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Discussion 5.1: Health Care Provider Training and Supports

over 1 year ago
CLOSED: This discussion has concluded.

A 2014 Ipsos Reid Survey commissioned by the Canadian Hospice Palliative Care Association (CHPCA) of general practitioners, family physicians and nurses in primary care found that 20-25% of practicing physicians are not very comfortable or not comfortable at all, 50% are only somewhat comfortable and only 25-30% of practicing physicians felt very comfortable providing palliative or end of life care.

How could interactions between health care providers and persons with life-threatening conditions be improved?

This consultation is now closed. 


  • AdvantAgeON about 2 years ago
    In long-term care settings, we need to ensure that ALL core health care providers are trained in palliative care. This means that the full care team – physicians, nurse practitioners, registered nurses, registered practical nurses and personal support workers – should be knowledgeable about palliative care so that the quality of care patients receive is not only comprehensive, but also consistent. Improving training, embedding palliative care in education, and making resources/tools about palliative care readily available can improve the interactions between health care providers and persons with life-threatening conditions.
  • Weston7050 about 2 years ago
    In long-term care settings, we need to ensure that ALL core health care providers are trained in palliative care. This means that the full care team – physicians, nurse practitioners, registered nurses, registered practical nurses and personal support workers – should be knowledgeable about palliative care so that the quality of care patients receive is not only comprehensive, but also consistent. Improving training, embedding palliative care in education, and making resources/tools about palliative care readily available can improve the interactions between health care providers and persons with life-threatening conditions.
  • JusticeinDying about 2 years ago
    The creation of Communications: A Palliative Approach to Care through collaborative healthcare, social sectors, long term care and workplace education has stimulated much needed conversations.

