Palliative Care
Description
The goal of the Palliative Care rotation is to provide learning opportunities that will enable
residents to develop skills required for care for dying patients and their families in a collaborative
model.
Objectives
By the completion of this rotation, residents will be able to:
Family Medicine Expert
PAL2. Demonstrate an effective approach to advance care planning
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2.1 Discussion of Advance care plans: Initiate advance care planning discussions with patients
and families and participates in the development of highly specific and detailed advance care plan
documents that clearly outline the patient’s wishes that will serve to direct care in the event of
certain clinical conditions.
2.2 Quality of Life: Identify the elements that define “quality of life” for an individual patient living
with advanced disease. Understand that family members may differ in opinion from the patient
when prioritizing these elements.
2.4 Differing opinion: Appreciate that family members may differ in opinion form the patient when
prioritizing elements of quality of life
2.5 Legal definitions: Describe the elements of substitute decision-making, power of attorney, and
living wills.
2.6 Consultation: Refer for consultation (specialty or ethics) those patient with complex issues
PAL3. Discuss the patient’s goals of care, and needs (spiritual, emotional and psychosocial)
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3.1 Patient Feelings: Discuss and address the patient’s feeling, impact on function, ideas, fears
and expectations about their illness, dying and palliative care.
3.2.Values: Determine patient and family values, wishes, needs (physical, spiritual, emotional and
psychosocial) and how this may impact decisions regarding end-of-life care.
3.3 Conflict: Identify potential goals conflicts between the patient and others and seek to resolve
them.
PAL4. Assess function and symptoms using palliative care tools
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4.1 Tools: Demonstrate appropriate use of standard symptom assessment and communication
tools (e.g. Edmonton Symptom Assessment Scale, Palliative Performance Scale)
4.2 Resources: Use evidence based palliative symptom management resources (including
educational resources, books and tools) to support patients.
PAL5. Assess and manage pain by multiple modalities and delivery systems
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5.1 Assessing pain: Perform a comprehensive assessment of pain and non-pain symptoms.
5.2 Approach to pain: Develop an approach to pain management using key principles including a
consideration of pain patho-physiology, the World Health Organization pain ladder, and includes a
role for opioids, adjuvant medications and non-pharmacological tools.
 5.3 Opioid prescribing: Prescribe opioids effectively including proper initiation, dosage, titration,
rotation, breakthrough dosing, side effect prevention and use of oral and parenteral routes
a) Opioid toxicity: Describe and manage the clinical presentation of opioid neurotoxicity
 5.4 Adjuvant treatment: Integrate adjuvant therapy in the management of pain.
a) Pharmocological adjuvants: Select appropriate medication from commonly used adjuvants in
the management of pain (NSAIDS, anti-convulsants, tricyclic antidepressants
b) Non-phramacological adjuvants: Utilize non-pharmacological adjuvant therapies when
appropriate (radiotherapy, surgery, splinting, physiotherapy, TENS)
PAL6. Assess and manage common non-pain symptoms in the last year of life
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6.1 Common EOL symptoms: Prevent, identify and manage common EOL symptoms including:
nausea
vomiting
constipation
bowel obstruction
urinary retention
urinary incontinence
dyspnea
cough
delirium
anxiety
fatigue
anorexia
cachexia
oral problems
wounds
ascites
edema
PAL7. Recognize and appropriately address palliative emergencies.
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7.1 Palliative care emergencies: Recognize and address the following palliative care
emergencies:
spinal cord
compression
malignant bowel
obstruction
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SVC syndrome
cardiac tamponade
seizures
urinary obstruction
hemorrhage
7.2 Refer: Refer appropriately for specialty consultation.
FAM 5. Perform family medicine specialty-appropriate procedures to meet the needs of individual
patients and demonstrate an understanding of procedures performed by other specialists to guide
their patients’ care
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5.1 Selection: Determine the most appropriate procedures or therapies.
5.2 Consent: Obtain and document informed consent, explaining the risks and benefits of, and the
rationale for, a proposed procedure or therapy.
5.3 Prioritize: Prioritize a procedure or therapy, taking into account clinical urgency and available
resources.
5.4 Performance: Perform the following procedures in a skillful and safe manner, adapting to
unanticipated findings of changing clinical circumstances:
nasogastic tube insertion
parecentesis
thoracocentesis
5.5 Aftercare: Develop a plan with the patient for the aftercare and follow-up after completion of a
procedure.
