care planning fee
• James is now ready for referral to BC Palliative Care
Benefits Plan and a Home Care Referral for
assessment of the home.
• Discuss a safety net.
• Complete BC Palliative Care Benefits Plan referral and
the No CPR form.
• 30 min palliative planning visit.
17100 Office Visit
14063 Palliative Care Planning Fee
188
Community patient conferencing fee
• You contact the Home Care nurse to
discuss the likely trajectory and anticipated
events. You and the nurse discuss the care
plan, agree on channels of communication
and ensure the MOA is aware of these
priority arrangements. 15 minutes total
conferencing time.
14016 Community Patient Conferencing
189
House call
• Joint visit with the Home Care Nurse and
assess their current goals of care and
capacity to remain at home.
• Following the visit, you and the Home Care
Nurse review and revise the plan of
management based on input from James
and his family – 20 min.
14016 Community Patient Conferencing
00103 House Call
1X200 Out of office age appropriate visit
fee for additional pts seen at house
call
190
Support of home care nurse
• Home care nurse agrees to call you at
least weekly regarding the situation
and you decide to visit every couple
of weeks. Plans are made for an
expected death at home.
13005 Advise about patient in community care
00103 Home Visit
1X200 Out of office age appropriate visit fee for
additional pts seen at house call
191
Other fees
• 00127 +/- 13338 Terminal care facility visit (depending
on patient Dx/condition only regardless if in “palliative
bed” or not - acute/LTC/hospice).
• 00115 Urgent LTC visit 0800 – 2300, 7 days/wk.
• 00114, +/- 13334 Routine long term care visit.
• 00112, 01200-2 + out of office visit Specially called to
see in acute care or hospice.
• 13008/13028 +/- 13338 Acute care visits.
• 14015 Facility Patient Conferencing.
192
Practice Support Program
Dr. Cathy Clelland
193
GPSC and PSP
• General Practice Services Committee (GPSC) –
who, what, why
• Practice Support Program (PSP)
– Who, what, why
– Reimbursement
– Accreditation – Mainpro C, Mainpro M1
194
Train the Trainer sessional payments
Train the Trainer Sessions (2 days)
2 x 1 day (max)
GP
Session x
4
$ 1,623*
MOA
16 hours
$320
Action Period (1 period)
Session x 2
$812*
195
Develop office approach
Dr. Douglas McGregor
196
Patient registry and flagging charts
• Include terminally ill patients with:
– Cancer
– COPD
– Chronic heart disease
– Renal failure
– Neurological conditions
– Dementia
• Develop EOL registry from CDM-based one
197
Office procedures
• Proactive planned recall or house calls near end stage
• Tools that can help communicate within the office
– Huddle Sheet
– Ringed physician specific communication binder
– EMR
• Put copies of the form/information toolkit (e.g. No CPR)
into examination room
• Physician - MOA dyad
• Specific arrangements about how healthcare professional
can get through to you
198
Planning for action period
Judy Huska
199
Model for Improvement
Fundamental questions for improvement
1. What are we trying to
accomplish? (Aim)
2. How will we know that
a change is an
improvement?
(Measures)
3. What changes can we
make that will
result in an
improvement? (Tests
of change)
200
Moving forward… with measurement
“If it is not measured, it's not medicine.”
- Dr. Marshall Dahl
“Some is not a number, soon is not a time.”
- Dr. Don Berwick
“Without data, everyone is perfect.”
- Dr. Paul Murray
“Data drives improvement.”
- Dr. Neil Baker
“The pride in which you wallow, without data may be hollow.”
- Dr. Dan MacCarthy
201
Measurement
• The purpose of
measurement is
for learning not
judgement
202
Practice aims:
What are we trying to accomplish?
The care for patients and families living with, suffer and
dying from life limiting and chronic illness can be improved
by redesigning primary care practices
– Early identification and use of palliative approach.
– Increasing the number of End of Life conversations.
– Development of collaborative care plans.
– Increasing use of assessment tools –
ESAS and/or Palliative Performance Scale (PPS).
– Improving physician confidence.
– Improving patient and family experience.
203
Measures:
How will we know that a change is an improvement?
• # of patients identified and placed on a registry.
• % of patients on a registry with a collaborative proactive
care plan in place.
• % of patients on patient registry that have been given My
Voice and having an ACP conversation.
• % of patients on the registry that had an ESAS and or
PPS (as appropriate).
204
Measures:
How will we know that a change is an improvement?
• % of GPs and healthcare providers that have an
improved experience in caring for patients at End of Life.
• % of GPs that are confident when engaging patients and
their family in conversations about End of Life (1-10
confidence scale).
• % of patients/caregivers who feel comfortable with their
End of Life care plan.
• % of caregivers who feel supported when caring for
patients at End of Life.
Data Tracker and Narrative Report
206
Just try it!
A P
S D
Better
assessment and
adequate pain
control = Better
death
A P
S D
A P
S D
Use of
screening
tools
Cycle 3: Try appropriate tools (ESAS,
PPS and pain diary ) on 5 patients and
encourage use of pain diary as needed
in the following month.
Cycle 2: Recall patient A in one week to review
pain diary. Was intervention successful?
Cycle 1: Try appropriate screening tools (ESAS, PPS) on patient
A on Tuesday and encourage use of pain diary to assess
effectiveness of intervention.
207
Where to start: What changes can we make
that will result in an improvement?
• What are you going to do
next Tuesday?
• What is the plan?
• Remember to think about
how you will
measure/track
improvement.
• Record on Action Plan
and report back in 15
min.
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Action period expectations
• Try tests of change.
• Measure and track your progress.
• RSTs may want to schedule practice visits with GPs
2nd week of January.
• Participate in monthly teleconferences in January
and February – Report back on completed PDSA
templates and Data Tracker and Narrative Report.
Support throughout the action period you can
expect: Practice visits from the coordinator.
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Next steps
Dr. Cathy Clelland
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Next steps
• Recruit Specialists
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•
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Respirology
Nephrology
Cardiology
Neurology
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Anaesthesiology
Gastroenterology
Physical Medicine
Emergency Medicine
Action Period activities
EOL TTT2 - March 3, 2011
Evaluation Form
CME Credits
Training material will be available at pspbc.ca
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Thank you!
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