A whole community approach to palliative care planning

“It’s a real privilege providing nursing care in people’s homes and to be a guest in their homes.” In a nursing career that has spanned more than four decades and several different care settings—including a stretch in critical care—Elisabeth Antifeau’s true love is community nursing. Helping people to live well and die well where they live is Elisabeth’s north star.

Interior Health, a predominantly rural-based health authority encompasses a vast and disparate geography, and serves a large population with limited access to specialist palliative care teams. Interior Health adopted a primary generalist palliative care model of service delivery, in order to better serve its communities. Elisabeth explains, “This means that palliative care has to be in the hands and hearts of every health care provider who delivers care where people live.” To build the system capacity to meet this vision, Interior Health needed a comprehensive palliative education strategy that supports competencies for front line providers to have the knowledge, attitude, and comfort to deliver this care. They selected Pallium Canada’s LEAP™ courses as the foundational palliative education program for Interior Health. The fact that LEAP™ engages the whole care team was important. Elisabeth leads Interior Health’s 14 Facilitator Dyads (Pallium certified LEAP™ Physician/Nurse Dyads) to deliver LEAP™ courses to colleagues across the authority. Since August 2016, Interior Health has provided 81 LEAP™ sessions for 1,964 health care professionals to learn and use a palliative approach to care.

Building local capacity to deliver a palliative approach to care

The concept of holding weekly palliative care rounds that are ‘whole community’ in focus was another timely local operational innovation that supported the  primary generalist model of palliative care in Interior Health. Elisabeth learned about the concept of ‘the whole community’ from emergency management groups who use it as a philosophical community approach to emergency response. Elisabeth’s aha moment came on the heels of a particularly destructive forest fire in British Columbia where miscommunication between authorities and community organizations was widespread. Drawing connections to her own work in palliative care, Elisabeth realized that too much of the current thinking was fragmented by palliative care in ‘this hospital’, in ‘that community’, in the ‘long-term care home over there’. Care was not always integrated, and opportunities were being missed to engage with relevant  people and organizations in these small towns who could be included to help support a palliative approach to care and better meet the individual’s goals of care.

Thus, Whole Community Palliative Rounds (WCPR) were developed as a hub and spoke model across the vast Interior Health geography. The ‘circle of care’ at community levels was purposefully widened to include health professionals both internal and external such as physicians and contracted partners to the health authority as well as external partners such as hospice coordinators, community paramedics, First Nations, and band-employed nurses.

The purpose of these weekly Whole Community Palliative Rounds is to have interdisciplinary discussions that focus on detailed care planning to address real-time symptom burden and distress. A three-pronged care planning approach to address active symptom management includes a pharmaceutical perspective, non-pharmaceutical approaches, and the intentional use of patient and family information as a critical support. This final area of patient and family information recognizes that to support people to live well, we need to help them understand their illness trajectory and empower them to self-manage their changing health needs. Health care professionals must companion them in their advancing illness. Elisabeth explains, “This means walking alongside them in their illness journey, figuring out their lived experiences with an advancing illness, how they are impacted every day, and what choices will support them to live as best as possible.” This companioning work also involves serious illness and advance care planning conversations. Elisabeth says, “We might be miles ahead of the patient about what we see is coming, but if we are not travelling the same journey with them then we are doing the person and family a disservice.”

At Interior Health, Whole Community Palliative Rounds includes a weekly meeting attended by interprofessional, cross-sector health care providers and inter-agency staff, who are there for the purpose of care planning real-time symptom burden and distress. Discussions include understanding where a person is in their disease trajectory, PPS and rate of change, reported symptom burden and distress and the details of that distress using a Symptom Assessment O to V tool. The Whole Community Palliative Rounds ends with documented action items and tweaks to the care plan which are shared back with the individual via their clinician, and their physician or nurse practitioner. “If those tweaks work for the person, their case doesn’t come back into the next round,” says Elisabeth, but if the care plan doesn’t work and the person is still experiencing symptom burden, “We bring their care needs back as many times as necessary to find something that works to better support this person and family.”

Today, there are 13 Whole Community Palliative Rounds that provide local palliative support to over 58 smaller spoke communities in Interior Health. Whole Community Palliative Rounds has improved communication across different health service programs and providers and across health sectors in Interior Health to ultimately improve care for people and their families.

In 2020, Elisabeth’s Regional Palliative and End-of-Life Care team received an award in recognition of Whole Community Palliative Rounds by the BC Patient Safety & Quality Council.

Whole Community Palliative Rounds also received national attention from the Canadian Home Care Association (CHCA) as a High Impact Practice. CHCA invited Elisabeth and her CNS colleague Vicki Kennedy to Ottawa in 2019 to participate in a national SPRINT collaborative event for nine communities across the country who were interested in launching Whole Community Palliative Rounds. Since then, Elisabeth has also contributed her experience and knowledge of Whole Community Palliative Rounds to the Palliative Care ECHO Project, a national initiative that cultivates communities of practice and supports continuous professional development among health care providers across Canada who care for patients with life-limiting illness.

Elisabeth Antifeau is a Regional Clinical Nurse Specialist for Palliative Care in Interior Health and is a Master Facilitator and Coach for Pallium’s LEAP™ courses.