5.6 Complications: Describe the normal post-operative healing course and recognize and manage
post-operative complications.
PAL8. Provide end-of-life care in multiple environments: hospital, hospice, care facility, home
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8.1 Last hours: Plan and manage for the care of the dying patient during the last hours of life.
a) Impending death: Recognize signs and symptoms of impending death
8.2 Setting: Recognize and access the differing resources in different palliative care setting:
patients' homes, hospice, nursing / retirement/ long-term care home, specialized palliative care
environment or in the hospital.
a) Home care: Access home care resources appropriately, identifying unique aspects of caring for
dying patient in the home.
8.3 Death certification: Pronounce death and conduct death certification. Identify situations in
which the coroner must be contacted.
a) Anticipation of death at home: Complete required documentation for patients planning to die
at home
Communicator
PAL9. Demonstrate an effective approach to conveying bad news and discussing prognosis
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9.1 Breaking bad news: Demonstrate sensitivity, compassion, empathy and respect when
conveying difficult news to patients.
9.2 Prognosis: Inform patients of the diagnosis of life-threatening or life-limiting illness or change
in trajectory of chronic illness. Inform patients of progression of disease and complications.
PAL10. Communicate with patient, families and care team about palliative and end-of-life care
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10.1Communicating with families: Identify situations that may benefit from a family meeting and
facilitate these meetings
10.2. Supporting families: Support patients and families coping with loss and bereavement, grief
(including anticipatory grief), risk factors for atypical grief and develop an awareness of local
resources to assist families through this process
Collaborator
FAM13. Work effectively with physicians and other colleagues in the health care professions
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13.1 Relationship: Establish and maintain positive relationships with physicians and other
colleagues in the health care professions to support relationship-centered collaborative care
13.2 Team communication: Demonstrate clear and effective communication (both written and
verbal) with physicians and other colleagues in the healthcare professions.
13.3 Shared decision-making: Negotiate overlapping and shared responsibilities with physicians
and other colleagues in the health care professions.
13.4 Positive work environment: Implement strategies to promote understanding, manage
differences, and resolve conflicts in a manner that supports a collaborative culture
Leader/Manager
FAM17. Engage in the stewardship of health care resources
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17.1 Resource allocation: Allocate health care resources for optimal patient care, including
referral to other health care professionals and community resources
17.2 Cost-appropriate: Apply evidence and management processes to achieve cost-appropriate
care
Scholar
FAM24. Integrate best available evidence, contextualized to specific situations, into real-time
decision-making
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24.1 Identifying knowledge gap: Recognize practice uncertainty and knowledge gaps in clinical
encounters and generate focused questions that can address them.
24.4 Integrating evidence: Integrate evidence into decision-making in their practice by reviewing
and appropriately applying guidelines from organizations such as Health Canada, the College of
Family Physicians of Canada, and relevant specialty societies such as the Canadian Pain Society.
Professional
FAM27. Demonstrate a commitment to patients by applying best practices and adhering to high
ethical standards
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27.1 Professional behavior: Exhibit appropriate professional behaviors and relationships in all
aspects of practice, reflecting honesty, integrity, commitment, compassion, respect, altruism,
respect for diversity, and maintenance of confidentiality.
27.2 Commitment to excellence: Demonstrate a commitment to excellence in all aspects of
practice.
PAL11. Recognize ethical challenges in providing palliative care and demonstrate the use of an
ethical framework for decision-making.
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11.1 Ethical framework: Employ ethical frameworks or tools for decision making in common EOL
situations as they arise in any environment
11.2 Decision-makers: Describe a sound ethical and legal approach to: obtaining informed
consent, assessment of capacity and substitute decision making
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11.3 Physician assisted suicide: Distinguish between physician assisted suicide, euthanasia,
palliative sedation and withholding and withdrawing therapy using an ethical framework.
PAL12.1 Personal impact: Demonstrate skills in self-reflection on the personal impact of
patient’s illness, dying and death
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12.1 Discomfort: Recognize personal comfort or discomfort in responding to patient and family
spiritual issues
12.2 Personal experience: Recognize how personal life experiences may affect their interactions
with patients and their families.
12.3 Sharing: Identify a colleague or resource with whom to share discomforts or challenges
Entrustable Professional Activities
 Perform common family medicine procedures.
• Provide palliative end-of-life care.
Evaluation
Field Notes
In-training Assessment Report (ITAR)