ORAL PAPER PRESENTATIONS

Sunday, April 22, 2018

1:00 pm – 2:15 pm SERIES 1
Paper 1
Health Outcomes Remote Patient Monitoring Palliative
Health Outcomes Remote Patient Monitoring Palliative

Program Objectives
To determine if a remote monitoring system in the homes of patients with palliative illnesses can reduce  hospitalization and ER visits.
To determine if clients completing daily assessments of vital signs experience improved health.
 
Methods

Study included 74 patients with COPD or CHF from one hospital catchment area. Clients were 18 years with at least one ER visit in the previous six months. They spoke English and were capable of giving consent. The average age was 72.
A comprehensive in-home nursing assessment was completed on each client and an individualized learning plan created. Clients were monitored for three months using a remote system that allowed them to check blood pressure, heart rate, oxygen level and weight and enter data electronically. This data was monitored by a nurse who contacted clients when alerts were triggered.
 Each client was contacted three months post discharge to assess ER and hospitalization admissions and client satisfaction

Results and conclusions

There was a dramatic 68% reduction in ER visits and 35% reduction in hospitalizations during the three month in-home monitoring period.
Of the clients, 70 % strongly agreed that they felt more confident managing their signs and symptoms related to diagnosis.
Almost every client (97 %) recognized when to go to emergency department, when to monitor at home, and when to see their physician before a flare up.
Nine out of ten clients rated satisfaction of program as very good or excellent and would recommend this program to  friend or family.  

Author:
Olwen Redwood RN BScN, National Manager Patient Support Programs, CBI Home Health, Toronto, ON


Presenter: Olwen Redwood RN BScN, National Manager Patient Support Programs, CBI Home Health, Toronto, ON

Paper 2
Daisy Makes a Difference
Daisy Makes a Difference

While research is limited in this area, there are findings that interaction with a therapy dog can provide a number of benefits that include: reducing anxiety, providing a distraction, promoting conversation or just being wonderful listeners in bereavement work.   As we are in the first year of owning our dog statistical information is not available.
 
Hospice Simcoe is the first residential hospice in Ontario to own a certified service dog.  Daisy, our facility/service dog works at the residence a full 40 hour week.
 
Residents and clients quickly build a relationship with the dog and look forward to the recurring visits.  In addition to general service dog training, Daisy completed 20 hours of intense training specific to our facility.  She intuitively recognizes people, whether a family member of a staff member, who may be stressed and chooses to sit with them to offer comfort and companionship. 
 
Our presentation will include a demonstration, details on acquiring a dog and the commitment involved.

Author:
Lynda Murtha, Fund Development Manager, Hospice Simcoe, Barrie, ON


Presenter: Lynda Murtha, Fund Development Manager, Hospice Simcoe, Barrie, ON

Paper 3
Learning from Experiences of Feeling Heard: A Qualitative Study of Hospice Volunteers
Learning from Experiences of Feeling Heard: A Qualitative Study of Hospice Volunteers

Hospice volunteers value their role listening to patients’ stories. Yet they have also expressed needs for more training in listening and communication skills. To help meet these needs, participants in a recent study said that they appreciated the training they received from chaplains, which offers an approach to listening that can help patients feel valued and heard. These findings corroborate previous research that showed how hospice volunteers valued the training they received from chaplains with regard to aspects of nonverbal communication.  While previous research has demonstrated how different listeners embody distinctive listening styles stemming from their unique backgrounds, including differences of gender, culture, and vocation that can influence how storytellers shape the telling of their stories, the purpose of this study was to explore further how different experiences of being listened to and feeling heard and understood (or not) can be formative and influential for hospice volunteers in how they listen to others. Data generated in body-anchored interviews with ten individual hospice volunteers illuminate the quality of listening they received (and did not receive) from key role models in their lives. Narrative thematic analysis suggests that occasions of receiving listening are rare, pivotal, and spiritual events that can be used to learn more about how to listen more effectively to others, particularly in end-of-life care. This paper closes with some recommendations for enhancing emotional support for hospice and palliative care volunteers, and for more training in reflective practice, including new approaches to teaching active empathetic listening and communication skills.

Author:
Robert Mundle, Spiritual Health, Providence Care Hospital, Kingston, ON


Presenter: Robert Mundle, Spiritual Health, Providence Care Hospital, Kingston, ON

1:00 pm – 2:15 pm SERIES 2
Paper 1
Take My Hand Aromatherapy Hand Massage
Take My Hand Aromatherapy Hand Massage

A New Approach to Healthcare for Palliative Care and at the End of Life: Take My Hand Aromatherapy Hand Massage program for community hospice.

The overlying goal of this whole conference is to improve quality of life for both the patient, family and healthcare provider with compassion, respect and dignity. Aromatherapy is a safe mode of care to enhance well-being, reduce disease burden and enhance quality of life.  This approach is based on established methods and backed by scientific data.  The Odorem Rose method will show how a greater focus in this area will not only elevate the overlying goal to a new level, it can also enhance your facility’s offerings and provide underlying cost saving measures to an already overburdened budget.

Imagine being able to provide a calming multi-sensory method in your facility or to home care, for both the resident and caregivers, at a time of life that is the most precious and vulnerable.  Imagine being able to decrease anxieties and the perception of pain and being able to sustain this collaborative program that could include nursing, physiotherapy, recreation and other professional caregivers and families.  Odorem Rose specialized method is appropriate at any age and at any stage in a serious illness.

Rose Cottage Visiting Volunteers is the only community hospice in west Niagara that provides a host of support services to clients and caregivers whether in their own home, care facility or hospital.

Authors:
Sonya Stern Podrebarac1, Sherry Cain2
1.  Certified Aromatherapist, Odorem Inc.
2.  Executive Director of West Niagara Palliative Care Services o/a Rose Cottage Visiting Volunteers


Presenter: Sonya Stern Podrebarac, Certified Aromatherapist, Odorem Inc.

Paper 2
Medical Assistance in Dying (MAiD) and the Role of Palliative Care: Hearing Family and Provider Perspectives on How We Can Work Together?
Medical Assistance in Dying (MAiD) and the Role of Palliative Care: Hearing Family and Provider Perspectives on How We Can Work Together?

Many palliative care organizations have publically distanced themselves from MAID, which became legal in Canada in 2016.  The World Hospice Palliative Care Association, for example, states “[e]uthanasia and physician assisted death are not part of palliative care practice.” Similarly, some healthcare providers express the need for “better palliative care, not assisted dying.” Such declarations falsely position palliative care and MAiD as mutually exclusive options for both clinicians (i.e. one can provide palliative care or MAiD, but not both) and patients (i.e. one can receive palliative care or MAiD, but not both).
 
However, this conceptual separation is not borne out in practice. Some clinicians will provide both palliative care and MAiD. Some patients want access to both services. A steadily growing body of patient narratives suggests that they don’t see them as mutually exclusive. International data shows that in practice palliative care and MAiD can coexist; for example, 73% of MAiD recipients in Holland also received palliative care.
 
We maintain that patient-centeredness and equity require that patients’ voices are heard, particularly in the context of MAiD. In our presentation, a physician shares the story of his wife who accessed both palliative care and MAiD in the Central West LHIN. We will also hear from health care providers who care for patients who access both palliative care and MAiD at end of life. The inclusion of such voices can challenge the false conceptual dichotomy between palliative care and MAiD and help ensure that all patients can access the care that they want and need.

Authors:
Paula Chidwick1; Jill Oliver1; Angel Petropanagos1; Ed Weiss2; Roger Bunn1; Melissa Devlin1
1. William Osler Health System, Brampton, ON
2. University Health Network, Toronto, ON


Presenters: Roger Bunn, William Osler Health System, Brampton; ON, Ed Weiss, University Health Network, Toronto, ON

Paper 3
A Men & Grief Group
A Men & Grief Group

Following the death of a significant person in their lives from life limiting illness, an individual may seek  support in their community. Hospices are well placed to offer bereavement support as part
of their complement of services. This presentation is a  look at a Men & Grief group through the lens of a program evaluation.

Bereaved individuals  self refer to Hospice Care Ottawa’s bereavement support. An Intake interview  is used for assessment, providing information and resources, and obtaining consent for services. The Men & Grief group is co-facilitated by two trained and experienced male Volunteers following  the Companioning Model of Dr. Alan Wolfelt.

Although each bereaved individual will be unique the Volunteers endeavor to create a safe space where men can feel comfortable to be vulnerable. The group provides an avenue for men to both give and receive confidential, non-judgemental support. Together they can share their struggles with isolation, their feelings, and aspects of transition that can lead to growth.

