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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.


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.


Creating and documenting an individualized, person-centred care plan improves the quality and efficiency of care. Care plans place the patient at the focal point and guide the care that is provided. The use of care plans promotes communication, continuity of care, and coordination of care. The care plan should include the person’s goals and wishes, treatment decisions and consents to treatments or plan of treatment, preferred care setting, current and anticipated care needs, and the resources required to meet those needs. The care plan is documented in the medical record so that all team members have access to the information. The care plan is shared with the patient or their substitute decision-maker. The person’s ability to be involved in making decisions may change as their condition changes, and the care plan should be updated accordingly.

For Patients, Families, and Caregivers

Your care team should work with you to create a care plan that fits your values, wishes, and goals. Your care team should use this plan to provide palliative care that meets your needs. This care plan should be updated as often as you need.


For Clinicians

Collaborate with people with identified palliative care needs to create and document a care plan that reflects their individual values, wishes, and goals of care. This plan should be created at the start of their care and then reviewed and updated as needed.


For Health Services

Ensure that all health care settings have the tools, systems, processes, and resources in place for health care professionals and people with identified palliative care needs to create, document, and share individualized, person-centred care plans.

Process Indicators

Percentage of people with identified palliative care needs (or their caregivers) who state that they worked together with their health care provider to develop a care plan

  • Denominator: total number of people with identified palliative care needs (or their caregivers)
  • Numerator: number of people in the denominator who state that they worked together with their health care provider to develop a care plan
  • Data source: local data collection

Percentage of people with identified palliative care needs (or their caregivers) who state that they have had the opportunity to review and update their care plan when they wanted to do so

  • Denominator: total number of people with identified palliative care needs (or their caregivers) who have a care plan
  • Numerator: number of people in the denominator who state that they have had the opportunity to review and update their care plan when they wanted to do so
  • Data source: local data collection

Outcome Indicator

Percentage of people with identified palliative care needs who have a documented care plan in their medical record

  • Denominator: total number of people with identified palliative care needs
  • Numerator: number of people in the denominator who have a documented care plan in their medical record
  • Data source: local data collection
Individualized, person-centred care

Individualized, person-centred care consists of care and treatment that is customized for each person based on their values, wishes, goals, and unique health needs. The person with the progressive, life-limiting illness drives the care provided; a person-centred approach involves a partnership between patients and their health care professionals.


Care plan

A care plan is a written document that describes a person’s health needs and goals and the care that will be provided to meet them. A care plan is not the same as having a discussion about goals of care. Nor is it a decision or consent for treatments. A care plan is broader and different than a plan of treatment. A plan of treatment is associated with a health care decision and requires informed consent from the patient or substitute decision-maker.

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