Skip to main content

Evidence to Improve Care

Palliative Care

Care for Adults With a Progressive, Life-Limiting Illness

Click below to see a list of brief quality statements and scroll down for more information.


Quality standards are sets of concise statements designed to help health care professionals easily and quickly know what care to provide, based on the best evidence.

See below for the quality statements and click for more detail.

Quality Statement 1: Identification and Assessment of Needs
People with a progressive, life-limiting illness have their palliative care needs identified early through a comprehensive and holistic assessment.


Quality Statement 2: Timely Access to Palliative Care Support
People with identified palliative care needs have access to palliative care support 24 hours a day, 7 days a week.


Quality Statement 3: Advance Care Planning—Substitute Decision-Maker
People with a progressive, life-limiting illness know who their future substitute decision-maker is. They engage in ongoing communication with their substitute decision-maker about their wishes, values, and beliefs, so that the substitute decision-maker is empowered to participate in the health care consent process if required.


Quality Statement 4: Goals of Care Discussions and Consent
People with identified palliative care needs or their substitute decision-makers have discussions with their interdisciplinary health care team about their goals of care to help inform their health care decisions. These values-based discussions focus on ensuring an accurate understanding of both the illness and treatment options so the person or their substitute decision-maker has the information they need to give or refuse consent to treatment.


Quality Statement 5: Individualized, Person-Centred Care Plan
People with identified palliative care needs collaborate with their primary care provider and other health care professionals to develop an individualized, person-centred care plan that is reviewed and updated regularly.


Quality Statement 6: Management of Pain and Other Symptoms
People with identified palliative care needs have their pain and other symptoms managed effectively, in a timely manner.


Quality Statement 7: Psychosocial Aspects of Care
People with identified palliative care needs receive timely psychosocial support to address their mental, emotional, social, cultural, and spiritual needs.


Quality Statement 8: Education for Patients, Substitute Decision-Makers, Families, and Caregivers
People with a progressive, life-limiting illness, their future substitute decision-maker, their family, and their caregivers are offered education about palliative care and information about available resources and supports.


Quality Statement 9: Caregiver Support
Families and caregivers of people with identified palliative care needs are offered ongoing assessment of their needs, and are given access to resources, respite care, and grief and bereavement support, consistent with their preferences.


Quality Statement 10: Transitions in Care
People with identified palliative care needs experience seamless transitions in care that are coordinated effectively among settings and health care providers.


Quality Statement 11: Setting of Care and Place of Death
People with identified palliative care needs, their substitute decision-maker, their family, and their caregivers have ongoing discussions with their health care professionals about their preferred setting of care and place of death.


Quality Statement 12: Interdisciplinary Team-Based Care
People with identified palliative care needs receive integrated care from an interdisciplinary team, which includes volunteers.


Quality Statement 13: Education for Health Care Providers and Volunteers
People receive palliative care from health care providers and volunteers who possess the appropriate knowledge and skills to deliver high-quality palliative care.


10

Transitions in Care

People with identified palliative care needs experience seamless transitions in care that are coordinated effectively among settings and health care providers.


Transitions in care that are based on patient needs involve logistical arrangements to move a person from one care setting to another or from one care provider to another. To ensure continuity of care, transitions in care should be coordinated among knowledgeable and skilled health care professionals who are familiar with the person’s clinical status, goals of care, plan of treatment, care plan, and health information needs.

Timely and effective communication is essential to prevent problems that may occur if services and supports are not well integrated (e.g., delayed transfers, readmissions, or poor care). Identifying a member of the care team to be accountable for care coordination supports a smooth transition between settings and prevents communication failures. Information-sharing between settings to ensure all health care providers are aware of the person’s current condition is part of effective and coordinated communication. All information-sharing during care transitions must consider legislated privacy and security requirements.

Families and caregivers also play a vital role in transitions. Health care professionals should have informed discussions with them about available care settings. Health care professionals should work together, and with the patient, their family and their caregivers, to ensure that transitions in care are timely, appropriate, and safe.

For Patients, Families, and Caregivers

When you change care settings or care providers (for example, if you return home after being in hospital), your care team should work with you to make sure you and any new team members have the right information (such as information about your medication). They should also make sure you receive the services you need (such as plans for follow up).


For Clinicians

Ensure that people moving between care settings or care providers experience coordinated and seamless transitions. This includes facilitating communication between settings and other related processes.


For Health Services

Ensure that systems, processes, and resources are in place to facilitate communication and information-sharing between care providers and care settings during transitions.

Process Indicator

Percentage of people who receive palliative care whose medical record identifies the member of the care team responsible for care coordination

  • Denominator: total number of people who receive palliative care

  • Numerator: number of people in the denominator whose medical record identifies the member of care team responsible for care coordination

  • Data source: local data collection


Outcome Indicator

Percentage of people who receive palliative care (or their caregivers) who state that they experienced seamless transitions between care settings

  • Denominator: total number of people who receive palliative care (or their caregivers)

  • Numerator: number of people in the denominator who state that they experienced seamless transitions between care settings

  • Data source: local data collection

  • Similar question available in the CaregiverVoice Survey: “To what extent did he/she experience smooth transitions between all settings of care during the last 3 months of life?” (Response options: “Always, Most of the time, Sometimes, Rarely, Never, Don’t know”) 

Seamless transition

A seamless transition consists of a set of actions designed to ensure the safe and effective coordination and continuity of care when patients experience a change in health status, health care professional, or location (within, between, or across settings).


Coordinated effectively

Coordinated care is the deliberate organization of patient care activities between two or more participants involved in a patient's care (including the patient) to facilitate the appropriate delivery of health care services. Organizing care involves coordinating people and resources to carry out required patient care activities and is often managed by exchanging information among those responsible for the various aspects of a patient’s care.

Let’s make our health system healthier

Join Our Patient, Family and Public Advisors Program

Patients, families and the public are central to improving health quality.


Man smiling

Sign up for our newsletter

Are you passionate about quality health care for all Ontarians? Stay in-the-know about the newest programs, reports and news from Health Quality Ontario and sign up for our electronic newsletter.

Health Quality Connect - Health Quality Ontario's newsletter - on an iPad and a cell phone