Testimonial comment by a male bereaved client: “Did it help? Absolutely.” The Volunteer co-facilitators “showed us there was hope and you will find your way out of the dark maze of despair to find the sunshine.”

Analysis of data resulting from this group shows  participant numbers were low. Evaluation  and testimonial results show the impact of the Men & Grief group for many bereaved who participated was great. Continuing to monitor and improve this group through program evaluation will be key to fostering high quality equitable service.

Author:
Sandy Curtis Arnot
BA, RN, CHPCNc, Hospice Care Ottawa, Ottawa, ON


Presenter: Sandy Curtis Arnot BA, RN, CHPCNc, Hospice Care Ottawa, Ottawa, ON

2:45 pm – 4:00 pm SERIES 3
Paper 1
Loss of Relationship: A Qualitative Study of Families and Doctors After Home-Based Palliative Care Ends
Loss of Relationship: A Qualitative Study of Families and Doctors After Home-Based Palliative Care Ends

Background
Home-based palliative care is care of the patient in the comfort of their own home. Family involvement naturally cultivates a relationship between HCPs and the family. Once the patient dies and care ends, this relationship is abruptly terminated, which may be challenging to both parties. This study explored HCPs’ and family members’ thoughts regarding the loss of relationship and their opinions on a system that allows for contact post patient death.

Methods
Perceptions of 63 participants (32 HCPs and 31 family members) were explored using semi-structured interviews and qualitative research methodology. HCPs were interviewed primarily at a home-based palliative physician group (TLCPC), and at two hospitals, while family members were recruited from the deceased patients of TLCPC physicians.

Results
Six overarching themes emerged: 1) Both HCPs and families recognize the intimacy of home palliative care; 2) both parties expressed dissatisfaction with the abrupt ending of relationship; 3) open and clear communication with HCPs is beneficial to family members, especially after patient death; 4) HCPs recognize that resources are insufficient and there is a gap in bereavement services; 5) a proposed system to mitigate loss of relationship has multiple perceived benefits; 6) logistical challenges and boundary issues are concerns for HCPs.

Conclusions
The findings obtained in this study portray how HCPs and families perceive home palliative care, and their thoughts regarding loss of relationship. Overall, families and HCPs do not like this halt in contact, and recognize the potential benefits of an approach that would allow for communication going forward.

Authors:
Megan Vierhout(Research Student), Jaymie Varenbut(Research Student), Elizabeth Amos(Palliative Care Physician) MD, Sandy Buchman(Palliative Care Physician) MD, CCFP, FCFP, Amna Husain1 (Palliative Care Physician) MD, MPH, James Meuser1 (Palliative Care Physician) MD, CCFP, FCFP, Mark Bernstein1,2 (Palliative Care Physician and Neurosurgeon) (MD, FRCSC, MHSc)

1Temmy Latner Center for Palliative Care, Mount Sinai Hospital, Toronto, ON, 
Division of Neurosurgery, Toronto Western Hospital, Toronto, ON


Presenters: Megan Vierhout, Jaymie Varenbut, Division of Neurosurgery, Toronto Western Hospital, Toronto, ON

Paper 2
RCVV Tele-Visits Program
RCVV Tele-Visits Program

Background
Palliative care providers connect with clients and caregivers in order to address their individual needs. This population faces a myriad of symptoms early in their illness trajectory, therefore supportive services is the key to their wellbeing. Tele-visits provides this continuum of support services. 

Description

The purpose of tele-visits is aimed at providing psychosocial and emotional support to the client and caregiver. This community initiative provides more geographically accessible, timely care to clients as it helps leverage social interaction from the comfort of their home. Particularly in terms of accessibility, this service is favorable as telephone support can be provided regardless of inclement weather, in addition to preventing isolation for clients with communicable diseases.
A pilot test of this tele-visit service was implemented in order to test the effectiveness of this intervention on the caregiver population. Based on the pilot test for the caregiver population, the tele-visit services were proven beneficial in providing psychosocial and emotional support, as well assisting the caregivers with grief and bereavement needs. This work also has the most potential for growth if addressed early in the client’s illness trajectory, as this service offers strategies to enhance the psychosocial coping of these clients through their disease progression.
Overall, this idea is favorable, as tele-visit is a new practice-based solution designed to be interactive and innovative to support the changing technological needs of today’s society. In addition, telephone based services changes the volunteer role through increasing the client/ volunteer match and overall sustainability of the program.

Authors:
French, Claire1; Warriner, Kyle1
1. Faculty of Applied Health Sciences, BScN, Brock University, St. Catharines, ON 


Presenters: Claire French, Kyle Warriner, Faculty of Applied Health Sciences, BScN, Brock University, St. Catharines, ON

Paper 3

Improving Access to Palliative Care for Ontario’s Long-term Care Residents who have the Substitute Decision Maker of “Last Resort”
Improving Access to Palliative Care for Ontario’s Long-term Care Residents who have the Substitute Decision Maker of “Last Resort”
Ontario’s Health Care Consent Act (HCCA) ensures that anyone found incapable of making a treatment decision has someone else to make that decision on his or her behalf – a “substitute decision maker” (SDM).  If a person has nobody appointed as SDM, then the health care provider can turn to family members, in the particular order set within the HCCA; but if the person has no family members who are capable, willing, and available to make decisions on his or her behalf, the HCCA identifies the Office of the Public Guardian and Trustee (PGT) to make these decisions as a “last resort.”

Through participation in the Prevention of Error-Based Transfers (PoET) Project, Sienna Senior Living homes have identified a particular type of error-based transfer which, at its core, indicates inequity.  These transfers involve residents who have no SDM other than the PGT, and for whom consent for a palliative treatment plan that includes death in the home has not been secured.  In cases such as these, residents can continue on with acute interventions and transfers to hospital until death instead of accessing palliative care.

This presentation will summarize the misunderstandings and practices that can contribute to this inequity, and will also present tools and strategies that can help to ensure long-term care residents in this situation receive equitable access to the palliative care available in their own home. 

Authors:
Jill Oliver1, Metzie Lacroxi2, JoAnne Prokopchuk2
1. William Osler Health System
2. Sienna Senior Living


Presenters: Metzie Lacroxi, JoAnne Prokopchuk, Sienna Senior Living 

2:45 pm  – 4:00 pm SERIES 4
Paper 1
Death is a Social Justice Issue: Results of a Needs Assessment
Death is a Social Justice Issue: Results of a Needs Assessment

The Ministry of Health & Long Term Care (MOHLTC), health care providers, social service agencies and community partners seek to better understand palliative care for vulnerable and underserved Ontarians.  Access to quality palliative care has a deep impact on quality of life for both the dying and their families.  Northwestern Ontario is unique, with a total population of 235,900 people, large geographic area, land mass of 47% of Ontario and approximately 21.5% of the population identifies as Indigenous.  Sixty nine First Nation communities are within the NW LHIN.  Death and dying are matters of social justice and understanding what a population needs are is imperative to address system gaps and barriers.  In partnership, Dilico Anishinabek Family Care submitted a proposal to the MOHLTC to conduct a needs assessment in the NW LHIN to survey service providers and users to better understand what is required to achieve support for vulnerable and underserved people with life-limiting illness.  What can be done to improve their comfort, dignity, and quality of life before death?  The presentation objective is to have mutually beneficial discussions about the results and provide firsthand knowledge about what is occurring and how service providers can approach palliative care for underserved and vulnerable members of our society no matter where they are situated.  Results will be presented with community based solutions and recommendations as to how to address palliative care needs of our most vulnerable and underserved populations in Northwestern Ontario, homeless and vulnerably housed.

Author:
Yolanda Wanakamik, Integrated Policy Officer, Dilico Anishinabek Family Care


Presenter: Yolanda Wanakamik, Integrated Policy Officer, Dilico Anishinabek Family Care

Paper 2
Pallium's Compassionate Communities Start-up Kit
Pallium's Compassionate Communities Start-up Kit

Background: Pallium Canada has been providing palliative care education for healthcare professionals across Canada since 2001, and is now invested in helping Canada mobilize Palliative Care in the community setting, primarily through Compassionate Communities (CC). A compassionate community understands that death, dying, loss and caregiving are a natural part of life and that it is everyone’s business to care for one another at times of crisis and loss.  

Objectives: To mobilize communities across Canada to participate in creating their own CC’s.   To share best practice tools with interested individuals to continue the movement.  