    We have become a society of tools and assessments yet finding education that supports the necessary interpersonal skill development that enhances care providers confidence in supporting persons- families in the dying- death and grief aspects of care is critical.
  • Sunflower52 about 2 years ago
    How do we improve these conversations? I decided to google this topic and I was very surprised to learn there are is a lot of research suggesting that poor communication style equates with poorer patient satisfaction (given) and poorer care and poorer outcomes. It's been researched and found to be true, that effective communication is essential to providing good health care.
    There are many competency building programs that improve interpersonal communication. Training is needed, and it should be ongoing. Remember that people get into habits that make their daily routines easier, and this includes lazy and ineffective communication styles. Less experienced health care providers may be intimidated and uncomfortable by some of the difficult conversations but on the other hand, those who are experienced health care providers might have become too insensitive.
    I am just wondering, of all the training programs there are, would something that shows the health care providers the patient perspective, as in how communication is perceived by the patient have the most impact? How about Sensitivity Training from the Patient’s Perspective?
    I have seen these training modules done for customer service reps, and I am sure there are some for health care providers too, but if not, I think it’s a worth while idea for someone to do. They are particularly effective when they are acted out. You get to see and hear the conversations. (and I might add do not under rate the impact of humor. If a person can laugh at something they do every day as opposed to feeling defensive, it’s a far more powerful learning tool)
    I had a friend who was told by a doctor that an operation to save her life would give her a 20% chance of survival and so it was not feasible. I can hear him say that and I think, “Its doctor speak.” I suspect this is something doctors say all the time. But to say it to a palliative patient! She died believing that the SHE was ‘not viable’. If that doctor could ever have seen the impact those words had on her, I think it would have been a powerful and life changing experience.
    So I think mandatory and ongoing sensitivity training and/or effective interpersonal communication for those in the health care field EVERY YEAR, would help. (especially doctors because they really do have the biggest impact on patient care.) And if possible, lets get some of those awkward and difficult conversations and show how they impact the patient – the good, the bad, and the ugly. Seeing how you impact a patient and their family is very powerful and should initiate improved communication.
  • SLD about 2 years ago
    I have found in general, that even before palliative care, many physicians know little on how to care for the elderly. I have experienced a lot of running around to get a proper diagnosis for loved ones over 80 as they are seen as in the death waiting room, and often their symptoms reduced to "well for their age..." Similarly with a terminal prognosis, it is not the end of care. Everyone should have care and dignity until the end; that is what a palliative care specialist knows better than any other physician in general.
  • Tia about 2 years ago
    early exposure to palliative care during training in addition to emotional, psychological support in processing those horrid feelings of helplessness in the face of watching someone die. No one will ever be comfortable with it, nor should one ever be. But the ability to know when you've done all you can and to let go would go a long way in helping physicians and nursing staff in finding some comfort and peace in these otherwise distressing situations.
    Hide reply (1)
    • Tia about 2 years ago
      to add, it may seem simpler to forego or reduce palliative care options and to move immediately to end of life options such as physician assisted death; however, as a dying person, what an awful thing it may be to realize that palliative care options have been reduced to nothing and the only option left is to die much earlier than you ever had to and, before you are ready, because no one around you is comfortable to be with you as you sort your life and go through the time and process you need. That would be tragic indeed.
  • lorlorntor about 2 years ago
    Early exposure during medical training to people who are dying should help all concerned to be more comfortable with the aspect of healing that is "being with" rather than "fixing the problem"
  • bjpalliative about 2 years ago
    Experience is the best teacher! One would think that is true, but often it's medical oncologists, who have the most experience, who have the more difficult time discussing hospice palliative care with their patients. They have the most trouble having those difficult conversations with patients. This is very odd. Health care providers, especially primary care doctors and nurses, need to practice this skill; it is not easy, but compassion will get you through just about anything. Role playing really works, but I suspect most doctors would resist such a strategy (too emotional, or some such thing). It's like learning to do injections; first, practice on an orange often, then do the real thing. After the first difficult discussion, it only gets better after that. Canada's health care system was developed largely using the British model and this model is alive and well today. Stiff upper lips and the use of cold, medical language still is very common. They need to learn to warm up, get close, share tough experiences with colleagues and find out just how rewarding it is to take care of the dying.
  • bg about 2 years ago
    With education/ training and empowerment of students and professionals in the field of health care.
  • Hirst about 2 years ago
    Clearly, the discussion of palliative and end of life care needs to be part of the training for health care practitioners and there should be opportunities post graduation for them to learn about and get comfortable with these two areas of health care. The emphasis on "cure" is not helpful.
  • hospice about 2 years ago
    CHPCA does not provide healthcare services first-hand, but rather develop, provide and advocate for the resources required
    for healthcare professionals to deliver palliative care services. This includes a robust network of online resources available
    through both chpca.net and advancecareplanning.ca, and advocating for more funding and resources for palliative care at all
    levels of government.
    The CHPCA aims to establish national benchmarks for palliative care education for all health care providers at all stages of
    their professional education, and to establish palliative care competencies for all health care providers and set a consistent
    minimum standard. This includes requiring that all health care providers and allied health professionals be trained in the
    basic principles and practices of palliative care; requiring that additional skills training be provided for those who frequently
    care for adults and children with advanced conditions; and requiring and providing expert training for all hospice palliative
    care specialists and educators. As well, the CHPCA mandates support and training for hospice palliative care volunteers
    across all sectors. The CHPCA also publishes a monthly eblast with resources and updates, which reaches approximately
    8,000 subscribers.
  • hospice about 2 years ago
    Many health care practioners want training in a palliative approach to care but do not have the means to do that what with time constraints and other pressures. We need to find the means to support additional training. With this additional training I think interactions will improve. Also, we should advance the practice of having ACP conversations between the health care providers and patient and family/caregivers. This has improved over time but we have a long way to go.
  • Maryisarat about 2 years ago
    I feel I was very lucky - both my mother-in-law's doctor and my father's doctor were very up front and able to talk about the reality of their cancer diagnoses and prognosis. Both died in different but larger urban areas where there was a strong hospice community and hospice beds. My mother-in-law ended up dying in her own home under palliative care...my father died in a hospice ward. Both were very positive experiences under the sad circumstances.
