How physicians in Fraser Northwest are improving palliative care for patients and families

Supporting patients with a life-limiting illness is never easy. The goal, for doctors and other health care professionals, is to deliver care in the most compassionate way possible, understanding and acknowledging the needs of the patient. This can be a challenge, especially when there is lack of clarity about the range of services available and little communication between professionals all dealing with the same challenges.

Since 2019, the Fraser Northwest Division of Family Practice with support from the Shared Care Committee has been bringing family doctors together with palliative care doctors and nurses to better understand the challenges and develop programs to help provide improved palliative care. The Palliative Shared Care Initiative has now released their final report that shares the steps they have taken, including creating provider resources to help increase awareness of the services available, enhancing family physicians’ skills, and fostering better communications between professionals involved in palliative care.

The division found that one of the biggest challenges is that many patients with life-limiting illness do not have a family doctor. Patients with a life-limiting illness with a prognosis of less than one year were identified as the top priority. The team worked with the Fraser Northwest Attachment Hub to triage and urgently attach these patients to a family doctor. "It was important to prioritize palliative patients as they typically endure severe illnesses or conditions, necessitating a comprehensive approach to pain management, symptom alleviation, and emotional support," explains Dr Ali Sanei-Moghaddam, physician lead for the project.

"Overall, access to palliative care for primary care providers and patients results in enhanced patient-centred care, comprehensive symptom management, emotional support, care coordination, improved communication, and shared decision-making,” adds Dr Ali Sanai-Moghaddam. “This integration of palliative care principles into primary care settings improves the quality of care and outcomes for patients facing serious illnesses.

With the complexity of palliative care across BC, as seen by Ridge Meadows’s recent project, education for providers and resource availability was top of mind for the Fraser Northwest project team. The group hosted five workshops for primary care providers based on the top challenges identified during the needs assessment. With an average registration of more than 30 participants, sessions aimed to advance primary care providers’ palliative care knowledge and skills. In preparation for the Advance Care Planning (ACP) workshop, the team partnered with the Fraser Health Authority ACP team to develop the ACP Pathway—a helpful tool for physicians that provides the most relevant and applicable information based on specific clinical contexts.

To address the lack of clarity around existing palliative care resources for primary care providers, the team developed the Palliative Approach to Care Cheat Sheet. This tool includes links to learning opportunities, clinician forms, and community supports.

Another key component of one of the workshops was for primary care providers to meet the diverse health care providers that support the palliative care teams in order to foster interdisciplinary connections and understanding of the different roles. A diversity of physicians and providers were present at the workshop, including family physicians and palliative physicians, Home Health nurses, palliative nurse clinicians, a social worker, and others.

As efforts across BC continue to refine this critical area of care, the Fraser Northwest Division remains committed to working with palliative physicians and teams to stay connected and maintain the educational resources they developed. At the project's end, family physicians confirmed the need to improve communication across care settings to clarify and accentuate care plans as well as roles and responsibilities. Continuous communication and collaboration between the palliative care team and the Division is needed to sustain the successes and work accomplished.