Results: It has been demonstrated that when best practice supports are shared with communities looking to develop their own CC, they can reduce the start-up time by roughly 50%.  The resources included in the start-up kit are: 1) PowerPoint presentation to show why and how to build a CC, 2) Compassionate City Charter framework summary sheet, and 3) Activity to evaluate the audience interest in starting a CC.

Conclusion: Pallium has received repeated requests for help in starting CCs from all across Canada. In hopes of mobilizing the spread of CCs across Canada, Pallium created the start-up kit to help champions feel comfortable enough in launching their own CC initiatives. This health care community approach will lead to a more wholistic palliative journey.  

Author:
Tompkins, Bonnie1
1. Compassionate Communities National Lead, Pallium Canada, Ottawa, ON


Presenter: Bonnie Tompkins, Compassionate Communities National Lead, Pallium Canada, Ottawa, ON

Paper 3
Healing through Architecture
Healing through Architecture

The terms curing and healing are often used interchangeably but have distinct definitions. The term curing refers to the relief of the symptoms of a disease or condition. The term healing refers to the alleviation of a person’s distress or anguish. In order to fully take advantage of the body’s healing potential in palliative care facilities, environments hold the ability to stimulate the senses and become active healers themselves to minimize negative effects of stress on the body, one’s biggest obstacle in healing. Many hospital settings inflict so much stress on patients, it actually slows down healing, creating more discomfort. Stark white walls, bright fluorescent lights, little-to-no privacy and loud announcements do anything but calm a person in distress. 
 
Calming environments have several elements in common: natural light, colour, privacy, and connection to nature. These spatial considerations are vital assets in healthcare to place patients in a state where they have the best opportunity for psychological and emotional healing.
 
The design proposal at Grand River Hospital focused on a design with vertical gardens, offering opportunities for patients to focus on living plants that represent hope, growth, and renewal; attempting to humanize the space by making patients feel more than just sites of a disease.
 
When people feel happier they feel more comfortable, which all starts with the environment to which a patient is subjected. This research attempts to continue the ever-important conversation around the value of equity among these patients and designing for the person, not just the patient.

Author:
Huynh, Jennifer1
1. Healthcare Architecture, HDR Inc., Toronto, ON


Presenter: Jennifer Huynh, Healthcare Architecture, HDR Inc., Toronto, ON

Monday, April 23, 2018

10:45 am – 12:00 pm SERIES 5
Paper 1
Strengthening Partnerships in Interdisciplinary Relationships-Overview of the Evolution of Community Rounds in the Barrie Area
Strengthening Partnerships in Interdisciplinary Relationships-Overview of the Evolution of Community Rounds in the Barrie Area

Strengthening Partnerships in Interdisciplinary Relationships-Overview of the Evolution of Community Rounds in the Barrie Area 
Community Rounds in the Barrie area has occurred for almost 40 years. This presentation will provide an opportunity to learn how primary care works collaboratively with other community providers/health care agencies as partners in end of life care. This presentation will provide a historical time-frame of the Barrie and area palliative rounds, present membership of the multi-disciplinary team, why and how change happened, current meetings, future direction and pearls of wisdom. Community Rounds terms of reference will be explored. Community Rounds focus will be explored as it supports patients dying in their place of choice, symptom management, alleviate ER visits at end of life, provides client and family support and education, early identification of clients that would benefit a palliative approach to care, linkage to community support and resources, support of palliative care providers and role recognition, enhance communication and identify system gaps.  

Authors:
Tammy Pollard, Residential Care Manager, Hospice Simcoe
Lynn Augustino, Registered Dietitian, Barrie and Community Family Health Team


Presenters: Tammy Pollard, Residential Care Manager, Hospice Simcoe, Lynn Augustino, Registered Dietitian, Barrie and Community Family Health Team 
Paper 2
When Patients Ask to Die: The Role of Nurses in Medical Assistance in Dying
When Patients Ask to Die: The Role of Nurses in Medical Assistance in Dying

Background
Canadians are increasingly living with chronic illness heightening the importance of palliative and end of life care. Nurses have significant involvement in end of life care which, in Canada, may now include medical assistance in dying (MAiD).

Purpose
To explore the perspectives of palliative care nurses regarding best practices in care related to MAiD.

Methods
The aim of this study was to understand and describe a phenomenon. Interpretive description, an approach to qualitative research was used to guide this study. Individual interviews with nine experienced palliative care nurses were used for data collection.

Findings and Implications
The analysis produced three overarching themes of: (a) Business as usual which reflects participants’ perspective that MAiD is an aspect of existing practices in end of life decision making in palliative care; (b) Nursing role within MAiD discusses the importance of patient centred care and includes assessment, liaison, intervention and bereavement; and (c) Support for Nurses to Provide MAiD Care reflecting the support required for nurses providing this care and includes (a) palliative education required, (b) conscientious objection to MAiD, and (c) give and take of the final intervention.

The concept patient directed death is introduced in response to these findings, and aligns MAiD within existing patient centred end of life care. The findings from this study can inform nursing best practices related to MAiD in order to support quality end of life care.

Authors:
Sheridan, Laura
1; Donelle, Lorie1; Regan, Sandra1; Kirkwood, Ken2.
1. School of Nursing, Faculty of Health Sciences, Western University, London, ON
2. School of Health Studies, Faculty of Health Sciences, Western University, London, ON


Presenter: Laura Sheridan, School of Nursing, Faculty of Health Sciences, Western University, London, ON

Paper 3
Promoting Equity in Palliative Care for LGBTQT Persons: Challenges and Opportunities
Promoting Equity in Palliative Care for LGBTQT Persons: Challenges and Opportunities

The Prime Minister of Canada has recently apologized for Canada’s role in the systemic oppression, criminalization, and violence against the lLGBTQT community, acknowledging that these injustices have led to inequities for the LBGTQT community.  One of the overarching goals of Ontario’s 14 Regional Palliative Care Networks in to promote equity in access to services and care across the province.  This presents a variety of challenges, particularly when one narrows the focus to the unique palliative care needs of LGBTQT people and social inequities that continue to impact the health of this community.  As the Canadian population ages, so too does the LBGTQT community.  There are well-documented disparities and inequities that impact access, outcomes, and utilization of, as well as experiences with healthcare in this population who continue to experience homophobia, open discrimination, and stigmatization.  Understanding the unique needs of this group is a starting point to address underlying social and health equity issues and to promote the provision of patient-focused palliative care for LGBTQT persons.

In this oral presentation:
1) Challenges and opportunities for equity in palliative care service provision for LGBTQT persons in Ontario will be identified
2) Determinants of health impacting LGBTQT palliative care shall be summarized. 
3) Key findings and recommendations from the recent research and scholarly literature relevant to this issue will be stated. 
4) Areas for enhancing cultural competence in caring for LGBTQ patients and promoting equity in palliative care for this group will be proposed. 
5) Finally, some resources available to promote culturally-sensitive palliative care and health equity for LGBTQT will be shared, prior to a brief question/discussion period.

Author:
Free, David
Toronto Central LHIN, Adjunct Professor, Brock University School of Nursing


Presenter:
David Free, Toronto Central LHIN, Adjunct Professor, Brock University School of Nursing
10:45 am – 12:00 pm SERIES 6
Paper 1
Loss to Legacy: A Grief & Loss Support Program for Residents, Families, and Staff in Continuing Care
Loss to Legacy: A Grief & Loss Support Program for Residents, Families, and Staff in Continuing Care

Program Objectives:  The presentation demonstrates an attempt to integrate hospice palliative care into continuing care communities by exploring the process and content of creating a standardized Grief and Loss Support Program within communities of care. 

Design and Methods:  A nine month Participatory Action Research (PAR) study involving five communities of care, including one pilot site, were chosen to engage stakeholders, build capacity, complete evaluation and utilize all forms of evidence. 

Results:  In the first phase of this multiphase project, focus groups with residents, families, and staff at all participating communities highlighted the need for

a) discussion about end-of-life options

b) sensitive and compassionate care around end-of-life

c) improved communication within the communities to inform residents, family, and staff when a resident is actively dying and deceased

d) commemorative practices

e) palliative care education and

f) bereavement support for residents, families, and staff members.

In the Action phase, an interdisciplinary working group implemented the developing Grief and Loss Support Program at the designated pilot site with the community members. Focus groups at the conclusion of the pilot were used to finalize recommendations for the standardized Grief and Loss Support Program at each of the organization’s communities of care.  Conclusions:  Best practice suggestions describe Palliative Care Conferences, Compassion Carts, the White Rose program, ‘Leave As You Come’ and other commemorative practices, multicultural education on grief and loss, and ‘Making Memories’ social supports. Barriers to each initiative and limitations of the design are also discussed.

