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.


12

Interdisciplinary Team-Based Care

People with identified palliative care needs receive integrated care from an interdisciplinary team, which includes volunteers.


The model of care used to deliver health services can affect the quality of the care received. Team-based, integrated care facilitates continuity for people with a progressive, life-limiting illness, their family, and their caregivers. The team-based model of care includes the patient, family, and a nurse or physician with the knowledge and skills to deliver palliative care. The team may also include people in other roles, such as social workers, psychologists, spiritual advisors, personal support workers, healers, medicine people, Elders, or volunteers. The services provided by the team include symptom management, psychosocial care, care plan development, advance care planning conversations, goals of care discussions, and care coordination.

For Patients, Families, and Caregivers

You should have access to care providers who are knowledgeable about palliative care and who will work together to meet your needs and goals of care.


For Clinicians

Collaborate with other health care providers, volunteers, family, and caregivers to meet the needs of people receiving palliative care.


For Health Services

Provide adequately resourced systems and services to ensure that health care professionals, volunteers, and caregivers can work in teams to provide integrated palliative care.

Process Indicators

Percentage of people who receive palliative care (or their caregivers) who state that they have received care from two or more health care providers, such as a physician, nurse, social worker, psychologist, spiritual care provider, volunteer, and others

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

  • Numerator: number of people in the denominator who state that they have received care from two or more health care providers, such as a physician, nurse, social worker, psychologist, spiritual care provider, volunteer, and others

  • Data source: local data collection

  • Note: The survey respondent will be asked to select all that apply. Consider reporting by number and type of health care provider

Percentage of people who receive palliative care (or their caregivers) who state that their health care providers work well together

  • Denominator: total number of people who receive palliative care (or their caregivers) from more than one provider

  • Numerator: number of people in the denominator who state that their health care providers work well together

  • Data source: local data collection

  • Similar question available in the CaregiverVoice Survey: “When he/she was at home in the last 3 months of life, did the homecare providers work well together?” (Response options: “Yes, definitely; Yes, to some extent; No, they did not work well together; Don’t know”)

Integrated care

Health services are managed and delivered so that people receive care that is coordinated across the health system, at all levels and settings, and according to the patient’s needs throughout their life course. Integrated care involves the delivery, management, and organization of services for diagnosis, treatment, care, rehabilitation, and health promotion. Integration of care brings about better access, quality, user experience, and efficiency.


Interdisciplinary health care team

An interdisciplinary health care team consists of two or more individuals with different types of training and skills who work together to provide care based on a person’s care plan (see Quality Statement 5). The composition of the team varies depending on the services needed. The team may include various roles, as needed: physicians, nurse practitioners, registered nurses, registered practical nurses, social workers, psychologists, spiritual care providers, pharmacists, personal support workers, dietitians, and volunteers.


Team-based care

Team-based care refers to the provision of health services by a group of health care providers who work collaboratively with patients, family, and caregivers to meet their shared goals of care within and across settings of 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