Palliative Care is more than end-of-life care.
At Sienna, we consider quality clinical care to be the foundation of our long term care platform. Our approach to Palliative care is a big part of that.
Palliative care is often misinterpreted as End of Life Care – but End of Life Care is only part of the palliative care approach journey.
Palliative care is an approach that focuses on the quality of each individual’s life through relieving suffering and improving their quality of life at any stage of their illness not just end of life care. Palliative care aims to meet the individual's physical, psychological, social, cultural and spiritual needs through an interdisciplinary approach that involves the resident, families, caregivers and the care teams across the community.
Palliative care considers not just the resident’s journey, but also the family’s journey (and team member’s journey as well!).
The purpose of this guide is to detail the 4 key moments of the Palliative Care Journey, and who is involved in each.
Expand using the ‘+’ below for an overview of each of these four key moments.
This is the resident's first impression of the community and it allows the team members the opportunity to make positive connections with the resident and family right from their entry into their new home.
This is the care teams first opportunity to understand the goals of care for the resident. It can set everyone out on the right path for the rest of the resident's stay at the community.
While the resident lives with us, we want to make them feel comfortable and help them understand what we have to offer and really welcome them to a new home where the care team will get to know them.
It is important to start the conversation about a palliative approach to care during the first few weeks of move-in. The team will support discussions about the resident's current care needs within their illness trajectory. The health care team will collaborate with the resident/substitute decision maker to ensure that physical, emotional and social needs are met to the best extend possible, while always respecting their choices and preferences.
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RFEC
The Resident and Family Experience Coordinator (RFEC) who is a social worker/social service worker fosters relationships between residents, families, and team members, and is the main point of contact for residents and families during move-in.
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Care Team
The Care Team provides a holistic care approach that aims to enhance quality of life. The team will meet with the resident and their family members to assess current care needs and develop comprehensive plans of care that support their overall wellbeing.
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All Team Members
All Team members are crucial to welcome the resident and their families and make the resident feel at home in our communities regardless of their care needs.
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Tips for this key moment
• Encourage loved ones to bring in personal items as the room is the resident's home, and have them set up the room in advance where possible.
• Gather key documents around advance care planning such as who is the substitute decision maker and health care wishes.
• Our dedicated team are all engaged in the conversations to discuss palliative care approach to develop the plan of care of your loved one.
• The team will follow up with you and your love one after move in to ensure you have understood the palliative care process and the resources that we have available.
For resident, family and friends:
A change in health status is a progressive, life-limiting illness that affects an individual's health and quality of life, that gets worse over time, and that can lead to death in the near future.
Communicating about a significant change in condition focuses on early understanding of a resident's values, preferences for care. This will inform the goals of care decisions through ongoing communication with the resident and their loved one.
Residents with identified significant change in condition or their substitute decision-makers will have the opportunity to revisit the resident's goals of care with the interdisciplinary health care team. These values-based discussions will be focus on ensuring an accurate understanding of both the illness and treatment options so the resident or their substitute decision-maker has the information they need to give or refuse consent to treatment.
It is important to acknowledge that individuals may change their minds too! We want to hold discussions not just at move-in - but ongoing - to ensure we are up to date with everyone's preferences and goals of care.
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RFEC
The Resident and Family Experience Coordinator (RFEC) is the main point of contact for residents and families thorough their journey with us at Sienna.
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Care Team
The Care Team will meet with the resident and their family members to assess the changing care needs and to revise the plans of care.
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All Team Members
All Team members are crucial to help the resident and their families navigate through the palliative care journey. They are equipped with additional skills and training to deliver on a palliative approach to care allowing the resident to feel at home in our communities regardless of their care needs.
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Tips for this key moment
• Before a care decision is made consider your loved one's (the resident) end of life values or preferences. We will ensure the treatment options are in line with the resident's wishes.
• Our physicians/NP and the care team are all engaged in the conversations to prepare the resident and their loved one for the changes in the resident's health status.
For Resident/Family:
A palliative care approach includes developing a comprehensive plan with the resident/families to address end of life care needs including the ability of the care team to manage the resident's care needs with the preference to have the resident die in place in the long term care home. The care team builds trust and confidence with residents and families by having early conversations around the changes in the resident's illness and how care needs will be managed within the community.
Having conversations with team members, residents, and families will support everyone for the loss of the resident.
We deeply respect your loved one's dignity and autonomy throughout the process, we prioritize their wishes and values ensuring that their end of life experience is as peaceful and in align with their wishes and their beliefs as possible.
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RFEC
The Resident and Family Experience Coordinator (RFEC) is the main point of contact for residents and families thorough their journey with us at Sienna.
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Care Team
The Care Team will provide care and support to the resident and their family members.
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All Team Members
All Team Members promote range of services in a unified, integrated continuum of care with the goal of relieving the suffering of the resident and their families by the comprehensive assessment and treatment of physical, psychosocial, and spiritual symptoms experienced by residents. As death approaches the comfort measures intensify, as well as the support to the dying resident and family.
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Tips for this key moment
• Care teams will allow for flexible care approaches and service delivery that ensure that dedicated team members are available.
• Our team will keep you informed about your loved one's condition, the steps we are taking to manage symptoms and pain, and any adjustments in their plan of care.
• We encourage you to share your observations and concerns with us, as your insights are invaluable in delivering the best care possible. We work closely with you and your family to ensure that we fully understand their wishes and goals, both in terms of symptoms and pain management and overall quality of life.
• We provide balanced and nourishing meals that meet the resident's dietary preferences and nutritional needs. We ensure proper hydration and assist with feeding as needed.
For Family:
This is the moment where the focus may now be on the family.
We want you to know that you are not alone during this difficult time. Grief is a personal journey, and there is no right or wrong way to navigate it. It’s essential to allow yourself to feel the emotions that come, whether it’s sadness, anger, or even moments of laughter as you remember your personal journey with your loved one.
Your loved one’s legacy lives on in the impact they had on your life and the lives of others. As you navigate the journey of grief, we hope that you find solace, support and a path towards healing. You are part of a community that understands and cares, and we are here to support you.
We respect the rituals or tributes to honour your loved one's life. What matters most is that the tributes and rituals you choose feel meaningful and will provide you valuable insights and emotional support for this process.
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RFEC
Resident and Family Experience Coordinator (RFEC) communicate to the community of the resident's passing and send a sympathy card to the family.
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Care Team
The Care Team communicate on PCC when a resident has passed.
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All Team Members
All Team Members provide emotional support to the families. Guide them through this process and allow them time for any rituals around death.
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For Family:
Advance Care Planning
Resources for resident, family and friends: