Palliative Rotation at Princess Margaret

Team Members & Morning Rounds

Team members

• The Consult team consists of two Advance Practice Nurses (APNs) and 1 – 2 staff physicians.

Morning rounds

• Morning report rounds are on 17B – 219 at the Clinical Nurse Specialist office.
• On Mondays, the rounds start at 9:15 am following the Journal Club rounds which start at 9:00 am. Journal Club rounds are from 9:00 – 9:15 am followed by regular morning rounds. If there is no Journal Club, then rounds will start at 9:00 am.
• From Tuesdays to Fridays, rounds are at 9:00 am.
• Print a copy of the Sign-out Tool and bring to rounds.

Sign-out Tool

• New consults will be entered on the Sign-out Tool under pending.
  • To access the Sign-out Tool, go to EPR ▹ Sign-out Tool ▹ Palliative care ▹ PMH.
• Once you have seen the patient:
  • Fill in information about diagnosis, recent issues, symptoms, goals of care and disposition and discharge plan;
  • Click “Active”; and
    
  • Update the list at the end of each day.

Consults and Reasons for Referral

• Pain and symptom management at any stage of illness.
• Palliative care planning.
• Establishing goals of care.
• End-of-life care.

Consult note format

• Write the consult notes on the duplicate yellow consult forms available on each unit.
• Complete the white sheet with the patient’s information and PPS and ESAS scores.
• After reviewing the patient with the palliative care physician, return the white copy of the consult note to the palliative care office in 16-757.
• All consult notes need to be dictated, unless otherwise specified.
• See Approach to a Palliative Care Consult.

Daily Activities

• Most, but not all, patients should be seen on a daily basis and followed for symptom management.
• Involvement in planning and liaising with the clinical associate, oncology, residents or fellow or attending oncologists is common.
• All orders are "suggest orders" and should be reviewed with the palliative staff physician. Unless otherwise indicated, the orders are usually entered into EPR.
• Tests should be recommended to the attending team but not entered or ordered directly. Any urgent orders or findings should be discussed with the RN and MD on the ward as soon as possible.

Discharge follow-up and referral practices

• Ensure patients and families are given our palliative care contact sheet and explain access to the palliative care team when they are discharged home.
• Contact palliative care physician’s administrative assistant prior to discharge if​:
  • Patients are going home and require a follow-up appointment in the palliative care clinic. You will need to contact the palliative care physician’s administrative assistant for an appointment prior to discharge (see contact sheet).
  • Patients are going home and need to be referred to a community palliative care physician or team.

Outpatient Palliative Care Clinics

Refer to Clinic Schedule for daily location and staffing.

• Clinics run Monday to Friday, with patients booked from 9:30 am – 12:30 pm and 1:30 – 4:30 pm.
• Patients are referred by surgeons and oncologists for a variety of reasons, the most common being symptom management, future planning or to take over care following discontinuation of active treatments such as chemotherapy and radiation.
• RN case managers are key to the running of the clinics, and do an initial assessment on all patients, including completing the Edmonton Symptom Assessment Scale (ESAS) and getting a list of medications, and discussing primary issues for the visit.
• Most new patients are booked for a 1 – 1.5 hour time slot, and follow-ups for 30 minutes. This includes both RN and MD assessment.

When Attending Clinic

• Arrive 15 – 30 minutes early so that you can review the patient chart before seeing the patient.
• Many of the RNs and MDs in clinic use a worksheet to help organize notes and to assist with dictation.
• For new patients, confirm their oncologic history and review their past medical history, current medications, social history and current investigations. Some of these may be reviewed by the RN case managers and do not need to be repeated. Focus should be placed on the patients’ current symptoms, recent changes and goals of care/concerns for the future.
• Discuss a plan for management of the patients’ symptoms, follow-up, on-call services and future planning. Most of these discussions should take place with the staff physician present.

Dictation

• Clinic notes are dictated using the UHN system. Urgent notes should be marked as such by entering “*9” during dictation.
• Notes are generally available in EPR within a week.
• Review all of your dictated notes and, if needed, print and correct/edit them.
• Corrected notes can be handed into the palliative care physician or the palliative care office for delivery to medical records.
• Dictation instructions can be found on the UHN Intranet.

On-Call Responsibilities

• Not all residents are required to participate in on-call while in rotation.
• Residents are on-call for Saturday and Sunday.
• On-call responsibilities include coverage of the PCU, consult service and outpatient calls, but are shared between resident(s) and the staff physician. Generally, outpatient and overnight calls are taken by the staff physician, new consults and admissions are covered by the resident and then reviewed, and rounding on patients known to the service is shared.
• It is rare to have to return to the hospital after completing rounds, consults and admissions during the day. Discuss with the staff physician on call your start time and whether you are expected to be available by pager in the evening and overnight.

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