Authors:
Gillard, Kaitlyn1; Walji-Shivji, Salimah2
1. Faculty of Social Work, University of Calgary, Calgary, AB, Adult Bereavement Program Coordinator, St. Joseph’s Hospice, Sarnia, ON
2. Chief Client Engagement Officer, General Counsel, AgeCare, Calgary, AB


Presenter: Kaitlyn  Gillard, Faculty of Social Work, University of Calgary, Calgary, AB, Adult Bereavement Program Coordinator, St. Joseph’s Hospice, Sarnia, ON
Paper 2
Onset and Duration of Palliative Care Approach in the Community: Differences Between Palliative Care Call Group Versus Non-Palliative Care Call Group Family Physicians
Onset and Duration of Palliative Care Approach in the Community: Differences Between Palliative Care Call Group Versus Non-Palliative Care Call Group Family Physicians

Objectives: Ontario data demonstrates inequities in palliative care access.  The MOH has incentivized family physicians to provide palliative care through call groups.  We compared the onset/duration of palliative care for patients with malignant and non-malignant diagnoses by family physicians in or outside call groups (CG).  

Methods:
A retrospective chart review of deceased adult FHT patients from January 1, 2011 to December 31, 2015 in a mid-size Ontario city.  OHIP palliative care billing codes (e.g. A945, G512, K023) determined if patients had received Palliative Care.

Results:
Charts of 79 non-CG versus 11 CG physicians were assessed, finding 1,589 deaths. 668 charts were excluded due to age <18 (n=27), lack of provider information (n=152), care from non-family physician (n=19), or unknown death date (n=470) leaving 921 charts. 759 deaths were in the non-CG vs 162 in the CG cohort. In the non-CG cohort 37.7% were managed palliatively vs 76.5% in the CG cohort (p<0.0001). Mean palliative care duration was longer for non-CG (484.2 days) vs CG (309.2 days) cohorts.  Of palliated patients, 61.3% from CG had malignancy whereas only 42.7% from non-CG had malignancy (p<0.0001).

Conclusions: CG physicians provided more palliative care services per physician. There was longer duration of palliative care by non-CG vs CG physicians; likely due to CG accepting referrals at later disease stages. It was comforting to note that all family physicians were providing palliative care to patients with diverse diagnoses.  Further work is required to assess equity of access to palliative care from family physicians.


Authors:
Blake, Christopher1,2, Lai, Jacky Chung Kit2, Orava, Matthew2, Parbtani, Anwar2
1. Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON
2. Family Medicine Teaching Unit, Royal Victoria Regional Health Center, Barrie, ON


Presenters: Christopher Blake, Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON; Family Medicine Teaching Unit, Royal Victoria Regional Health Center, Barrie, ON, Jacky Chung Kit Lai, Family Medicine Teaching Unit, Royal Victoria Regional Health Center, Barrie, ON
Paper 3
The Lived Experience of Bereaved Caregivers: Caring for Loved Ones at End of Life in Rural Ontario Home Settings
The Lived Experience of Bereaved Caregivers: Caring for Loved Ones at End of Life in Rural Ontario Home Settings

The purpose of this study was to explore the lived experience of bereaved caregivers who cared for their loved ones at end of life in rural Ontario home settings. van Manen’s hermeneutic phenomenology research method was utilized to guide this study and to gain a rich understanding of the lived experience through participants’ interviews. This study’s sample consisted of eight participants from rural locations in the Eastern and Waterloo-Wellington counties of Ontario, Canada. Five major themes were uncovered: (1) Facing a Terminal Prognosis and Deciding to be a Caregiver; (2) Being in it for the Long Haul; (3) Drawing on Sustaining Reservoirs; (4) Haunting Concerns and Comforting Memories; (5) Reflecting on an Invaluable Journey. This paper presentation will provide an overview of my study’s findings, discussion and gaps in our knowledge regarding palliative caregiving in rural settings and help participants gain a deeper understanding of the overall lived experience. Key Words: palliative, end of life, terminal, rural, remote, caregiver, bereavement, phenomenology, qualitative, lived experience.

Author:
Amell, Travis1,2
1. Ontario Palliative Care Consultant’s Network
2. Acclaim Health’s Palliative Care Consultation Program


Presenter: Travis Amell, Ontario Palliative Care Consultant’s Network; Acclaim Health’s Palliative Care Consultation Program
PRESENTATION CANCELLED
1:15 pm – 2:30 pm SERIES 7
Paper 1
Providing Nursing Practice Supports for Integrating a Palliative Approach to Care (ProNIP): A Nursing Professional Practice Initiative
Providing Nursing Practice Supports for Integrating a Palliative Approach to Care (ProNIP): A Nursing Professional Practice Initiative

Integral to nursing practice is the ability to care for patients with advanced life-limiting illness (Stajduhar, 2010). Within the hospital setting, nurses care for these patients in various clinical areas such as inpatient general and specialty units, Emergency Department (ED), Intensive Care Unit (ICU), and ambulatory clinics.  Thus, it is important to ensure that principles of palliative care are integrated into nursing practice regardless of the care setting so that they are able to positively shape the experience and outcomes for patients and families with advanced life-limiting illness.
The ProNIP Initiative, aimed at providing practice support systems to enable the integration of a palliative approach to care by nurses in various clinical areas was undertaken at a large multi-site organization. The group which consists of nurses with expertise in palliative care, adapted the EdCaN© model (2017) developed by Cancer Australia, to identify gaps and develop pragmatic solutions to support all nurses within the organization with building their knowledge and skills on palliative care.  An online learning needs assessment survey was administered to a representative sample of nurses including Registered Nurses, Registered Practical Nurses, and Advanced Practice Nurses across the organization, with a 53% response rate.  Findings from the survey enabled the group to better understand nurses’ perspectives on the challenges the supports required to integrate a palliative approach to care in practice. Practice support strategies and priorities were identified and implemented for each group using the EdCaN Model©, and informed by the Canadian Hospice Palliative Care Nursing Standards of Practice.

Authors:
Cordon, C1,2., Reis, C1., Andrychuk, S1., Babineau, T1., Banjar, A1., Durepos, P1,2., Evans, D1., Gitta-Low, C1., Hirst, L1,2., Macabuag, E1., McEwan, S1., Passarelli, P3., Proba, J1., Robinson, A1., Skradski, L1., Toscher, I1., Wilson, D1,2., Edwards, D1.

1. Hamilton Health Sciences
2. School of Nursing, McMaster University
3. Patient and Family Advisor


Presenter: Charissa Cordon, Hamilton Health Sciences; School of Nursing, McMaster University, Hamilton, ON
Paper 2
Culturally Competent Palliative Care Education and Training in Long-Term Care and Hospice Settings: A Scoping Review
Culturally Competent Palliative Care Education and Training in Long-Term Care and Hospice Settings: A Scoping Review

Context: Long-term care (LTC) and hospice settings are becoming increasingly diverse environments, both in terms of the workforce/volunteers and clientele. As such, educating care providers to offer palliative care in a culturally competent manner is of paramount importance. 

Objective: The aim of this scoping review was to describe the presence, nature, and effect of culturally competent palliative care education and training within long-term care and hospice settings.

Methods: Arksey and O’Malley’s framework was employed. Five electronic databases were searched for relevant literature targeting cultural competence, palliative care education and training, and LTC and hospice settings. Additionally, a search of the Grey literature and a hand-search of references from key articles were conducted to ensure all relevant resources were assessed. Data from relevant articles were extracted and thematically grouped to describe the nature and scope of the literature in this context.

Results and Conclusion: A total of 1,003 titles and abstracts were identified, with 31 articles meeting inclusion criteria. The literature reports considerable variation in levels of cultural competence among palliative care providers in LTC and hospice settings, and a similarly wide range of education and training efforts to address this. Those having greater educational attainment and previous diversity training exhibit greater cultural competence. While cultural competence education sessions make participants more knowledgeable, regardless of method, the findings suggest that care providers still struggle to confidently implement this knowledge in their clinical practice. Further research is needed toward best practice approaches and turning evidence into practice.

