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

Brenne, Anne-Tove; Løhre, Erik Torbjørn; Knudsen, Anne Kari; Thronæs, Morten; Lund, Jo-Åsmund; Kongshaug, Nina; Neverdal, Marte Nilssen; Rystad, Kristina; Johansen, Marianne Haug; Braseth, Tone Inga; Kaasa, Stein

doi:10.1007/s40487-021-00176-y

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 dataset^a) Depression assessment tool (PHQ9^b) Functional status (WHO^c, Karnofsky^d) Assessment of carers needs (CSNAT^e) 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

^aEuropean Association for Palliative Care basic dataset [53]
^bPatient Health Questionnaire 9 [54]
^cWorld Health Organization International Classification of Functioning Disability and Health (ICF) [55]
^dKarnofsky performance status [33]
^eThe Carer Support Need Assessment Tool [56]

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