Links to best-practice tools from around the world to support primary care providers in the delivery of palliative care.
Tools are organized according to the 3-step model of best practice proposed by the
Gold Standards Framework
(GSF): Identify, Assess, and Plan. This evidence-based approach has been adopted broadly across the United Kingdom. Work has also been done to adapt the GSF in British Columbia for an
End of Life Care Module
developed by the General Practice Services Committee. For resources tailored to support First Nations, Métis and Inuit families and communities, please see
Tools for the Journey: Palliative Care in First Nations, Inuit and Métis Communities
, a Resource Toolkit, developed by the Aboriginal Cancer Control Unit at Cancer Care Ontario
To view a detailed map of the standard of care and support that all cancer patients and their families should receive, please refer to the
Psychosocial Oncology/Palliative Care Pathway
(Cancer Care Ontario).
Identify persons who may benefit from a palliative care approach early in the illness trajectory by using available tools.
Specific details for this step are described in the
Early Identification & Prognostic Indicator Guide developed by Mississauga Halton LHIN.. This tool has been adapted from the Gold Standards Framework (GSF) Prognostic Indicator Guidance Tool developed by the GSF Centre in the UK.
Surprise Question: “Would you be surprised if this person were to die in the next year?”
Indicated preference or need for comfort care
General indicators and disease specific indicators
Assess the person’s current and future needs and preferences across ALL domains of care (see
Domains of Issues Associated with Illness and Bereavement - PDF
) using validated screening tools, and through an in depth history, physical examination, and relevant laboratory/imaging tests.
1. Regularly screen for distress and other needs using validated screening tools. Type and timeliness of assessment will depend on the severity, interference with life, urgency and complexity of the symptoms or needs identified.
2. Use the results of screening to prompt further discussions, including critical conversations about a person’s illness understanding, their values and beliefs, and their goals and wishes for current and future care. These conversations are iterative and should be revisited regularly.
Advance Care Planning (Speak Up Campaign)
Engaging in Illness Understanding and Goals of Care Conversations
Obtaining Consent (to deliver, withhold or withdraw treatment)
Plan and collaborate ongoing care to address needs identified during assessment, including prompt management of symptoms and coordination with other care providers.
Collaborative Care Plans (Cancer Care Ontario)
The following documentation and forms are Ontario specific resources that may be required as part of the care you provide.