Authors:
Abetkoff, Selina, MEd(c)1; Hsieh, Jessica, MSW2,3; Mirza, Raza, PhD2,3​; Klinger, Christopher A., PhD2,3

1. Ontario Institute for Studies in Education, University of Toronto, Toronto, ON;
2. Institute for Life Course and Aging, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON;
​3. National Initiative for the Care of the Elderly, Toronto, ON


Presenter: Selina Abetkoff, MEd(c), Ontario Institute for Studies in Education, University of Toronto, Toronto, ON
PRESENTATION CANCELLED BY SPEAKER
Paper 3
Finding Purpose and Community through Music
Finding Purpose and Community through Music

Often patients living with a life threatening illness feel a lack of purpose in their lives.  Perhaps they are no longer able to do some of the tasks that they did around the house for their families or activities in the community.  Often they become more isolated which can lead to depression and a sense of worthlessness or being a burden. 

This presentation will show how the starting of a music program where the participants play live music has led to the expansion of their community and a sense of renewed purpose.

Background:  Seven years ago I started a musical jam where anyone regardless of their level of musical skills could come together to play live music.  Hospice would provide all the basic equipment such as PA ,  amplifiers, drum set and keyboard as many patients were unable to carry heavy equipment due to their medical condition.  We called it “Jammin for Wellness” with our mission being that we were playing music for our physical, emotional and spiritual wellness.  While our numbers increased slowly I noticed how friendships were renewed or developed and how they looked forward to coming each week not only to play music but to visit and support one another.

After a couple of years I approached some of the more accomplished players to see if they would be willing to form the Hospice Wellness Band here we would play music for Hospice events and volunteer our time to play for benefits for patients that were raising money to offset the costs not covered by OHIP.  Since that time we have played at 100’s of such events to help members of the public.  One such event was for a sexually abused boy who needs to raise funds to get the first ever service dog used for sexual abuse.  It was after played these events that some of the band members started to share how they felt better about themselves; that they were giving back to the community and they had a renewed sense of purpose.

Application:  I feel that all Hospices that offer day programming could have their own “Jammin for Wellness” or “Wellness Band”.

Author:
Joe Perry, MSW, RSW, Director, Patient and Family Services, The Hospice of Windsor & Essex County Inc., Windsor, ON


Presenter: Joe Perry, MSW, RSW, Director, Patient and Family Services, The Hospice of Windsor & Essex County Inc., Windsor, ON
1:15 pm – 2:30 pm SERIES 8
Paper 1
Incorporating the Palliative Approach to Care into the Refreshed Coordinated Care Plan (CCP) to Improve Patient Care
Incorporating the Palliative Approach to Care into the Refreshed Coordinated Care Plan (CCP) to Improve Patient Care

Since 2015 the Health Links approach to care has focused on enhancing and coordinating care for patients living with multiple chronic conditions and complex needs. Up to 40% of patients per year are identified as those that would likely require a palliative and end-of-life approach and that would benefit from coordination of care. A coordinated care plan (CCP) is a communication tool central to this work to ensure optimal patient care and most importantly, is grounded in understanding of patients’ goals for care. 
 
As Health Links have matured, the purpose for the CCP has evolved from a detailed care plan into a tool to coordinate care for patients across sectors. In 2017, Health Quality Ontario, with its partners, conducted a refresh of the CCP template to remove duplication, expand to include social determinants of health, update the Advance Care Planning section, and added a Palliative Approach to Care module. This new CCP, launched in June 2017, includes physical, functional, spiritual, mental and social components, and information such as preferred place of death, most responsible person for care, grief supports, and bereavement supports. The role of the CCP is to help integrate care plans among patients, providers and caregivers to enhance communication and improve care. The CCP is currently being implemented by all care teams involved in Health Links across the province and embedded in digital solutions that will enable care. Given the important involvement of patients in the development of the CCP, it has created an important opportunity to engage them in early discussions of palliative and end-of-life care.

Authors:
Kim Kinder
1, Dr. Ahmed Jakda2, Julie Darnay3, Lee Fairclough1, Lorri Eckler1, Sue Jones1, Courtney Paxton1, Shannon Brett1,  Stacey Bar-Ziv1

1. Health Quality Ontario
2. Provincial Lead, Ontario Palliative Care Network
3. Manager, Hospice Palliative Care


Presenter: Kim Kinder, Health Quality Ontario
Paper 2
Supporting Research to Ensure Equitable Access to Palliative and End-of-Life Care
Supporting Research to Ensure Equitable Access to Palliative and End-of-Life Care

The Canadian Cancer Research Alliance (CCRA) as part of its pan-Canadian plan for cancer research, Target 2020, identified development of a research framework for palliative and end-of-life care as a key tactic for 2017. With leadership from Dr. Stephen Robbins, Scientific Director of the CIHR Institute for Cancer Research and Dr. Deborah Dudgeon, in her capacity as Senior Scientific Lead, Person-centred Perspective for the Canadian Partnership Against Cancer, and a working group consisting of CCRA member representatives and researchers, Dr. Judy Bray, the consultant, developed a framework over the course of several months. A literature review, and data generated from an online survey, and key informant interviews, helped identify research priorities that were grouped into three major themes: transforming models of caring, patient and family centredness, and equity.
The two recommendations related to equity were to support research: 1) to inform the design of culturally sensitive models of care, tools and educational resources tailored specifically to the unique challenges of special populations, including studies to inform the integration of their needs into the development of mainstream palliative and end-of-life care programs, and 2) via targeted investment to inform interventions and models of care that address the health inequities experienced by hard-to-reach populations living at the margins of mainstream society.

Special populations specifically identified include children and young adults, indigenous populations, those living in rural and remote locations, the frail elderly, immigrants, refugees and other ethnic groups, the mentally ill, the physically disabled, and the homeless population. 

Authors:
1. Sara Urowitz, MSW, PhD, Executive Director, Canadian Cancer Research Alliance
2. Judy Bray, PhD, Consultant
3. Deborah Dudgeon, MD, Senior Scientific Lead, Person-centred Perspective for the Canadian Partnership Against Cancer
4. Stephen Robbins, PhD, Scientific Director of the CIHR Institute for Cancer Research


Presenter: Kimberly Badovinac, MA, MBA, Manager, Canadian Cancer Research Survey, Canadian Partnership Against Cancer
Paper 3
Palliative Care Early and Systematic (PaCES): Barriers to Providing Palliative Care to Advanced Colorectal Cancer Patients. A Province-wide Survey of Gastrointestinal Oncology Clinicians' Perceptions
Palliative Care Early and Systematic (PaCES): Barriers to Providing Palliative Care to Advanced Colorectal Cancer Patients. A Province-wide Survey of Gastrointestinal Oncology Clinicians' Perceptions

Introduction: Palliative care (PC) is part of the recommended standard of care for advanced cancer in Canada. However, delivery of PC is inconsistent across the country. Patients who could benefit from PC services are often referred late, or not at all. In planning for PC-oncology practice improvements, we sought to identify barriers to providing PC, as perceived by oncology physicians, nurses, and allied staff, involved in the care of patients with metastatic colorectal cancer across the province of Alberta.
Methods:
We used Michie’s Behaviour Change Wheel, and knowledge of previously identified barriers, to guide the development of a 31 question survey. The survey was distributed by email via provincial gastrointestinal tumour group leaders.

Results: Responses were obtained from 57 clinicians (40% response rate). The most frequently cited barriers were Opportunity-related. Clinicians identified their lack of time (>60%), lack of space for consultations, and lack of access to specialist PC staff or services. Qualitative responses revealed that limiting resources differed by cancer centre location. In urban centres, time and space were key barriers; in more rural centres, access to specialist PC was the main limiter. Self-perceived Capability to manage PC needs was a barrier for 40% of physician and 30% of nurses. Motivation was the greatest facilitator, with 89% of clinicians perceiving that patients benefit from PC.

Conclusion: Based on Michie’s behaviour model, interventions that address the barriers are enablement and environmental restructuring. These findings are informing the development of an intervention plan to improve PC-oncology practices in a provincial healthcare system.

