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The following provides local relevance to each Collaborative Care Plan

Stable Phase: Cancer Patients: PPS 70-100%, Non-Cancer Patients: stable in identified trajectory

ü Begin goals of care discussions and end-of-life planning, including identifying the patient's substitute decision maker, document in the patient's medical record. For guidance on how to have these discussions refer to the following resources:

ü Complete Do Not Resuscitate (DNR) Confirmation Form (sample), if appropriate. This form can be ordered by visiting the Government of Ontario website.

ü Consider referral to Home and Community Care Support Services Mississauga Halton Palliative Care Program for community support such as Palliative Care Nurse Practitioner, Register Nurse, Personal Support, Occupational or Physio Therapy. 

ü Assess coping of patient and family, consider visiting hospice referral for support:

Transitional Phase: Cancer Patients: PPS 40-60%, Non-Cancer Patients: changing needs in trajectory

ü Revisit goals of care discussions. For guidance on how to have these discussions refer to the following resources:

ü Based on goals of care, begin making plans for end-of-life, including discussion regarding preferred place of care and document in the patient's medical record.

ü Refer to residential Hospice, if appropriate:

ü Complete Do Not Resuscitate (DNR) Confirmation Form (sample), if appropriate.  This form can be ordered by visiting the Government of Ontario website.

ü Complete Planned Death at Home Form, if appropriate.  Consider completing “just in case” even if primary plan is not home. Discuss in detail what to do when/if death occurs at home. Ensure your 24-hour contact for notification of death at home is on the form.

ü Refer to Home and Community Care Support Services Mississauga Halton Palliative Care Program for community support. 

ü Consider ordering a Symptom Management Kit (if PPS <50 or risk of severe symptoms).

ü Assess coping (patient and family), consider visiting hospice referral for support:

ü Consider ordering home oxygen, if needed.

  • Qualify for chronic funding, if feasible in hypoxic setting.
  • “Palliative funding” (i.e. no need to qualify) only approved for 3 consecutive months/lifetime from time of initial activation.
  • If not hypoxic but feeling short of breath, consider using bedside fan or cool cloth on face or pharmacologic management (opiates) to reduce sensation of dyspnea.

End of Life Phase: Cancer Patients: PPS 10-30%, Non Cancer Patients: end stage of illness

ü Revisit goals of care discussions and confirm plans for end-of-life, including preferred place of death and back-up plans, document in the patient's medical record.

ü Notify involved community providers of decline in clinical status for re-assessment.

ü Discuss common end-of-life symptoms (e.g. stop eating/drinking, breathing and skin changes, potential for terminal delirium) in advance to help prepare families for the end-of-life process, and how to access help if needed.

ü Consider the patient will not likely be able to leave their home in this phase.  Ensure provision for possible home visits by prescribing practitioner if complexity (see secondary supports if needed).

ü Consider the patient’s ability to take oral medication.  When nearing end-of-life discontinue non-essential medication. Anticipate transition to parenteral (subcutaneous) comfort medications as swallowing becomes difficult. Consider ordering a subcutaneous pain pump to replace routine oral pain medication when swallowing becomes too difficult.  Need help making the conversions?  In Mississauga Halton, Bayshore pharmacists can help: 1-888-313-6988.

ü If not hypoxic but feeling short of breath, consider using bedside fan or cool cloth on face or pharmacologic management (opiates) to reduce sensation of dyspnea.