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Table 3 Content of the standardized care pathway for cancer patients treated with palliative intent in the Orkdal Region. Three sub-pathways were developed, each adapted to the setting where the patient was cared for

From: Implementing a Standardized Care Pathway Integrating Oncology, Palliative Care and Community Care in a Rural Region of Mid-Norway

Location (1) Referral (2) Treatment and follow-up (3) End-of-life care
Home or nursing home Referral address
Telephone numbers with access to cancer and palliative care 24/7
Structure of referral letter
Referral criteria
No home care:
 Information about rehabilitation
 Information about local initiatives for cancer patients outside of hospital
 Contact information to community cancer and palliative care nurses
Home care or nursing home:
 Five checklists for nurses
1. Admission to and discharge from hospital
2. Receiving electronic health information from hospital before discharge
3. First visit (assessment visit) from community nurse at home or after admission to nursing home
4. Assessment checklist for cancer patients (addition to checklist 3)
5. Assessment checklist for the palliative patient
Assessment tools
 Symptom assessment tool (EAPC basic dataseta)
 Depression assessment tool (PHQ9b)
 Functional status (WHOc, Karnofskyd)
 Assessment of carers needs (CSNATe)
 Assessment of pain, patients who cannot self-report (Doloplus-2 [51])
 Mini mental status evaluation, short version [52]
Care of the carers
 How to take care of children (checklist)
 Structure of family meeting
 Structure of family meeting when the patient is dying
 Application form for up to 60 days care allowance
Multidisciplinary collaboration with hospital
Symptom treatment
Nutrition
Procedures for technical equipment
Coordination of care
Procedures for coordination of admission and discharge from hospital
Patient-held record
Dying at home:
Nurse checklists
Link to the four most important medications at the end of life
Structure of a family meeting when a patient is dying
Plan of action when a patient is dying
Carers
Structure of meeting with the bereaved
Link to information about death and dying from Norwegian Health Authorities
Dying in nursing home:
As for “Dying at home”
Integrated outpatient clinic Description of routines when receiving a referral letter General:
Nurse checklist
Assessment tools
Care of the carers
 Structure of family meeting
 Children as carers
Multidisciplinarity: Offers at Orkdal Hospital
Symptom treatment: Link to national guidelines in palliative cancer care
Nutrition
Procedures for technical equipment
Coordination of care
 Coordination of services between Integrated Clinic and dept. of internal medicine, surgery and anesthesia at Orkdal Hospital
 Patient trajectory for malignant medulla compression
 Referral procedures to Cancer Clinic at Trondheim University Hospital
Ongoing anti-cancer treatment:
Structure of oncologist’s and palliative care team’s visit note
Patient trajectory for neutropenic infection patients
General guidelines for chemotherapy treatment
Link to description of side effects
Referral procedures to dept. of anesthesia get central venous access
Anti-cancer treatment stopped:
Structure of oncologist’s and palliative care team’s visit note
Available for counseling
Home visit on request
Hospital ward Structure of referral letter to integrated outpatient clinic
Description of who can be referred
Referral addressed to integrated outpatient clinic
Relevant telephone numbers with access to cancer and palliative care 24/7
Admission:
Nurse checklist
Discharge:
Structure of physicians’ discharge report
Nurse checklist
As for integrated outpatient clinic:
Assessment tools
Symptom treatment
Nutrition
Coordination of care
Care of the carers
Procedures for technical equipment
Multidisciplinarity
Dying in hospital:
Link to the four most important medications at the end of life
Structure of a family meeting when a patient is dying
Plan of action when a patient is dying
Procedures when a death occurs in-hospital
  1. aEuropean Association for Palliative Care basic dataset [53]
  2. bPatient Health Questionnaire 9 [54]
  3. cWorld Health Organization International Classification of Functioning Disability and Health (ICF) [55]
  4. dKarnofsky performance status [33]
  5. eThe Carer Support Need Assessment Tool [56]