Authors:
M.A. Earp PhD1, A. Sinnarajah MD MPH2,3,4, M. Kerba MD2 , P.A.Tang MD2 , J. Rodriguez-Arguello BHSc1, S. King MSc5, S.M. Watanabe MD6, J.E. Simon MB ChB2,3,5

1. W21C Research and Innovation Centre, Cumming School of Medicine, University of Calgary, Calgary, AB
2. Department of Oncology, University of Calgary, Calgary, AB
3. Department of Community Health Sciences, University of Calgary, AB
4. Department of Family Medicine, University of Calgary, Calgary, AB
5. Division of Internal Medicine, Department of Medicine , University of Calgary, Calgary, AB
6. Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB


Presenter: Aynharan Sinnarajah, Medical Director, Palliative & End of Life Care, Alberta Health Services (AHS) – Calgary Zone;  Section Chief, Palliative Care, Dept of Family Medicine, AHS – Calgary; Assistant Professor, Div of Palliative Medicine, Dept of Oncology, University of Calgary; Physician Consultant, Clinical Informatics, AHS – Calgary

3:00 pm – 4:15 pm SERIES 9
Paper 1
The Good Wishes Project: An End-of-Life Intervention for Individuals Living in Homelessness
The Good Wishes Project: An End-of-Life Intervention for Individuals Living in Homelessness

Inspired by the Three Wishes Study, the Good Wishes Project is a partnership between the Inner City Health Associates’ PEACH (Palliative Education and Care for the Homeless) program and Haven Toronto, funded by the Sovereign Order of St. John of Jerusalem. The program facilitates granting wishes to patients who are living in homelessness with a goal of enhancing comfort and personalizing the end-of-life experience. The main objective of this study was to elicit provider perspectives on the utility of the Good Wishes Project in the delivery end-of-life care to this population. This was investigated with a mixed methods approach. Semi-structured interviews were conducted with health and social service professionals (n=7) in shared care with the PEACH program. Interviews were recorded, transcribed verbatim and analyzed thematically. Good Wishes Project participant information and wish data was collected anonymously and analyzed using descriptive statistics. At 14 months after the project’s launch, there were a total of 27 participants and 40 wishes made, 24 of which had been granted. Wishes were classified into 5 categories: basic necessities, end-of-life preparations, personal connections, paying it forward and leisure. From the provider perspective, the project was found to have utility in 3 main domains: establishing and enhancing connection, satisfying basic needs, and promoting person-centered care. We conclude that the Good Wishes Project is a promising psychosocial intervention in providing palliative care to individuals who are living in homelessness, whose lives have largely been burdened with hardship and marginalization.

Authors:

Tedesco, Alissa1Dosani, Naheed2; Shanks, Leslie2
1. Department of Family and Community Medicine, University of Toronto, Toronto, ON;
2. Inner City Health Associates, Toronto, ON


Presenters: Alissa Tedesco, Department of Family and Community Medicine, University of Toronto, Toronto, ON; Naheed Dosani, Inner City Health Associates, Toronto, ON
Paper 2
Speaking Up and Speaking Out: A Toolkit for Healthcare Professionals Caring for Older LGBT Adults Facing the End of their Lives
Speaking Up and Speaking Out: A Toolkit for Healthcare Professionals Caring for Older LGBT Adults Facing the End of their Lives

A recent review of the literature in this area found that older LGBT adults have concerns about interfacing with the healthcare system and fear discrimination from healthcare providers at the end of their lives. Fears about unequal treatment and prior experience of discrimination within the Canadian healthcare system were echoed in recent focus groups with LGBT older adults from across Ontario. While healthcare providers often maintain a heteronormative outlook when providing care, evidence suggests that educational resources and interventions can enhance their ability to meet the needs of LGBT older adults, especially at end-of-life.  This presentation will highlight findings from focus groups with healthcare providers focused on the educational needs, gaps in knowledge, and learning preferences of healthcare professionals who care for this diverse population.  Informed by focus groups, a toolkit has been developed for use with trainees and current healthcare providers.  Elements of the toolkit will be presented within this session and participants will have the opportunity to offer feedback and engage in dialogue about its use as a mechanism for creating a more responsive and inclusive health system for LGBT older adults as they face the end of their lives.

Authors:
Kortes-Miller, Kathy1 Durant, Keri-Lyn1 ,  Wilson, Kim2,  Stinchcombe, Arne3
1. Lakehead University, Thunder Bay, ON
2. University of Guelph, Guelph, ON
3. St. Paul’s University, Ottawa, ON


Presenters: Kathy Kortes-Miller; Keri-Lyn Durant, Lakehead University, Thunder Bay, ON
Paper 3
Examining Clinician Identified Barriers to Participating in Goals of Care Decision-Making in Long-Term Care
Examining Clinician Identified Barriers to Participating in Goals of Care Decision-Making in Long-Term Care

Background
Goals of care (GOC) communication and decision-making is a conversation between patients, their substitute decision-maker (SDM) and the healthcare team to establish the goals of treatment at end-of-life (EOL). Long-term care (LTC) is an important setting for GOC communication; residents in (LTC) will likely remain there until end-of-life; yet GOC communication seldom happens effectively. 
The aim of this study was to identify LTC clinician-reported barriers to GOC conversations.

Methods
A survey examining EOL decision-making in LTC was administered to 1282 LTC clinicians (physicians, nurses and other allied health professionals (AHP)) in two settings in Southwestern, Ontario: a Continuing Medical Education event (n=211); and from 35 LTC facilities (n=1071). 
Barriers relating to patient-SDM, LTC clinicians, and healthcare system factors, were rated on seven-point Likert scales (1=extremely unimportant; 7=extremely important).

Results
Of the 563 clinicians willing to participate the response rate was 75% (n=422). Nurses comprised 77.5% of respondents. Mean clinician ratings of barriers were high (>5/7). 
All clinicians identified ‘POA difficulty in accepting a resident’s prognosis’ as a top barrier.  Physicians rated barriers related to patient-SDM highly; nurses were more likely to rate system barriers highly (e.g. lack of prior Advance Care Planning (ACP) to guide discussions, insufficient time, and poor documentation of prior ACP).

Conclusions
LTC clinicians highly rated the importance of many barriers to GOC communication.  There is a need to promote better preparation of residents and SDMs for discussions.  Tools to support engagement in this process are needed for LTC clinicians, and residents and their SDMs.

Authors:
Siu, Henry Yu-Hin1; Elston, Dawn1; Arora, Neha1; Lancaster, Karla1; Vahrmeyer, Amie2; Howard, Michelle1

1. Department of Family Medicine, McMaster University, Hamilton, ON
2. Extendicare Assist, A division of Extendicare, Markham, ON


Presenter: Henry Yu-Hin Siu, Department of Family Medicine, McMaster University, Hamilton, ON

3:00 pm – 4:15 pm SERIES 10
Paper 1

Palliative Care for Homeless Persons in North East Ontario: Identifying the Issues for Palliative Care Services
Palliative Care for Homeless Persons in North East Ontario: Identifying the Issues for Palliative Care Services
The Ministry of Health and Long-Term Care (2016) identifies a need to explore the best delivery of tailored palliative care to Ontarians. A subpopulation, vulnerable to systemic inequities, inclusive of palliation, are living with homeless. Homeless adults envision a good death as peaceful, spiritual, without suffering, and with friends and family (Ko et al., 2015). The North East Palliative Care Network and North East Local Health Integration Network recently funded a study to address gaps in palliative care for homeless persons. This presentation examines the variable nature of homelessness and consider the need for flexible palliative services for this population. This presentation begins with an overview of variable types of homelessness in North East Ontario. Using narrative method, issues related to dying as experienced by people who live with homelessness are illustrated based on an analysis of interview transcripts from ten case studies. The results focus on systemic barriers in access to palliative care services. The implications are discussed with regard to challenges and changes required in order to achieve equity in palliative care services for those who are homeless.
 
References:

Ko, E., Kwak, Jo., & Nelson-Becker, H. (2015). What constitutes a good and bad death?: Perspectives of homeless older adults. Death Studies, 39, 422-432.
 
Ministry of Health and Long-Term Care (2016). Palliative and End-Of-Life Care Provincial Roundtable Report – A Report from Parliamentary Assistant John Fraser to the Minister of health and Long-Term Care. Ottawa, Ontario: Queen’s Printer for Ontario. 

Authors:
Honsinger, Melanie, MSW, RSW
; Ballantyne, Barbara, RN, MScN; Kauppi, Carol PhD; Montgomery, Phyllis PhD; McCauley, Karen, MSW, PhD.
1.  Executive Director, Hospice West Parry Sound, Parry Sound, ON
2. Clinical Nurse Specialist, Symptom Management Clinic of Health Science North, Sudbury, ON
3. Professor and Director, Centre for Research in Social Justice and Policy, Laurentian University, Sudbury, ON
4. Professor, School of Nursing, Laurentian University, Sudbury, ON
5. Assistant Professor, School of Social Work, Laurentian University, Sudbury, ON


Presenter: Melanie Honsinger, MSW, RSW, Executive Director, Hospice West Parry Sound, Parry Sound, ON

Paper 2
Implementation of an Education Intervention Pilot for General Internal Medicine (GIM) Residents around the 'Comfort Measures Strategy' for End of Life
Implementation of an Education Intervention Pilot for General Internal Medicine (GIM) Residents around the 'Comfort Measures Strategy

Background: More than 50% of Canadians die in acute care hospitals.  With approximately 16 deaths per week, death and dying are significant elements of the patient, family, and health care team experience at Sunnybrook Health Sciences Centre (SHSC).