  • @truedignity about 2 years ago
    We had conflicting comments made by doctors about each other. One doctor said another has given too much false hope about cancer treatments, and the patient's expectation to recover was then highly unlikely. In such as case, should the patient been counselled to request end of life options? Nurses were saying that one of the doctors at the hospital also was giving a false sense of hope and perhaps palliative care ought to have been given much earlier, so that instead of all the anguish - there would have been much better pain management earlier when watching a loved one die slowly, starving, in excess physical distress over weeks as family witnesses this in distress. The bottomline is that there can be a professional assessment of likelihood of death - and when a patient is forced to die naturally, slowly, it is torture. We ought to be able to make our wishes known and witnessed by lawyers/doctors in advance, and when a situation arises where a patient's life-threatening condition cannot be reversed and the outcome would be starvation to death - like untreatable hyponatremia - my father inlaw was no longer given an option - simply by having untreatable hyponatremia, he was considered of not sound mind when he could still take instructions for a swallow test and have a brief conversation with family about grandkids - he had to die over days of physical distress, agitation and duress on his immediate family who found it torture to witness. We are all still not recovered from all of the impacts of the prolonged illness over the last 6 months. I pray that I will not have to go through this, or anyone else, or my close family. Do we each have to go through this - one by one as we face our mortality? Health care providers need advanced training from the Netherlands on how to effectively deal with end of life care and options.
    Hide Replies (3)
    • wellkabwell about 2 years ago
      true dignity 's story is all too familiar. Many people starve to death because they can no longer swallow. This can be as a result of alzheimer's or other dementia, stroke, cancer, etc. Their deaths can be excruciatingly slow (e.g., 10 days) especially if they were fed by tube before the decision to let them die a natural death. In other words, their bodies were artificially nourished before they began starving to death. Many palliative care physicians say that pain and other discomforts can be managed but it is not true in many cases. I have heard that palliative care for certain cancer patients cannot manage pain and discomfort. We are not being kind to these patients who have the right to choose how and when to die and to be supported to the end.
      Hide Replies (2)
      • @truedignity about 2 years ago
        The false hope of recovery was upsetting when it seemed that some doctors and nurses seemed to know that was not going to happen, so why allow someone to slowly and excruciatingly suffer? We felt horrible and helpless witnessing my father in-law, my husband's Dad suffer for almost two weeks. We were terrified it could be longer, but we couldn't tell when it would happen which made it even more stressful, incredibly distressing to family members whose health is also being impacted by long days and weeks of experiencing this duress (lack of sleep, poor eating, work/home stresses, financial stresses, physical ailments...). Even when in palliative care, the pain meds had to be adjusted and increased incrementally until my father in-law stopped appearing in distress and discomfort. I use the the word torture, because my sister in-law in complete sobbing said it was torture to see someone you love go through this. My mother in-law, my husband, myself, the grandchildren were sobbing for days on end in complete uncertainty about what would happen - no one wanted to leave his side, but we couldn't continue indefinitely like this or we'd all get sick from round the clock care after 7 years of a rollercoaster ride of cancer treatments and care-giving to extend life and beat mortality. What is this costing us as a society - not (just) financially, but physically - health-wise, emotionally and inter-generationally? it is traumatic to be party to allowing someone die slowly after they are knowingly going to die and so backward in this day and age. I am hopeful that this consultation will lead to some effective solutions and supports for practitioners as a number of the comments have provided by wellkabwell and pallium canada's comments.
        Hide reply (1)
        • alliedhealthworker about 2 years ago
          Sorry to hear you and your family had such a challenging experience, @truedignity. Just putting out there for public knowledge the fact that there is palliative sedation for use when individuals are experiencing intractable/unmanageable symptoms and when either they do not wish to hasten their own death (e.g., for personal values/beliefs) or when individuals are not candidates for MAiD. Not necessarily saying that that option would have been a good fit for your loved one or family, again, just mentioning it in case anyone participating in the discussion would benefit from knowing it exists. That being said, I can see how there could be challenges related to access (e.g., practitioners familiar with protocols, access to specific medications, etc.).
  • valeighgirl about 2 years ago
    By normalizing discussions around death and using the words "death", "die", "dying" instead of euphemisms. By not using the actual words, we perpetuate the death-denying culture in which we live, which continues to make having these essential conversations more difficult than they need to be. I have been told on numerous occasions how glad family and patients are that I don't shy away from using the word "death" in their presence- that it's "like a breath of fresh air" because there is no longer a 'pink elephant' in the room and we can actually speak frankly and openly about what is happening right in front of us.
    Hide reply (1)
    • alliedhealthworker about 2 years ago
      Agree. The open approach you mention also removes any possible ambiguity so to promote all members of the team (including patient/family) being on the same page and reducing opportunities for misunderstandings.
  • HPCReady about 2 years ago
    Best-practice comprehensive education designed to support adult learning. A physician’s comfort in palliative care provision is only a part of what makes a professional competent to provide palliative care. Confidence does not equate competence, although confidence is necessary to practice competently. There are many professionals who indicate that they practice palliative care, when in fact it is not according to evidence or standard acceptable practice. Health care providers should be held to that standard, which is grounded in best evidence-informed practices.
    Do Ontarian's know that presently, you do not have to have ANY standardized training in hospice palliative care to call yourself a palliative care provider? Including physicians. Or that many health care providers aren't supported to get the longer, palliative care training courses by their organizations? Or that many healthcare providers think that sitting through a single session on palliative care is adequate to claim competency or comfort in providing palliative care? Do Ontarian's know that there are actual, evidence-based programs out there that provide comprehensive palliative care education, but that the healthcare system we work in doesn't embed funds or time for education and updating? Nor are there enforcible consequences for not assessing for palliative care needs or providing a person with palliative care.
    Hide reply (1)
    • alliedhealthworker about 2 years ago
      Agree with you. Hopefully it's at least somewhat reassuring to know that there are current works in progress in Ontario through the Ontario Palliative Care Network to develop a competency framework for interprofessional healthcare providers working in hospice palliative care.
  • alliedhealthworker about 2 years ago
    Found an interesting article that speaks to patient empowerment with advanced disease. Some of the factors included self-identity, personalized knowledge in theory and practice, negotiating personal and healthcare relationships, acknowledgement of terminal illness and navigating continued losses. Perhaps by explicitly supporting patients and families by providing education (on disease as well as navigation of the healthcare system), we can encourage more open discussions and interactions.

