Palliative Care Toolkit

Identify if the patient would benefit from palliative care early in their illness trajectory.

The following triggers help identify patients who may benefit from palliative care: 

• The Surprise Question: “Would you be surprised if the patient were to die in the next year?”
• Indicated preference or need for comfort care
• General indicators and disease specific indicators

Specific details for Step 1 are described in the Early Identification & Prognostic Indicator Guide (PDF) developed by the Mississauga Halton Health Integration Network. This tool was adapted from the Gold Standards Framework Prognostic Indicator Guidance Tool.

Assess the patient’s current and future needs and preferences across all domains of care. Assessment should include validated screening tools, an in-depth history, physical examination and relevant laboratory and imaging tests. Specific details on domains are described in Domains of Issues Associated with Illness and Bereavement (PDF).

Screening Tools

Screen regularly for distress and other needs using validated screening tools. Type and timeline of assessments depend on the severity, extent of life interference, urgency and complexity of the symptoms or needs identified.

• Edmonton Symptom Assessment System (ESAS, Cancer Care Ontario)
• Palliative Performance Scale (PPS, Cancer Care Ontario)
• Ken Rockwood 9 point Frailty Tool (Dalhousie University)
• Patient Reported Functional Status (PRFS/ECOG, Cancer Care Ontario)

Conversation and Consent Tools

Use the results of screening to prompt further discussions about a person’s wishes, values, beliefs, understanding of wellness and any illnesses, and goals for current and future care. These conversations are ongoing and should be revisited regularly.

• Healthcare Consent and Advance Care Planning: The Basics (Advocacy Centre for the Elderly)
• Substitute Decision Makers in the Healthcare Consent Act (Advocacy Centre for the Elderly)
• Conversation Starters (Speak Up Ontario)
• Advance Care Planning Conversation Guide: Clinician Primer (Speak Up Ontario)
• Engage in advance care planning discussions: Primary Care Toolkit (Speak Up Ontario)
• Encourage expression of wishes: Ontario Workbook (Speak Up Ontario)

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

• Symptom Management Guides (Cancer Care Ontario)
• Hospice Palliative Care Symptom Guidelines (Fraser Health Authority)
• Pathway Maps (Cancer Care Ontario)
• Expected Death in The Home protocol example (Central Local Health Integration Network)
• Ontario Drug Benefit Formulary/Comparative Drug Index (Ministry of Health and Long-Term Care)
• Billing and Payment Guide for General Practitioner Focused Palliative Care Physicians (Ministry of Health and Long-Term Care)                                          

Cancer Care Ontario’s Collaborative Care Plans

• Stable Collaborative Care Plan
• Transitional Collaborative Care Plan
• End of Life Collaborative Care Plan
• Condensed Version: Collaborative Care Plan

The following documents and forms are Ontario-specific resources that may be required as part of the care provided.

• Request for an Unlisted Drug Product - Exceptional Access Program (Government of Ontario)
• Request for Death Certificate (Government of Ontario)

These are additional palliative care tools created by Cancer Care Ontario and other organizations.

• Psychosocial Oncology and Palliative Care Pathway Map (Cancer Care Ontario)
• Palliative Care Toolkit for Aboriginal Communities (Cancer Care Ontario)
• End-of-Life Care Module (General Practice Services Committee)