Department of Family & Community Medicine

Enhanced Skills Program: Care of the Elderly Home Palliative Care Rotation Goals and Objectives

By the end of the rotation, the resident will be able to:

Medical Expert

  • Perform a complete home palliative consultation including the physical, psychological, social, spiritual, functional and safety needs of patient and family.
  • Demonstrate proficiency in the appropriate and effective use of opioids and adjuvant medications in pain management. Manage serious complex side effects of these medications.
  • Demonstrate the ability to develop and implement appropriate management plans for common symptoms relevant to patients receiving palliative care(i.e nausea, dyspnea, constipation, cachexia) including patients with advanced non-malignant diseases.
  • Demonstrate proficiency in using symptom screening and performance assessment tools in implementing end-of-life care.
  • Demonstrate knowledge and skills in the management of symptoms and issues arising in the last days and hours of life, including nutrition and hydration, terminal delirium and terminal respiratory secretions.
  • Demonstrate proficiency in addressing grief and bereavement.
  • Demonstrate proficiency in addressing psychosocial, cultural, religious, spiritual and existential issues.
  • Assess level of suffering for a patient, family member or caregiver and determine the appropriate intervention.
  • Demonstrate the ability to pronounce the patient in the home setting and provide bereavement support at the time of death.
  • Demonstrate the ability to manage issues pertaining to de-escalation of therapy, withdrawing therapy, palliative sedation and MAiD.

 

Communicator

  • Accurately elicit and synthesize information from, and perspectives of, patients and families, colleagues and other professionals. Conduct an interview or family meeting with multiple participants to gather information about factors affecting the patient and about a patient and family’s beliefs, concerns, expectations and illness experience.
  • Accurately convey needed information and explanations to patients and families, colleagues and other professionals.
  • Develop a common understanding of issues, problems and plans with patients and families, colleagues and other professionals to develop, provide and follow-up on goals of care and a shared plan of care.
  • Respect diversity and difference, including but not limited to the impact of gender, religion and cultural beliefs on decision making at end-of-life.

 

Collaborator

  • Participate in a collaborative inter-professional palliative care home visiting team.
  • Understand, recognize and respects the diversity of roles, responsibilities and competencies of other professionals in relation to their own.
  • Work with others to assess, plan, provide and integrate care for patients at the end of life.
  • Work collaboratively with other health care professionals and community organizations to provide coordinated care for patients at home at the end-of-life.
  • Respect differences, misunderstandings and limitations in oneself and other professional. Reflects on inter-professional team function.

 

Leader

  • Demonstrate time management skills to reflect and balance priorities for patient care, sustainable practice and personal life.
  • Demonstrate the effective use of resources across the health care system, demonstrating awareness of the just allocation of health care resources in the home.
  • Describe and appropriately engage available community resources in supporting dying patients in their homes.

 

Health Advocate

  • Respond to individual patient health needs and issues as part of patient care. Advocates for individual patients around relevant health matters.

 

Scholar

  • Maintain and enhance professional activities through ongoing learning.
  • Critically evaluate medical information, its sources and relevance to their practice, and apply this information to care for older patients at the end of life at home.

 

Professional

  • Demonstrate a commitment to excellence in clinical care and personal ethical conduct. Exhibit proper professional behaviour including adhering to legal and ethical codes of practice.
  • Fulfill the regulatory and legal obligations required of current practice, including obligations around death.