  • Blackman about 2 years ago
    Compassion compassion compassion on the part of health care providers. I hear that this is one of the key experiences people in palliative care or family members of palliative care did not experience.
  • miserator about 2 years ago
    While this may come as a shock, physicians are not the only folks in palliative care. If fact many of them do not spend much time with their dying patients. Not because they are lacking but because of time pressures on them. We really need to stop looking at Palliative care from a physician only point of view. There are thousands of nurses and allied health professionals that spend way more time than physicians do with dying folks. Start providing nurses and other care providers with education and experience, and with the ability to contact a Palliative Care Team for support and guidance if needed
    Post secondary education for nurses and physicians and allied health should include a large and strong palliative component. A change from the current education of touching on it lightly. EVERYBODY dies and we can do it well, and should because this is a huge and profound time in any human being's life. One class or a week even in palliative care in post secondary education for anyone in medicine is crazy. You may never work with cardiac patients, or in obstetrics, etc. but you will, at some point, work with a dying person so why are healthcare providers SO poorly prepared.
  • pcresearcher about 2 years ago
    Synthesizing what is discussed below, there are several core components of health provider training and supports:
    -Improving medical and nursing school curriculum to incorporate a section on palliative care
    -Ensuring all physicians and nurses have a palliative care rotation
    -Encourage and possibly rendering mandatory ongoing palliative care education for providers
    -Have palliative care providers engage in capacity building exercises with non-formally trained palliative care providers
    -Create support services for palliative care providers to present/reduce burnout
  • inverarymary about 2 years ago
    In-service for nurses, doctors and psws is urgently needed for them to learn approaches that work with people suffering from dementia.
  • hfbkn about 2 years ago
    Make training in how to have such discussions with patients and their families a significant and mandatory part of medical school training.
  • HPCnurse about 2 years ago
    There is one area with great potential for improving the provision of hospice and palliative care in all care settings. Interactions between health care providers and people with life-limiting conditions could improve when all health care providers receive standardized, competency-based education that includes competencies addressing hospice palliative end-of-life care.

    Competencies may not sound exciting... but I have come to appreciate how competencies can guide and determine education.

    Competencies related to hospice palliative and end-of-life care identify the attitudes, knowledge and skills required by the health care provider to provide excellent care for people with life-threatening conditions and for their community/family.

    Competencies developed by those who regulate the profession or approve college education/certificates, provide direction to curriculum developers and to educators. Competencies make it clear what is expected of students upon graduation.

    We are fortunate in Canada to have a number of competency documents developed by the Canadian Association of Schools of Nursing (CASN), the College of Licensed Practical Nurses of Alberta (CLPNA), the Canadian Association of Continuing Care Educators (CACCE), the Ontario Ministry of Training, Colleges and Universities (MTCU), and the Quality Palliative Care in Long Term Care - Palliative Alliance research project. (For links to these documents go to blog posting at https://www.lifeanddeathmatters.ca/upon-time-competencies/.)

    We use competencies to guide curriculum and resource development at Life and Death Matters. The recently published text, “Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse” is based on the nurse’s competencies listed above.

    More recently, the Nova Scotia Palliative Care Program developed a palliative care competency framework which was published in 2017 (https://library.nshealth.ca/ld.php?content_id=34202519).

    The BC Center for Palliative Care will publish their competency framework later in 2018 and I understand that the Ontario Palliative Care Network will follow in later 2018 or 2019.

    What I see is a barrier is that health care curriculum is overly full – and without a clear mandate to address hospice, palliative, and end-of-life care competencies, these competencies are too often not addressed. This includes education for physicians, nurses, personal support workers, rehab specialist and paramedical workers.

    As we look to the future, it is essential that all health care programs be mandated to integrate hospice palliative end-of-life care content in core curriculum, and graduate students who meet nationally identified competencies.

    It is also imperative that we develop and provide resources that are accessible and engaging for students, and provide support for educators in curriculum development as they weave palliative care into and through their health care programs.
    Hide Replies (2)
    • wellkabwell about 2 years ago
      I agree that all doctors need certain competencies in end of life care in order to begin the conversation with their patients and to refer them as required. However, I do believe that end of life care requires a certain kind of doctor (just as skill and comfort in the courtroom is not shared by all lawyers). Over and above the knowledge and skills required, end of life care requires the doctor to be personally suited to caring for people when they are grappling with religious, spiritual and cultural views and assumptions about life and death. We cannot assume that we all share the same values and notions of what is right and what is respectful. For example, when I and my siblings said no to the insertion of a permanent feeding tube in my mother (as per her requests) a PSW in the LTC home questioned whether we had hearts. Obviously she felt that extreme measures should be taken regardless of the patient's wishes. I don't deny her the right to hold true to her own views, I am simply explaining that end of life care requires a very broad understanding of what might be appropriate care.
    • jhr about 2 years ago
      As a nurse educator, I have had the opportunity to engage with nursing students in a core nursing course devoted to palliative nursing care for the past 9 years. Over this time period, I had been constantly searching for a Canadian textbook that was user friendly, but also based on Canadian competencies, which did not exist. Fortunately, in December of 2017, I was introduced to the recently published text, Murray, K. (2017). Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse. Revised Edition. Victoria: BC: Life & Death Matters. This textbook allows nurse educators to integrate a palliative approach into care by incorporating the principles and practices of hospice and palliative care across all care settings, early in the disease process for people with life-limiting illness. Student response to this textbook has been overwhelmingly positive!! We are so very fortunate to have this incredible resource available in Canada. My hope is that more educational institutions and healthcare settings become aware of this valuable asset and begin to incorporate it into their curricula and have it available as a resource on nursing units. I will definitely be doing my part to continue to share this resource with nursing students and inform my nursing colleagues about its existence.
  • genhlisk about 2 years ago
    It is probably too much to ask that every general practitioner develop an expertise in age-related/ palliative care/ long term care issues. It would be extremely useful however if they were aware of who you should/can consult beyond those agencies (unfortunately like CCAC) who simply offer you a dispassionate, canned response....if you don’t know what question to ask , you’re out of luck.
  • monkeymom about 2 years ago
    Not all specialists need to be comfortable with palliative care but certainly family practitioners do. This should be made a required part of their education and internship experience. There should be optional post-grad training for MDs who find they are dealing more frequently with palliative cases such as ER MDs and certain specialists. In my experience palliative care nursing requires very special and dedicated people. It is not for everyone but the training and support needs to be available to those who choose to pursue it.
  • Buffy70 about 2 years ago
    Perhaps they could provide special training for doctors so they could feel more comfortable in taking on this responsibility.
  • Aware about 2 years ago
    Health care providers in general, not just physicians, should be better trained in end-of-life management, INCLUDING, physician assisted end-of-life.
  • Sherry Moran about 2 years ago
    Medical pratictioners - including nurses - should be able to provide information to suffering people about their end of life choices, including both palliative care and medically assisted deaths.
  • Janus about 2 years ago
    There is very little training for doctors in Canada's medical schools about palliative care. While many doctors are technically competent, even palliative care physicians, as specialists, are faced with very difficult circumstances, with children dying, for example, or with loved ones arguing about life-ending or life-sustaining measures against the express wishes of the actual patient involved.

