Purpose and scope
This best practice guideline (BPG) provides evidence-based recommendations to nurses and the interprofessional health team who support adults experiencing the last 12 months of a progressive life-limiting illness, and their families and caregivers. The goals of the recommendations are to:
- improve delivery of psychosocial, spiritual and culturally safe care
- enhance co-ordination of care
- facilitate supportive work environments
The BPG applies to all practice settings in which people require palliative care and end-of-life care services (for example, acute care, community care, long-term care). Specifically, this BPG will focus on persons experiencing the last 12 months of progressive life-limiting illness and their families. It will address the following areas:
- domains of psychosocial, spiritual and culturally safe care
- interprofessional care planning and delivery
- strategies to support health providers who provide palliative care and end-of-life care.
Get started
Registered Nurses’ Association of Ontario. A Palliative Approach to Care in the Last 12 Months of Life. Toronto (ON): Registered Nurses’ Association of Ontario; 2020.
Recommendations
Recommendation 1.1: The expert panel recommends that health-service organizations implement an interprofessional model of care for the provision of palliative care and end-of-life care to persons and families.
Recommendation 1.2: The expert panel recommends that the interprofessional health team, in collaboration with the person and family, develop an individualized, person-centred plan of care and re-evaluate the plan of care based on the changing status, needs and preferences of the person.
The following recommendations are applicable within the context of an interprofessional health team (see Recommendations 1.1 and 1.2).
Recommendation 2.1: The expert panel recommends that nurses assess the cultural needs and values of persons and families.
Recommendation 2.2: The expert panel recommends that nurses perform ongoing assessments of persons and families for the following:
- values, beliefs, expectations and preferences about progressive life-limiting illness and death; and
- preferred place of death
Recommendation 2.3: The expert panel suggests that as part of a holistic assessment, nurses assess the spiritual, emotional and existential needs of persons and families, including:
- concerns about end of life; and
- presence of spiritual, emotional and existential distress.
Recommendation 2.4: The expert panel recommends that nurses address the person’s and family’s palliative care and end-of-life care expectations.
Recommendation 2.5: The expert panel suggests that nurses provide opportunities for life reflection to persons and families.
Recommendation 2.6: The expert panel recommends that nurses facilitate access to resources, space and services needed by persons and families for cultural, spiritual and/or religious practices.
Recommendation 2.7: The expert panel recommends that for persons who prefer to die at home, health-service organizations implement high-quality home and community care, which includes:
- access to after-hours services;
- care coordination; and
- support provided by an interprofessional health team.
Recommendation 3.1: The expert panel recommends that health-service organizations provide education and skills training for nurses and the interprofessional health team related to self-care, including stress management and mitigation of compassion fatigue.
Recommendation 3.2: The expert panel recommends that health-service organizations provide time and resources for nurses and the interprofessional health team to engage in debriefing.
