ALERT CONTENT PLACEHOLDER

Clinical Activities

Consult Service

  • The role of palliative care consult is symptom management (i.e., pain, nausea/vomiting, dyspnea, constipation), and assistance with planning place of care, and community supports, rather than medical management of patients.
  • ​The consult service is available to all inpatients at Toronto General Hospital. All inpatients units have clinical associates, staff physicians, fellows and residents managing the day to day medical care of patients.
  • The consults are called in to the palliative care office at extension 2674. If you have taken a consult from a service directly, please make sure our administrative assistant is aware.

Team members

  • The Consult team consists of 1 Advance Practice Nurse (APN) and 1 – 4 staff physicians on any given day. 

Morning rounds

  • Morning rounds take place in 9N – 924 at 8:30 am.
  • Print appropriate copies of the Sign-out tool ready for rounds.
  • On occasion rounds will be pre-empted by our administrative team meeting or Princess Margaret Pain & Symptom Management rounds. We will inform you in advance if this is the case.

 

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 ▹ TGH
  • Once you have seen the patient,
    • Fill in information about diagnosis, recent issues, symptoms, goals of care and disposition and discharge plan then click on "Activate";
    • Enter the initials of the staff with whom you reviewed in the “on-call” section; and
    • Update the list at the end of each day.

 

Consults and Reasons for Referral

  • Pain and symptom management.
  • Palliative care planning and discharge 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 or at our admin desk.
  • Complete the white in-take sheet with the patient’s information and PPS and ESAS scores. Please ensure that you record the service you provided, as it can differ from the reason given for referral.
  • After reviewing the patient with the palliative care physician, return the white copy of the consult note and the white in-take sheet to the admin desk.

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, liaising with the attending team or NP 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.

 

Expected number of patients by trainee level

  • Medical students will see about 3 – 4 patients
  • Residents will see about 4 – 6 patients
  • Palliative Care Fellows and upper-year residents will see about 6 – 12 patients

 

Day to day care

  • Flag your orders and place in the cart with the appropriate tag facing out.
  • If an order needs to be done, communicate directly with the RN as soon as possible.
  • To refer to LHIN, OT, PT, SW or Spiritual Care, write an order for this, with reasons such as mobility, home safety, PCU referral, etc.
  • If the patient is going home, LHIN, Pharmacy and PT/OT are usually needed to set up home care, review medications and determine equipment needs.
  • Some prescriptions are entered by the attending team and some by palliative care team. All CADD pumps orders are entered by the palliative care team. But if the patient requires a CADD pump in the community, these orders are sometimes completed by the attending team. The process general takes 24 – 48 hours. Your supervising staff physician can help with the order.

 

CADD pump orders

  • CADD pumps are available for use on 6ES, 13ES, and 14ES
  • The paper order forms are located on each unit. The order also needs to be completed on EPR.
  • Orders need to be discussed with the RN, the pharmacist and the unit charge nurse for the day.
  • Your supervising physician will assist you with ordering the CADD.
  • Drugs available for use in a CADD are Midazolam, Hydromorphone, Morphine, Fentanyl and Sufentanil.

 

Discharge follow-up/referral practices

  • Ensure patients and families are given any appropriate reading material and palliative care contact information.
  • Inform the palliative care administrative assistant before discharge if:
    • Patients who are going home require a follow up appointment in the palliative care clinics either at Toronto General or Princess Margaret Hospital.
    • Patients who are going home need to be referred to a community palliative care physician or team. The administrative assistant will prepare the referral form and package which you need to review and complete.
    • If it is an urgent request (requiring an MD to do a first visit within 72 hours or less), speak directly with that MD if possible. Our admin can assist you in identifying the appropriate MD or service based on the patient’s home address.

 

On Call

  • You will be assigned weekend call days prior to your rotation. Call is in hospital only during the daytime. We provide telephone support to admitting teams overnight. Call begins at 5:30 pm on Friday and ends at 8:30 am on Monday.
  • Prior to the weekend, staff and learners will review our patient list and designate which patients need follow up over the weekend. Only patients who have acute symptoms or require reassessment of CADD pump rates will be prioritized.
  • We try to complete all new weekend consults called in before 2:00 pm. If we are notified of a consult after 2:00 pm on the weekend, we can provide telephone advice to support the admitting team until the following day when we are available to see the patient.
  • If a consult is for planning only, it may be deferred until the next business day, depending on the volume of consults.
  • The on-call palliative care staff physician will coordinate meeting times and communicating throughout the weekend.

 

TGH Outpatient Clinics

  • There are numerous palliative care clinics run throughout the week associated with various clinics at TGH. Currently, the clinics are:
    • Heart Function, Wednesday 8:30 – 11:30
    • Lung Transplant, Tuesday & Thursday 1:00 – 4:00
    • Pulmonary Hypertension, alternating Wednesdays 1:00 – 4:00
    • VAD clinics running on alternating Thursdays 1:00 – 4:00
  • Patients are referred by respirologists, cardiologists, and transplant surgeons for a variety of reasons, the most common being symptom management and future planning.
  • Presently, the clinic schedule is managed by the palliative care administrative assistant. They can provide an accurate patient list for any given clinic.​
  • Most new patients are booked for a 1 hour time slot and follow-ups for 30 minutes. This includes both resident and staff MD assessment.

 

When attending clinic

  • Pick up the chart from the admin desk earlier in the day so you can review the patient chart prior to seeing the patient.
  • Many of MDs in clinic use a worksheet to help organize notes and to assist with dictation.
  • For new patients, confirm their illness history and review their past medical history, current medications, social history and current investigations. Focus should be placed on the patients’ current symptoms, recent changes and goals of care or 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 or 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.

 

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