Purpose: This study will evaluate the impact of an educational intervention on residents’ perceived self-efficacy in managing patients at the end of life, and on their uptake of the Comfort Measures order set (CMos). 

Methods: This research study will take place over nine 4-week rotations (Oct 2017 to June 2018) on one General Internal Medicine (GIM) ward (C4) at SHSC. The educational intervention will consist of a didactic module outlining the implementation the CMos; presence of palliative care consult team staff at GIM team rounds; and provision of supporting educational materials.  Residents, who wish to participate, will complete a pre/post Self-Efficacy in Palliative Care Scale. The uptake of the CMos for actively dying patients will also be tracked, for comparison to other medical wards where the educational intervention was not offered. Data collection and analysis will be collated after each 4 week rotation.
This study is a local QI project at the Sunnybrook site of the University of Toronto.  Project approval has been obtained from SHSC REB, and the University of Toronto Internal Medicine Program.

Data/Results: Data collected and analyzed from five 4-week rotations will be presented. 

Authors: 
Wynnychuk, Lesia1; Stilos, Kalli1; Damanjot, Otal2
1. Sunnybrook Health Sciences Centre, Toronto, ON;
2. Department of Family and Community Medicine, University of Toronto, Toronto, ON


Presenters: Lesia Wynnychuk, Sunnybrook Health Sciences Centre, Toronto, ON; Otal Damanjot, Department of Family and Community Medicine, University of Toronto, Toronto, ON

Paper 3
Not the Usual Suspects. What Informs Palliative Physicians' Responses to Medical Assistance in Dying? Some Surprising Answers
Not the Usual Suspects. What Informs Palliative Physicians' Responses to Medical Assistance in Dying? Some Surprising Answers

“To know yourself and to really know how you feel about an issue prepares you to deal with that issue, whether you’re for, or against, or somewhere in the middle.”
 
The 2015 Supreme Court ruling (Carter v. Canada) and Bill C-14 legalized medical assistance in dying (MAiD) allowing physicians to hasten death for competent patients who have “a grievous and irremediable medical condition.” Although legislation governing MAiD has been in place since June 2016, participation in MAiD by Palliative Care physicians in Ontario has been variable.
 
We conducted semi-structured, qualitative interviews with 45 of 48 Palliative Care experts in our region to understand their views about MAiD and the factors that inform their opinions. The interviews were carried out in April and May of 2016, prior to the legislation coming into effect. Interviews were digitally recorded, transcribed and anonymized. Transcripts were analyzed using conventional content analysis.
 
Our presentation will focus on participants’ rich descriptions of the variety of elements that inform their spectrum of views on MAiD. These descriptions highlight what underlies the nuanced response among palliative care physicians to this issue, and dispel the commonly held misperception of a homogeneous response based mainly on religiosity.
 
This is a new landscape for Canada, its physicians, and its citizens. There has been little reported on what informs palliative care physicians’ opinions and participation in assisted death. Our study helps to fill a critical gap in the literature, and will encourage reflective-practice in all health care providers confronted with MAiD. 

Authors:
Farag, Alexandra1; Swinton, Marilyn2
; O’Donnell, Caitlin3; Pellizzari, Joseph4,5; Shadd, Joshua1; Willison, Kathleen5,6; Frolic, Andrea7; Woods, Anne1,5
1. Division of Palliative Care, Department of Family Medicine, McMaster University, Hamilton, ON;
2. Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON;
3. Department of Philosophy, University of Waterloo, Waterloo, ON; 
4. Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, ON;
5. St. Joseph’s Healthcare, Hamilton, ON;
6. School of Nursing, Faculty of Health Sciences, McMaster University, Hamilton, ON;
7. Hamilton Health Sciences, Hamilton, ON


Presenters: Alexandra Farag, Division of Palliative Care, Department of Family Medicine, McMaster University, Hamilton, ON; Marilyn Swinton, Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON 

Tuesday, April 24, 2018

10:30 am – 11:45 am SERIES 11
Paper 1
Regional Palliative Care Priority Projects and the Palliative Care Quality Standard in the South East LHIN: Involving Primary Care in Improvement
Regional Palliative Care Priority Projects and the Palliative Care Quality Standard in the South East LHIN: Involving Primary Care in Improvement


Background: The 10th Primary Health Care Forum in the South East LHIN, a networking and education event, was held on October 5, 2017 in Kingston, Ontario. The Ontario Palliative Care Network (OPCN) and Health Quality Ontario have developed a provincial quality standard for people with progressive, life-limiting illness, their caregivers, and healthcare providers.
 
Objective:
This event was a key opportunity to involve primary care providers in gaining a better understanding of the OPCN, the Palliative Care Quality Standard, and the South East Regional Palliative Care Network’s (RPCN) priority areas of focus for the next 3 years.
 
Methods:
Each of the 13 quality statements from the quality standard were mapped to the RPCN’s 5 priority areas of focus. In the workshop, participants were asked to explore the current state of the region in the context of one priority area and a corresponding quality statement. Participants explored the gaps between current practice and the statement and identified 1-2 activities they could action to move toward the statement.
 
Results:
35 participants were divided into 6 groups. Key practice gaps identified include: variability in practice, inconsistent awareness/knowledge, poor communication, and lack of spiritual care support for Indigenous people. Examples of actionable activities identified include: conducting a needs assessment, connecting with community partners, and establishing consistency in practice.
 
Conclusions:
The priority areas of focus are well-aligned with the care described in the quality standard. Primary care providers identified key activities to carry out to improve the experience of patients with palliative care needs. 

Authors:
Van Manen, Lori1; Ye, Lisa2 ; Tse, Candace2; Summers Laframboise, Dana2; Kondor, Natalie3; Reynolds, Denise4; MacPherson, Trish5; Babcock, Amber6

1. South East Regional Palliative Care Network, South East Local Health Integration Network, Belleville, ON;
2. Health Quality Ontario, Toronto, ON;
3. South East Regional Palliative Care Network, Queen’s Palliative Medicine, Kingston, ON
4. South East Regional Palliative Care Network, Belleville, ON
5. South East Regional Palliative Care Network, Kingston Health Sciences Centre, Kingston, ON
6. Home & Community Care, South East Local Health Integration Network, Kingston, ON


Presenters: Lori Van Manen,  South East Regional Palliative Care Network, South East Local Health Integration Network, Belleville, ON; Lisa Ye, Health Quality Ontario, Toronto, ON

Paper 2
The Quality of Dying and Death in a Residential Hospice
The Quality of Dying and Death in a Residential Hospice

Background:
Residential hospices may be an optimal compromise between home and hospital settings for end-of-life care. The present study was undertaken to assess the quality of dying and death of terminally ill patients in residential hospice and to identify factors associated with this outcome.
 
Hypothesis:
The quality of dying and death in a residential hospice is positively associated with prior receipt of palliative care and negatively associated with  length of stay (LOS) < one week.
 
Methods:
A total of 100 caregivers of deceased patients who died in residential hospice were recruited 4–6 months after death of the patient. The quality of dying and death was measured, based on interviews with bereaved caregivers, using the Quality of Dying and Death (QODD) questionnaire.
 
Results:
The overall QODD score was 68.85+11.62 which is in the intermediate (“neither good nor bad”) range (30-70) of the scale. The lowest QODD subscale score was on the transcendence subscale, which evaluates death-related concerns; this was 59.48 (SD 25.37), with ratings in 14.6% of the sample in the ‘‘terrible’’ to ‘‘poor’’ range. QODD scores were higher for patients with hospice LOS >1 week (72.21+9.64) than for those with a shorter LOS (60.38+11.92) (p<0.001).
 
Conclusions:
The overall quality of dying and death can be relatively high in an urban residential hospice, although death-related distress may be present in a substantial minority of patients. A LOS  of stay of greater than  one week may be necessary to benefit maximally from the holistic care provided by residential hospices.