    The physician who treated my mother-in-law as she was dying possessed no emotional intelligence whatsoever. The way in which he imparted the news to my father-in-law, brutally, that his wife was dying was the worst example that I have ever witnessed of callous disregard for a loved one's emotions and well-being. If it had been up to me, I would have filed an official complaint with the CMA and with other bodies regarding that particular physician.

    No amount of technical competency in a physician can make up for an utter lack of compassion - or for a frequently-held view that old people are expendable - and have reached their best-before expiry date.

    Doctors should all be required to take a course in medical school, and later on in their careers, as part of continuing education about emotional intelligence or EQ to be applied at the end of life, with their patients and the accompanying family members.

    Palliative care doctors, who are highly qualified, often move into other medical fields, as the emotional toll they experience in dealing with end of life situations on a daily basis affects them personally. We need to put better supports in place for palliative care doctors.
    Hide reply (1)
    • wellkabwell about 2 years ago
      I agree that palliative care physicians and other HCPs involved in end of life care have an especially difficult role to play because the biggest part of their competencies are human competencies rather than strictly medical competencies. Also, they are overseers of what is for the patients and their families one of the most traumatic experiences of their lives. If they are lucky it could be a very intense and spiritual journey that they share. If they are not so lucky, it can be a bitter journey filled with regrets that they will never forget.

      There seems to be a very callous approach adopted by many doctors. One wonders if this is their human response to working in a very difficult environment where they must build a wall between themselves and their patients in order to do what they have to do. The HCPs must focus on symptoms, the results of standardized tests, their own experience and judgement, while they must often ignore the pain and discomfort that their patient is suffering in order to be able to maintain that focus on the best medical course to take. However, for the palliative care physicians, they must do two things: focus on what is medically necessary to be done while also focusing on what must be communicated, what options and decisions need to be taken, what their patients and families are saying (and really meaning). Human empathy and understanding are paramount to their success. They deserve all the support and training and understanding that we can give them, even when they make mistakes. I think we can support them immeasurably by becoming knowledgeable patients who find out what dying is all about, how most people die, what options there are at end of life and then describing, in writing, with examples, what we would like at our end of life. Even if we don't cover every possibility, even if we don't foresee every new medical intervention that might come along, our words and examples will help guide the end of life professionals and family caregivers in either accompanying us along the way or in helping us die the death we would choose.
  • CCBB_1544 about 2 years ago
    Doctors need to make themselves available to family members as necessary to provide information. Doctors also need to be specially trained in recognizing if death is imminent and changing course of treatment from life-sustaining to keeping the patient comfortable before dying. They also need to listen to the wishes of the family members if the loved one cannot speak for themselves. They know what is normal or not for their loved ones in most cases. When our Mother died last year, we had to demand palliative care (in a hospital) and the doctor did not believe us that our Mother was dying. She did not receive such care until mere hours before her death, yet she should have had it at least two days before. This was agonizing for our Mother and for us watching this happen. Palliative care also needs to operate, or at least be available onsite 24/7, not Monday to Friday.
    Hide reply (1)
    • wellkabwell about 2 years ago
      You are so right about the need for HCPs to recognize when it is time to help someone die a comfortable death rather than imposing on the patient a terribly painful and exhausting and unwanted struggle to maintain life when there is no reasonable hope of recovery and living a comfortable life. It was surprising to me that HCPs were reluctant to say it out loud that their patient is dying. When my mother was dying, a very kindly nurse who specialized in palliative care pointed out the many physical signals that were indicating that my mother was already dying and that it was time to make the transition from helping her live the best life she could to helping her toward the best death she could expect given the times (e.g., medically assisted death was not available then). It is a difficult transition to make, HCP and family feel like failures, but once acknowledged, it frees the patient and the family to begin the very intense spiritual journey of acknowledging the passing of a loved one and of exchanging the words that must be said before it is too late.
  • qualicumgirl about 2 years ago
    I don't think it is acceptable for someone carrying a licence to practice as a family physician to then say they are "uncomfortable" or "uneducated". Is there on line continuing education that any doc can access?
    What about the training of new docs?
    Is there anything in the payment of doctors that allows them to learn about palliative care and how to deliver it? If the payment is in 15 minute segments seeing patients, then it is hard to see how most overworked doctors would take the time out to upgrade from "not comfortable" to "part of my job" just like anything else.
    Do doctors have the ability to get paid for the two hour discussion that might be needed with a patient at the end of life, to answer their questions? If not the doc, than the practical nurse? Someone trained in the practice to manage this? (seems that dentists were able to build in dental hygienists and make a go of their business....then why not doctors with death doulas?)
    Hide reply (1)
    • wellkabwell about 2 years ago
      Because end of life care is so sensitive and involves so many areas of care, I think we can acknowledge that not all doctors will be equally knowledgeable or skilled. However all doctors should at least have the basic skills to begin the discussion and then refer their patients as appropriate. Just as not all lawyers are comfortable being courtroom lawyers, not all doctors, even family physicians will be equally comfortable and skilled in end of life care. It takes a very good listener, an empathetic understanding, and a very rounded individual to deal with patients with different moral, religious and cultural understandings of life, death, and the doctor's role in these.
  • Trish about 2 years ago
    We need doctors with specialization in geriatric care
    Hide reply (1)
    • wellkabwell about 2 years ago
      Many people facing end of life issues are not elderly. I think that HCPs who are trained in palliative care would be able to help patients of all ages, including the elderly. Each age group might have their own needs, and palliative care specialists might choose one age group to treat, but I would think that many of the skills and knowledge would be similar, although I have to admit that personal suitability would vary depending upon the age group the HCP chose to help.
  • alliedhealthworker about 2 years ago
    In our hospital, there have been recent initiatives to support advance care planning conversations as well as conversations to support families at the end of life by using simulation. There's no one "right" way to have a conversation (even though there are some better and some worse ways), so providing practitioners with opportunities to practice conversations can be quite powerful. Communication skills are important for all professions, but focused reflective learning experiences specific to palliative care are not yet widespread.
    Check these out:
    - https://www.youtube.com/watch?v=5MhdfUObCUA&feature=youtu.be&t=1h31m40s
    - https://www.youtube.com/watch?v=Dy4tvk7R9k8&feature=youtu.be&t=1h36m52s
    Hide Replies (3)
    • wellkabwell about 2 years ago
      alliedhealthworker, thank you for the links. It made me think that a lot of training could be offered online so that the HCP can see the videos repeatedly if necessary.
      Hide reply (1)
      • alliedhealthworker about 2 years ago
        Glad you found it useful, wellkabwell! http://www.virtualhospice.ca also has great online resources. I think access to info in lots of different modalities certainly helps with training and access to info. The challenge with conversations and interactions, though, is that there are a lot of skills that really do require direct practice. E.g., simulation or role play to really properly target/reflect on things like communication skills, language use to promote health literacy, use of nonverbal cues/gesture/tone of voice, etc. Some of those nuances are harder to train electronically (not to say it can't be done, just has to be designed mindfully).
    • @truedignity about 2 years ago
      I'm glad such resources and training can be provided to support practitioners. We also need effective policies that allow practitioners to provide humane end of life options, like in the Netherlands, to patients who are not going to recover so they don't suffer needlessly and to minimize their duress and that trauma on their loved ones' health.
  • janetangela about 2 years ago
    From my own experience I think communication between care providers poses the biggest problem.
  • CanadianVirtualHospice over 2 years ago
    Improving health care providers comfort and skills in having discussions with people who have an advanced illness or condition is essential to improving interactions between health care providers, patients and families. The Canadian Virtual Hospice (http://virtualhospice.ca) offers various tools to support practice in our For Professionals Portal (see link below) to foster improved communication between health care providers, patients and their families. A very popular article “Sit Down, Lean in” authored by our clinical team lead Dr. Mike Harlos discusses the importance of engaging the person (not the patient) in order to address suffering. Jim Mulcahy’s “A Story About Care” shares how a simple gesture from a nurse profoundly changed his health care experience. Our Tools for Practice section has over 800 categorized listings including resources about starting difficult conversations, being present, and person-and family-centred care. Tools are added on an ongoing basis and all are reviewed by our clinical team. Among the recommended organizations with resources to support improved communication are: Canadian Society of Palliative Care Physicians, http://DignityinCare.ca, Pallium Canada, Victoria Hospice Society, Life and Death Matters, deSouza Institute, and iPanel. Our Gallery features 100s of videos for professionals on various topics including videos on talking with patients and families. By sharing the stories of Indigenous people, immigrants and refugees from 11 cultures in over 600 video clips, http://LivingMyCulture.ca supports culturally safe palliative care. It is a useful tool for health care providers wishing to improve interactions and care outcomes by enhancing their knowledge and skills in providing care for a person from a different culture. The Quick Consult feature identifies challenging clinical situations not covered in text-books and provides guidance by our clinical team. It includes a section on communication. http://Methadone4Pain.ca is a free, accredited online training course on methadone for analgesia in palliative care that assists health care providers to address patient and family misunderstandings about methadone. Health care providers often use http://MyGrief.ca and http://KidsGrief.ca to enhance their understanding and support for those who are grieving. All the resources mentioned above can be accessed free of charge through For Professionals: http://www.virtualhospice.ca/en_US/Main+Site+Navigation/Home/For+Professionals/For+Professionals.aspx
    Hide reply (1)
    • wellkabwell about 2 years ago
      Thank you for sharing your knowledge and the links.
  • palliumcanada about 2 years ago
    We see education as the critical component to improving the interactions between health care providers and persons with life-threatening conditions. This education needs to include a focus on both the general public, with respect to the true meaning and value of palliative care, as well as health care providers regarding how to appropriately and effectively engage in and deliver an early palliative care approach. There is a strong and ever-growing body of evidence that shows that palliative care, particularly when integrated earlier in the illness, improves patients’ quality of life and reduces health care costs without reducing their life expectancy. If more care providers, and health teams, were trained in palliative care, they would be better prepared to provide care throughout the course of life-threatening illness, and those in their care would be more likely to receive care in their setting of choice. Since its inception in 2000, Pallium Canada has developed a large experience and empiric-base in this area and has completed extensive research on the quality, relevance, need, and impact of its LEAP courses. In our experience, palliative care is best provided by an interprofessional team and this approach to palliative care has been tightly integrated into all our products and LEAP courses though inter-professional team learning. This helps health teams improve communication and collaboration, which can reduce the risk of patients falling through the cracks and not receiving the care they need. Our research provides evidence that, across a number of professions that include physicians, nurses, pharmacists and social workers, the interprofessional Pallium LEAP courses are significantly improving knowledge, attitudes and comfort levels related to providing a palliative care approach. Equally, if not more importantly, our research provides important emerging evidence, through the commitment to change statements and reflections, that learners are implementing what they learn into their everyday clinical work with patients and families and alongside colleagues. The majority of commitments reported at 4-months post course were implemented into practice, with physicians and nurses reporting the highest rate of implementation (73%). There is strong evidence that Pallium Canada’s curriculum development and knowledge translation and diffusion models provide an effective approach with which to further spread and scale-up of the palliative care approach across Canada and provide health care providers with the educational and training supports that they need.
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    • wellkabwell about 2 years ago
      pallium canada has made some very good points. This consultation has raised a Question in my mind. Should palliative care teams also handle medically assisted death? Because they are a team that communicates all options and changing options with the patient and family caregivers, I think they are best equipped to deal with discussing the medically assisted death option. Presumably, another member of the team might specialize in the procedure itself.

