Title: Improving End-of-Life Care in the Community (funded)
Research Team: Doug Manuel, Deborah Sattler, Fred Burge, Susan Bronskill, Christopher Clinger, Beverley Lawson, Jose Pereira, Peter Tanuseputri, Robin Urquhart
Health care provided to the dying can help improve the quality of remaining life. A large proportion of dying Canadians, unfortunately, do not get optimal end-of-life care. Part of the challenge is the difficulty of identifying where people are in their death trajectory. We are currently creating tools to map out this trajectory for people in the community, using data collected for those who are requesting home care or long-term care. In this grant, we propose to pilot these tools on case managers who are doing the assessments, and also on patients and their caregivers. Our tools will provide a report on how close patients are to death (a range, predicted based on previous observations), and will provide a link to resources (e.g., advance care planning tools and available community supports) that will help their journey. Following our pilot, we will conduct focus groups to determine how we can make the tools more useful and acceptable. We will then modify our tools, and prepare for a larger roll-out in the Windsor-Essex County population that has formed a multi-sectorial coalition that aims to improve the care of those who are frail and nearing the end-of-life. Our goal is to create and implement a scalable tool that will help patients, caregivers, and health care providers anticipate death, so that integrated and optimal care can be provided.