Authors:
Isuri Weerakkody1,2,3, MD, MSc, Sarah Hales1,4, MD, PhD, Samantha Fernandes 1,2,MSc, Debbie Emmerson6, RN, William O’Neill6, Camilla Zimmermann1.2.5, MD, PhD, and 1.2.5Gary Rodin1,24.6, MD
1. Institute of Medical Science, Faculty of Medicine, University of Toronto,  Toronto, ON
2. Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, ON
3. Department of Family and Community Medicine, University of Toronto, Toronto, ON
4. Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON
5. Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON
6. Kensington Health Centre, Toronto, ON


Presenter: Isuri Weerakkody, MD, MSc, Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON; Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, ON; Department of Family and Community Medicine, University of Toronto, Toronto, ON
Paper 3
Revitalizing Palliative Approach To Care At an Urban Community Hospital
Revitalizing Palliative Approach To Care At an Urban Community Hospital

Located in the City of Toronto, St. Joseph’s Health Center resides in one of the most ethnically diverse metropolises in the world. It serves an urbanized population of over half a million individuals with an eclectic social and economic mix of communities ranging from affluent professionals to the working poor. At St. Joe’s, we strive to provide the best care and experience for the community we serve. As patients enter the final stages of life, this best care includes palliative care. In alignment with the Toronto Central LHIN Palliative Care Strategy and in partnership with the community, St. Joe’s plans to expand and coordinate supportive, palliative and end of life services to create a model of comprehensive care. With this expansion, we hope to improve the patient, family and community experience of the final stages of life. This initiative involves facilitating integrated service delivery of comprehensive inpatient and outpatient care across multiple diagnostic groups, supported by partnerships within the Toronto Palliative Care Network. This initiative is projected to be completed by the end of 2018 and will comprise a ten-bed inpatient unit, outpatient clinic and palliative outreach team.

This presentation will provide an overview of the data collected so far from our temporary unit of cohorted palliative patients on an acute medical unit. We hope to inform and be informed as we analyze the results of patient, family and interprofessional experiences and consider their impact as we plan for the future of palliative care at St. Joe’s. ​

Authors:
Rugg, Maria1; Hopfner, Jennifer1,2
1. St.Joseph’s Health Centre Toronto, Department Medicine and Senior’s Care, Toronto, ON
2.Faculty of Community and Family Medicine, University of Toronto, Toronto, ON


Presenter: Maria Rugg, St. Joseph’s Health Centre Toronto, Department Medicine and Senior’s Care, Toronto, ON
10:30 am – 11:45 am SERIES 12
Paper 1
Receipt of Home Care and Death in Hospital: A Population-Level Retrospective Cohort Study
Receipt of Home Care and Death in Hospital: A Population-Level Retrospective Cohort Study

Study objectives: To better understand the relationship between home care utilization in the last 3 months of life and place of death.

Methods: Health administrative data from the Institute of Clinical and Evaluative Sciences (ICES) were used to retrospectively construct a cohort of decedents who died in Ontario between April 1 2011 and March 31 2015 (n= 277,128). The primary outcome was death in hospital.  A logistic regression model was constructed to estimate the effect of different home care packages, and intensity of home care (i.e., hours of nursing or personal support, and presence of a palliative care nurse practitioner [PCNP]), on the odds of dying in hospital. Demographic variables (e.g., age, sex, rurality, neighbourhood income quintile) and chronic disease groups were controlled for in the model. Home care packages were broadly classified as: (1) the receipt of home care with palliative care intent; (2) long-stay maintenance and support; (3) other home care packages.

Results: Preliminary results suggest that in the last 3 months of life, receipt of long-stay maintenance and palliative intent home care significantly decreased odds of dying in hospital, compared to decedents who received other home care packages.  Provision of care from a PCNP further reduced the odds of dying in hospital. 

Conclusions: Ontarians who received home care with a palliative intent, especially those who had received home care from PCNP, were significantly less likely to die in hospital, compared to Ontarians not receiving any home care in the last three months of life.  

Authors:
Budhwani, Suman
1,3,4; Gill, Ashlinder1,3,4;  Spruin, Sarah2,5;  Tanuseputro, Peter1,2,3,5,7 & Hsu, Amy2,3,5,6

1. Bruyere Research Institute, Ottawa, ON;
2. Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON;
3. Health System Performance Research Network, Toronto, ON;
4. University of Toronto, Institute of Health Policy, Management & Evaluation, Toronto, ON;
5. Institute of Clinical and Evaluative Sciences (ICES), ICES uOttawa, Ottawa, ON


Presenter: Suman Budhwani, Bruyere Research Institute, Ottawa, ON; Health System Performance Research Network, Toronto, ON; University of Toronto, Institute of Health Policy, Management & Evaluation, Toronto, ON

Paper 2
Home Care Intensity at the End-of-Life: Measuring Access and Outcomes in Ontario Decedents
Home Care Intensity at the End-of-Life: Measuring Access and Outcomes in Ontario Decedents
Study Objectives: The purpose of this investigation was to describe patterns of home care delivery in Ontario, and its impact on client outcomes. 

Methods: A retrospective cohort study of Ontario decedents between April 1 2011 to March 31 2015 (N=277 128) was completed using administrative databases.  Weekly rates of nursing, palliative care nurse practitioner, and personal support worker (PSW) hours were measured over the last 3 months of life.  As per the Ontario Community Care Access Centre, home care packages were characterized by service level; palliative care intent (PC), and long stay maintenance (long-stay).  Home care was first measured across client demographics and service packages, and then compared across client outcomes (i.e., location of death, days in hospital, emergency department [ED] visits). 

Results: A total of 66 025 (23.8%) and 105 156 (37.9%) decedents received PC and long-stay services in the last 3 months of life.  Intensity of home care increased closer to death for all decedents.  Preliminary results suggest clients with PC home care received greater intensity of services, especially of nursing and PSW visits.  Long-stay clients experienced more days in hospital, ED visits, and greater odds of dying in hospital, compared to PC decedents. 

Conclusions: The receipt of PC home care package offers more intense service delivery, and was associated with lower acute care use. Factors that precipitate access to such care should be better understood, as an opportunity exists to either extend PC services, or better effectively deliver homecare to everyone in need. 

Authors:
Ashlinder Gill1,3,4; Budhwani, Suman1,3,4; Spruin, Sarah2,5;  Tanuseputro, Peter1,2,3,5,7; Hsu, Amy2,3,5,6

1. Bruyere Research Institute, Ottawa, ON;
2. Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON;
3. Health System Performance Research Network, Toronto, ON;
4. University of Toronto, Institute of Health Policy, Management & Evaluation, Toronto, ON;
5. Institute of Clinical and Evaluative Sciences (ICES), ICES uOttawa, Ottawa, ON;
6. University of Ottawa, School of Epidemiology and Public Health, Ottawa, ON;
7. University of Ottawa, Department of Family Medicine, Ottawa, ON


Presenter: Ashlinder Gill, Bruyere Research Institute, Ottawa, ON; Health System Performance Research Network, Toronto, ON; University of Toronto, Institute of Health Policy, Management & Evaluation, Toronto, ON
Paper 3

Quality End-of-Life Hospital Care for Advanced-Age Adults: Adult Children's Perceptions
Quality End-of-Life Hospital Care for Advanced-Age Adults: Adult Children's Perceptions
Dying advanced-age adults (85+) are a vulnerable population at risk of suboptimal end-of-life (EOL) care in hospital. Adult children are expected to have valuable insights on the quality of EOL care for their hospitalized parent. The aim of this mixed-methods study was to develop a theory of high quality EOL hospital care for non-surgical hospital patients who are aged 85 and older. The objective of the qualitative phase of this study was to explore adult child perceptions on the hospital care received by their parent aged 85+ during the last non-surgical admission that ended in death. Using grounded theory methodology, the researcher recruited a purposeful sample of adult children living in southwestern Ontario and conducted semi-structured interviews until data saturation. Preliminary results demonstrated that many adult children were not expecting their parent to die during their final hospitalization. Yet, several overlapping sub-themes were identified to describe high quality hospital care at the end of life: being kept informed vs. being left in the dark, receiving care with compassion vs. being treated uncaringly, receiving optimal care and comfort vs. falling through the cracks, and being treated with respect and dignity vs. being devalued as a person. This dissertation study presents a theory of high quality EOL hospital care for advanced-age adults. The study emphasizes the importance of initiating goals-of-care discussions soon after admission and prior to admission to hospital for very old persons who are likely to soon need palliative care.

Authors:
Crandall, Jacqueline1,2,3; Wilson, Donna1,4, 5
1. Faculty of Nursing, University of Alberta, Edmonton, AB
2. Department of Thanatology, King’s University College, London, ON
3. Division of Nephrology, London Health Sciences Centre, London, ON
4. School of Nursing & Midwifery, University of Limerick, Ireland
5. Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB


Presenter: Jacqueline Crandall, Faculty of Nursing, University of Alberta, Edmonton, AB; Department of Thanatology, King’s University College, London, ON; Division of Nephrology, London Health Sciences Centre, London, ON