      To make this all work, governments would have to have a policy that allows for HCPs to be paid for their time in providing this kind of care. The policy would have to take a different approach than the task-oriented approach that is normally used to pay health care professionals (e.g., PSWs have xx minutes to help a resident in a LTC home but have 0 minutes to sit and chat with them). In complex cases, there might have to be several discussions with patients and their families before all options are explored and understood and before a decision is made.
  • Poli about 2 years ago
    They must learn not to be afraid of using the word “Death”. This is just the end of life and should be talked about in a way that people don’t fear it.
  • Marnie about 2 years ago
    To me, that is what health care providers, particularly practicing physicians, should be asked. Why are 20-25% of practicing physicians not very comfortable and/or not comfortable providing palliative or end of life care? What would those practicing physicians find helpful with regards to increasing their comfort levels? Why are fifty percent (50%) of practicing physicians only somewhat comfortable providing palliative or end of life care? What would those practicing physicians find helpful with regards to increasing their comfort levels? What explanations do the 25-30% of practicing physicians who are (very) comfortable providing palliative or end of life care have with regards to their high(er) comfort levels? Can we increase the number of practicing physicians specializing in palliative or end of life care? It would be better to have physicians providing palliative or end of life care who want to provide, are good at providing, and are comfortable with providing palliative or end of life care.
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    • wellkabwell about 2 years ago
      I agree with Marnie's comments. Physicians are trained to save life and that is good, but to transition at some point to helping a patient die with respect and in as much comfort as possible is not taught in medical school. Only doctors who are comfortable with palliative care should be practicing it but all doctors should be trained and aware of the issues so that they can refer patients if they are uncomfortable providing the care. Surprisingly, many long term homes say they can provide palliative care but most LTC staff are not really trained adequately except from a strictly medication point of view.
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      • alliedhealthworker about 2 years ago
        I agree with both of these comments. I imagine that part of the challenge is in the feeling that death is a "failure" for those who are trained in saving lives (particularly if they have not received support/education or had experience with dying and death prior. I also agree that these questions might be worth asking providers directly - i.e., doing more digging/research to determine what factors underlie discomfort.
  • Vera about 2 years ago
    There needs to be more specialized Palliative units and Community Outreach teams. This would provide people with access to care provided by Palliative Care specialists.. Those working in other areas of the system need more training so they can become more comfortable with Palliative Care.
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    • wellkabwell about 2 years ago
      I support the idea of specialized palliative care teams who go into homes, hospitals, retirement residences or long term care homes. The LTC homes get VERY LITTLE training in palliative care. Also, the LTC staff have been helping people live as comfortably as possible and they find it difficult to transition to helping people die in comfort and according to their own choices. As we age (as I am) I want to control the circumstances and timing of my death and to make choices for myself as I did during my adult life.
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      • alliedhealthworker about 2 years ago
        I agree that more palliative care (and palliative care training/education/supports) should be available through LTCs. These facilities are people's homes, and the residents of LTCs should have the opportunity to die at home in comfort as other community-dwelling individuals do. Staff would need either access to specialty palliative consultation services to support this, education to empower them to provide that care themselves, or some combination of these.
  • gunits about 2 years ago
    If the health care team is not comfortable then get yourself out of the situation. When someone if diagnosed terminal there should be health care providers who take over for this situation alone. My father had this, the pallative dr came right to him when he was at home. He made the call to put him in hospice. This was an excellent way to do things. Takes the guilt from the family and gives them access to someone who is truthful with them. My mother on the other hand was surrounded by medical staff who were avoiding talking the truth and being in the room with her. I had to explain to them many times she is dying where is your compassion. I have seen people who do only this, so there are very special healthcare workers out there.
  • Caffy about 2 years ago
    Ensure that health care providers receive training to provide even basic services, whether during their medical training, and/or ongoing education. All healthcare providers should be aware of what is available in terms of services in their area. If they do not feel comfortable interacting with clients, then they need to ensure that they share with clients info and referral to agencies that do. Effective client interactions takes time and practice. I realize that some care providers are less comfortable in this role.this
  • Jasper about 2 years ago
    My mom and dad died four years apart, and had the same doctor. With mom, she wanted specific information from him about dying, the time she had left, etc. He brushed her off and told her she had five years. She had only weeks. When my dad was dying and asked for a visit from this same doctor, he refused to come. He had been my parents doctor for many, many years. That was heartbreaking for them, and for us. He was obviously very uncomfortable dealing with death - up until then he had been a good doctor. Definitely all family physicians need adequate training in dealing with matter of compassion and death. Death is part of life, and needs to be front and centre in medical schools.
  • Healthier about 2 years ago
    Spend more time with patients and improve your empathy skills.
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    • Marnie about 2 years ago
      You cannot force empathy and, sometimes, "familiarity breeds contempt." 😞
  • MAIDadvocate about 2 years ago
    After 40 years in health care, acute care physicians are not geared to talk about terminal illness (seen perhaps as a failure of medicine). There needs to be more open discussion of end-of-life care which ought to include MAID as a legal option.
    I have had relatives and seen LTC residents' family search for someone to assess their loved one while they are dying. I hate to see people die alone which happens in LTC homes with limited staff (which is all of them). I understand from someone working in Palliative care that there is an option for palliative care in LTC but I have yet to see it 6+ years later. I personally have connected with and consoled relatives in their time of need. Therefore more needs to be done in places where you know people are going to die.
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    • wellkabwell about 2 years ago
      This is so true. LTC staff are not equipped, nor will they ever be equipped, to support residents and families during the resident's end of life. Special teams who can provide support in all areas of palliative care are needed. This would also allow the staff to visit the resident, who has been part of their lives for perhaps years, and to grieve as any friend might do.
  • yeold about 2 years ago
    There needs to be more dedicated (funded) emotional and educational care and support to give people with a terminal illness agency over their end of life choices. Some medical personnel are wonderful with people, but they often do not have the time to spend (nor should they) supporting dying people with their emotional care. It's also somewhat counter-intuitive to what they usually do, help us live longer and healthier. This could have an impact on quality of life and possibly less people extending their life despite it increasing their suffering. This in turn would decrease the load on our overburdened medical system.
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    • wellkabwell about 2 years ago
      I agree that we should not expect all physicians to be able to deliver palliative care but all physicians should be able to discuss end of life issues with their patients and should be able to refer their patients for palliative care at the appropriate time. Handing out a leaflet with a list of palliative care providers would be a start but is not the whole picture of what a physician should be able to provide to their patients. I wholeheartedly agree that it is extremely difficult to transition from helping someone live to helping someone die in comfort and according to their own wishes. Mobile, independent palliative care teams providing care in the patient's home, wherever that may be, is the answer. These teams will have chosen palliative care because they are comfortable with it and feel they are providing a valuable service at a critical point in their patient's life (we hope).
  • Depression baby about 2 years ago
    In most of the comments already posted education is stressed. However, education of HCP is a meanngless waste of time without the policy and program support from Health Ministries.(federal and provincial). In practical, on the ground terms HCP must be afforded financial support for taking the time to deal with end-of-life patient issues/choices AND they must be afforded financial support for the actual responsive care required during the terminal stage. Almost everyone has experiencd or witnessed the abandonment by the specialist medical personnel whose sole focus is treatment and cure. Once that is no longer possible - they are no longer available often leaving the former patient in limbo (purgatory?) Not acceptable and contrary to the "do no harm" requirement.
    The corrollary to this is the abuse of a DNR directive. The DNR is not a license to cease all treatment; parking the patient to await expiry. This was my personal experience when a sudden bout of pneumonia that turned septic afflicted me. Once the emergency ward staff ascertained, verbally, from my son that I had a DNR, I was parked and largely ignored. Until my son (and advocate) lost his temper and explained that I was not a vegetable but a fully functioning human until felled by my illness. Only then was treatment started.
    Hospital policy is often the biggest barrier to effective end of life management. Financial pressures force staff to limit treatment, move patients as quickly as possible to the least resource consuming status and rarely permit staff the luxury of genuine interaction with either the patient or the patient's family.
    Palliative care - whether in house or provided by speciallist mobile teams is a no brainer, saving money, able to work in a patient's home, saving hospital space and resources, specially trained/educated to handle both the psychological and physical requirements of terminally ill patients.
    In my personal opinion and by observation and from reading - most patients prefer to die at home but are often discouraged from doing so by lack of trained home supports, lack of family/friends, fear of imposing burdens on same, etc. Most are also fearful of being warehoused in LTC facilities as the shortcomings of these institutions are all too well known.
    The geatest injustices are perpetrated against those unlucky individuals who have outlived all family, friends, advocates and cannot afford private care. Even those with private means are easily ignored and/or victimised - especially by the "angels of death" who plague health care.
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    • wellkabwell about 2 years ago
      Hospitals are not equipped to provide palliative care as well as independent mobile teams that are sent into the patient's "home" to provide the sort of comprehensive care that palliative care implies. In hospitals you tend to get the medical part of palliative care, not necessarily the support to patients and families regarding the comfort, moral, emotional, and spiritual supports that they need and that they might not be able to articulate.
  • Mairy about 2 years ago
    All the survey indicates to me is that physicians like most of us are rattled by approaching death. However they are professionals. They need to get over it. More training, and more support will help. Also nurses and nurse practitioners can do the bulk of the work in well-funded palliative care units. And always there should be the option for assistance in death for those who have made that decision.
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    • wellkabwell about 2 years ago
      I support the idea of nurses and nurse practitioners looking after palliative care. Doctors do not provide most of palliative care except writing the prescriptions. Palliative care should be provided in the patient's home as much as possible and LTC homes should not be excluded because they are not and will likely never be properly trained for palliative care which is really just a small part of what they do, even though a lot of people die in LTC.
  • kadahl1954 about 2 years ago
    Recent experience with my brother in his last days in university hospital in Alberta (highly rated) shows that when the hospital considers itself as "not good at palliative care" and wants to discharge quickly without adequate time for palliative treatment plan to be put in place elsewhere, it seems that family is not adequately consulted and informed. The patient who "doesn't present well" who appears frail or in a daze, perhaps due to drugs and/or age, the active treatment hospital continues to try to find a medical solution even though "comfort care" was prescribed earlier. Not clear to patient, family or doctor/medical practitioners how the forms need to be completed. Even the transition coordinator lacked full competence to ensure adequate paperwork done.

