Palliative Rotation at Toronto Western & Kensington Hospice

Morning paper rounds

• At 9:00 am, 1 to 2 staff physicians and our clinical nurse specialist will meet in McL 8 – Rm 431 or 433 to review follow-up patients and assign new consults using the Sign-out Tool

Sign-out Tool

• To access the Sign-out Tool, go to EPR ▷ Sign-out Tool ▷ Palliative Care ▷ TWH.
• Add your name and contact information to the team header at the top of the sign-out list.
• New consults will be entered in the Sign-out Tool under pending.
• Once you have seen the patient,
  • Fill in pertinent information regarding diagnosis, recent issues, symptoms, goals of care and disposition/discharge plan that would be important for our on-call team to know.
  • Click the radio button to "active".
• Include any information regarding next day follow-up or pre-planned family meetings in the ‘on-call’ section of the sign out tool for each patient
• Update the sign out list at the end of each day 

​Consult note format

• Write notes on the duplicate yellow consult forms available on each unit.
• After you have completed the consult note and reviewed the patient with the palliative care physician, bring the white copy of the consult note to Natalie Silva.
• Be sure to complete the white sheet with the patient’s information and PPS and ESAS scores and hand it to Natalie alongside the white copy of the consult sheets.

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/ NPs is common.
• All orders are "suggest orders" and should be reviewed with the palliative staff physician unless otherwise indicated. For medical and inpatient family medicine teams, non-urgent "suggest orders" are written as paper orders on the chart; however, if there is a change that needs to be made urgently, or if the patient is being followed by a surgical service, you should page the attending team to discuss the orders and then enter the orders into EPR if the attending team agrees
• Tests should be recommended to the attending team but not ordered directly.

Kensington Hospice

• The Palliative Care Physicians at Kensington Hospice are the most responsible physicians (MRPs) for patients at the hospice
• Note that the hospice is similar to a patient’s home in terms of the care available:
  • There is no pharmacy or laboratory on-site.
  • Blood work and subcutaneous hydration is only done in exceptional circumstances.
  • Medications ordered during business hours will be delivered to the hospice later that day or early evening by a community pharmacy.
  • There is an emergency drug box that contains common medications needed for symptom management if needed immediately and not already ordered for the patient. 

Morning hospice rounds

• You will arrange a time to meet with the staff physician and review overnight issues with nursing staff on your first day (typically at 9:00 am). Patients are seen in order of priority based on clinical need/symptoms 

Charting

• All physician orders are done in the patient’s paper chart, using an electronic pen and virtual fax paper.
  • We will show this to you on your first day.
  • The patient’s paper chart may also contain information from the patient’s previous location of care or previous consulting/attending physicians.
• Admission and progress notes are done in a web-based electronic medical record called ‘PointClickCare’, which can be accessed by going to https://www7.pointclickcare.com/home/login.jsp:
  • You will use your staff physician’s login and password for this program.
  • Please use the physician’s desk in the basement to do your charting.
  • Alternatively, if a computer is available in the first or second floor nursing station, you may use these computers to chart if our nursing colleagues do not need these computers.
  • Admission notes can be charted using similar headings to a consult note, and progress notes can be charted using the "SOAP" format
  • Please document the time-in and time-out with the patient in your note, and save your notes as "draft" (when starting a new progress note, select "Draft" from the drop down menus indicating "Type" of note). This allows your staff physician to review and sign-off your note at the end of the day.
  • You are expected to complete your notes prior to leaving the hospice each day. 

Daily activities

• On your first day you will be assigned patients to follow at the hospice.
• Information regarding patients can be found in: 
  • their paper chart, which contains information up to the time of admission and
  • the electronic medical record, which contains information from the time of admission onwards.
• Prior to seeing your patient, review
  • the electronic medical record, which contains the patient’s admission note and progress notes and
    
  • the electronic MAR for regular and PRN medication use. On your first day, review how to access this electronically.
• Note that because the focus of care is on symptom management, regular vital signs are often not charted.

Tuesday Morning Interdisciplinary Team Rounds

• You will attend interdisciplinary patient rounds at 9:30 am in the 3^rd floor conference room with all members of the hospice team.