    So much time is being spent keeping records, yet no one seems to read any further that the previous shift. When discharged and readmitted within hours, the patient needs to go back to the same floor and same records, not start anew.
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    • wellkabwell about 2 years ago
      I agree about the health care superstructure of filling out records that no one reads unless there is a subsequent complaint. The health care workers just ask the family or the patient who is often not in a position to answer completely. Also, it is common for active care hospitals to try to discharge patients to palliative care as quickly as possible leading to patients who are sent to independent retirement residences who claim they have the ability to care for them but who are inadequately equipped to provide the palliative care needed.
  • wellkabwell about 2 years ago
    There should be more public education and discussion about what happens when we die and our options as to how and when we die. This education is necessary for both individuals and for professionals so that we have a common understanding and language of death. Even among professionals with different backgrounds and training, the understanding of death is very limited in my experience.

    Also, I believe that professional caregivers must learn to respect the choices of the patient and the family. We don't all share the same opinions about what constitutes a comfortable death.
  • windsong about 2 years ago
    I honestly feel that the gap is not only with the comfort level of medical professionals but the lack of communication and education on death as a natural part of life. Our culture is about living, saving and sustaining. Death is inevitable for us all and it can't only be up to doctors and nurses to communicate and educate. We are not comfortable talking about death yet in reality we are all dying. A palliative diagnosis merely gives us a time frame for that particular person's life or death. While I do think that more communication skills on this subject would be beneficial for medical health care providers, I also think that more education on dying for all people would help. It is such an off-limits topic until something happens then the stress and emotion that naturally occurs is even higher because so much of it is new ground for lots of people.
  • Kate about 2 years ago
    Communication, openness, recognition that one person can’t know everything... team work! I feel there are some physicians very territorial about their patients care... my suggestion is learn more or share the care 😊

    I agree with the person who acknowledges policy too. It seems it is only with policy that we conform to new opportunities to care better.

    It seems the dollar is always important... so can we make this a ‘carrot’ so-to-speak!? Increased funding for those communities willing to support palliative care ventures ... from diagnosis on.
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    • NHRS about 2 years ago
      You touch on some very key points; commmunication, openness which increase likelihood of healthcare provider (HCP) becoming more comfortable with discussing and planning good care.

      I find that part of that conversation revolves around; (1) who holds the resource access (i.e., money and social supports), (2) who defines ‘good patient-centred care’ ? Loaded but important discussion. And then there is (3) the difference of rural and urban supports, especially when talking homecare and palliative access.
  • Jnunn76 about 2 years ago
    Provide physician's with End of life care training. Ensure med schools are teaching this as well. Provide funding for local specialists for a resource for Drs not familiar with palliative care. Within Ontario, for example, require 1 CAPSE or LEAP trained physician or nurse manager per team.
  • marox2419 about 2 years ago
    Surprise! Almost no one is comfortable talking about death. Funny - it's inevitable yet we continue to have difficulty talking about it. We can talk about birth ... it really is the same. Empathy training might help. Just start talking about death. Talk about palliative care. Talk about what it means to die. Talk about how you want to die. Get comfortable with your own choices. We who are aging want to have control over this part of our lives ... as we have had control over most of it so far. Dignity rather than suffering. My choice. And if you can't get comfortable ... please get out of the work so that others who are comfortable can step in.
  • Robynozz about 2 years ago
    Death is a process that needs to be supported - medically, emotionally, financially, and, in some cases, spiritually.
  • pspragie about 2 years ago
    I wonder how much communication training there is in medical, nursing, allied health professional schools? Perhaps communication about palliative care could be included as a competency? Mentoring or working with someone with good communication skills about palliative care and hopes for quality of life and what a good death might be to those persons with the person with the chronic or life-threatening condition and their family. Perhaps Atul Gwande's book, Being Mortal, should be required reading so that health professionals learn what palliative care might mean to the people they care for.
  • BSlawich about 2 years ago
    These interactions could be improved through the provision of specific training to allow health care providers how to handle communicating with patients with life-threatening conditions and discussing palliative care options with them. This training can be given at the same time as training for communicating about euthanasia, an equally difficult subject to discuss with patients.
  • LM-N2018 about 2 years ago
    End of life discussions are very delicate. The discussion needs to start around expectations . All expectations need to be laid out which includes the expectations of not only the person involved but also the doctor(s), family, nurses and anyone else who will be directly involved. I feel that if everyone understands what to expect from services and the process, it will be made a little easier. End of life is a very stressful time and what to expect during the end of life as in events and transitions as well as services are very important. If everyone goes in with different expectations in such a stressful and emotional time, misunderstandings are bound to take place, and will not be easily resolved. There are also times I am sure when one person many not feel that the decision to end care is the right one. And you can't change how a person feels. People must also be able to live with that. No-one should be forced to participate in an end of life transition if they disagree with the decision made to let life end.
  • QueenB about 2 years ago
    Physicians lack billable time to discuss end of life situations with patients. I am lucky enough to have a family physician who takes the time anyway and is educated in dealing with this situation. Most physicians are not educated or care to discuss these issues especially in walk-in clinics. Most people no longer have family physicians. Suggest that clinics specific to dealing with elderly or terminally ill patients be set up with all services in one place.
  • maddykate2 about 2 years ago
    Ongoing education is paramount for physicians. It is important that physicians draw on the health care team around them to support patients and families. Starting with a meaningful discussion around goals of care can be a starting point........these may shift at different points in an individuals hospital stay depending on clinical picture, set-backs and changes in functional ability.
  • Thantor about 2 years ago
    Training. This is a new role for general practitioners and so with medical school training made mandatory, physicians will become more comfortable. However, I am thinking that I should have access to a physician who is comfortable providing palliative and/or end of life care. This should be available to me, now.
  • ennaidret about 2 years ago
    It is my experience that our gp and gp’s who work in the emergency department are not well trained to deal with palliative patients. It is seen my me and my husband that they just do not care. Especially they avoid discussions with me, the caregiver. Find they receive my comments almost as contempt.
    Within the Integrated Palliative Care Program it is just the opposite. They respect and involve both my husband and I in all discussions and decisions. They have a lot to teach the health care system.
  • ennaidret about 2 years ago
    It is my personal experience that family doctors do not want to talk about it with the patient and caregiver. Homecare nurses are wonderfully trained and experienced at discussing care and providing support.
    In hospital nurses avoid talking about the problem and avoid the patient as much as they can. Once registered in the Integrated Palliative Care program the nursing staff, caregiver, Doctor, pharmacy, begin the coordination and collaborative approach to caring for the patient. This shift in care is remarkable.
  • hopeful caregiver about 2 years ago
    I feel the need to stress here that all professionals including social workers etc.. need proper training in providing palliative and end of life care. We could work on improving interdisciplinary training opportunities and learn to support each other and understanding each others' roles to enhance the care the provision of care will benefit both the team and the individuals and their caregivers and their families. Palliative care is more than doctor-nurse interactions, and the level of comfort in this provision of care is a necessity for all professionals.
    University curriculum need to take part in this conversation an find ways to better prepare healthcare professionals.
  • BennyB about 2 years ago
    The Dr. Jay Children’s Grief Centre (DJCGC) provides mental health support for children and youth, as well as their families through end of life. As the Ipsos Reid Survey mentions, an overwhelming number of physicians are not very comfortable providing palliative or end of life care. It is our experience that almost ALL health care providers, including physicians, are not comfortable providing palliative psychosocial support and care to families that include children, who are often the secondary if not primary victims of death and dying when they are ignored. Our counsellors provide specialized treatment services for children living with the dying and death of a loved one, and to dying children and their families, in their homes, and other supported settings such as hospice. It is important that all professionals who touch the lives of grieving children feel empowered to have competent age appropriate discussions and learn strategies to help them address their challenging circumstances. Dr. Jay Children's Grief Center provides training, education, mentorship and expertise to professional medical and counselling communities in the areas of children’s grief and pediatric palliative care. This specialized training needs to be expanded and made available throughout the Canadian health care system.
  • Hukie about 2 years ago
    Health providers require more discretionary time, that can be paid for and billed for, within their practices. So that they are able to hold in depth discussion in a relaxed manner, at the time the patient and or family are ready for such a discussion
  • nehamashira about 2 years ago
    There needs to be a strong foundation of trust between HCPs and those facing life-limiting illnesses. This provides the portal by which difficult conversations can be allowed to take place. The onus is on the HCP to do a great deal of deep listening in order to ascertain what the needs are and what the goals of care should be from a patient perspective.
  • sab472 about 2 years ago
    I find sometimes there is a disconnect between the ideal of palliative care being initiated early in the course of a health condition and what happens in practice. In my opinion, it is so much better when palliative care is initiated early. I wonder if having tools like a very clear decision pathway would help HCPs to initiate that care early every single time.
  • Alberta2018 about 2 years ago
    In Alberta, Hospice Calgary Child and Family Grief Counselling staff help to teach a module to family medicine students regarding working with families during times of palliative illness or expected/sudden death. It's a small start but is one time slot among many other learning demands. It would be helpful if more time was allotted for training of all health professionals, particularly when working with children/teens. One of the ongoing issues is that providers to do not have the time, or take the time, to really sit and listen to patients/families. Important information is provided quickly without time for it to be absorbed and questions to be asked. It is also more the norm that people are waiting long periods of time to have the appointment with the provider in order to get the tests results--time that increases anxiety.
  • lgshaver about 2 years ago
    We need more HCPs to be competent in the palliative approach to care, even if they are not providing end-of-life care to patients.

    I would hope that more care providers who are treating patients with chronic illness, frailty, or elderly patients receive training in the palliative approach to care through continued education. We have an incredible number of patients who would benefit from palliative care but do not receive it until it is far too late, if they receive it at all.

    A better understanding of palliative care will enable physicians to identify when patients may benefit from this care and will increase early referrals. Learning this approach to care may even help physicians in caring for the psychological, social, and spiritual needs of their patients who do not have life-limiting illness.

    Moreover, I think that we really need to start educating physicians and other HCPs to rethink mortality and dying through a humanities-lens, not a biomedical one. The current approach is too centred around curative medicine, and in our modern world of chronic illness, even though HCPs may be well-trained in pharmacotherapy for management of conditions, patients with chronic and life-limiting illnesses are finding it hard to connect with their HCPs because the HCP can't comprehend the patient's experience of their illness. There is such uncertainty and ambiguity in living with a chronic illness—especially when they're life-limiting—that the HCPs, who are so used to dealing in certainties, may find it a challenge to communicate with patients. Without understanding the patients' struggles, too, they HCPs may find themselves with-holding from making suggestions about palliative care because they begin to think they know what the patient and their family wants, they think that talking about death may scare the patient or make the patient believe there is no hope, but that is often not the case—research suggests patients want their physicians to be realistic [1]. Moreover, these discussions—especially if they involve family—can bring comfort.

    Ultimately, though, I think that there are grave misunderstandings of palliative care, and of mortality and illness themselves, among both patients and HCPs, alike. These misunderstandings prevent open, honest, and effective discussion. To ameliorate this, HCP education (continued- and undergraduate-level) in the humanities, specifically around life and death, combined with public awareness campaigns using a narrative approach could be effective.

    1. Hagerty, R. G., Butow, P. N., Ellis, P. M., Lobb, E. A., Pendlebury, S. C., Leighl, N., … Tattersall, M. H. N. (2005). Communicating with realism and hope: incurable cancer patients’ views on the disclosure of prognosis. Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology, 23(6), 1278–1288. https://doi.org/10.1200/JCO.2005.11.138
  • gtreschow about 2 years ago
    Emphasising care (quality of life) not cure this can be very difficult for health care providers. Canuck Place speaks this language fluently with regards to families and children. The issues of trust and safety for patients living with life threatening illness can be a slow and painful process and sometimes the disease does not take this into consideration.
  • tanysmit about 2 years ago
    I feel as though there isn't very much emphasis on the family physician's responsibility when it comes to taking care of their palliative clients, especially in home care. They do not answer their pages/calls and refuse to address palliative clients needs, but there is no repercussion for NOT following through with their clients. I also hear "what difference does it make, they are just dying anyways". So maybe mandatory training for physicians for palliative care symptom management might be and idea?
  • PCNCMJ about 2 years ago
    Improving interactions seems a simple thing, but it is one that requires CULTURE CHANGE. This means there is a responsibility on every person to have open, honest and early conversations, such as advance care planning and health education about disease process, very early on. Advance Care Planning and "normalizing" death as part of life, making it something that is not taboo, needs to begin in childhood. This is when we begin having the lived and learned experience of what living and dying is all about, we learn from those around us.
  • nickers about 2 years ago
    My experience was that the communication from the palliative care team to my mother's physical showed that they were not on the "same page." For example - palliative care team directs us to ask her physician to sign an DNR order, her physician thought that was to be done by the palliative care team as she was a palliative care patient. Maybe that's why they're not comfortable. they don't know what the other one is doing?
  • LuellaJane2 over 2 years ago
    Learners need to see /witness experienced providers have these conversations whether it begins in medical school or residency, but there has to be mandatory training - even using actors to have these conversations. Practicing physicians should also be offered these type of training opportunities.
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    • Visionary2018 about 2 years ago
      Heartily agree... OSCEs and medical training for all health care professionals must include mandatory education in discussing life and death issues with persons diagnosed with life-threatening illnesses.
  • fernandlily over 2 years ago
    There needs to be more training on practical ways to support people with life-threatening conditions. Much of the cultural norms of grief, loss and bereavement in our society are outdated and educational programs are reflecting that. For example, the use of stages in educating people about the process of loss and grief is detrimental, and yet it is being taught at university level courses. There needs to be a huge restructuring of how we teach. I also think we need to have education and practice on having difficult conversations. Part of a curriculum in health care training should include self care and education on grief for workers. Not just theory either, real practical and individualized information and support.