Table 2

Key tasks and domains of care for follow-up visits and telephone conversations

Domains and principles of care*
Symptom control
Assess and manage symptomsSystematically review symptoms and treatment toxicities at every visit; educate about medication effects and side effects
Assess understanding of illnessReview circumstances of illness and treatment options and patient’s understanding; discuss and explain signs of advancing disease
Assess individual and cultural practicesAssess individual and cultural beliefs, practices and values and how these relate to decision-making
Assist with decision-makingRegularly review goals of care; provide guidance in treatment decisions in accordance with patient’s goals of care
Future planning
Advance care planningDiscuss and document concerns and preferences for end-of-life care, power-of-attorney, making a will and code status
Transition of careTransfer care to home-based palliative care services or hospice when ECOG≥3/PPS≤50 or on request. Remain available as a resource to new treating team
Coping and support
Consolidate therapeutic relationshipProvide an ongoing atmosphere of trust and support while continuing to foster a therapeutic relationship with the patient and their family
Facilitate coping with advancing illnessProvide empathic care; assess coping strategies; refer to psychosocial oncology and spiritual care as necessary
Provide emotional and practical supportRegularly review supports; ensure sufficient home-based supports are in place, or set these up as necessary
Address family needsAssess and address needs of the broader family, including caregivers, spouse/partner, children and others
Bereavement careAcknowledge anticipatory grief of patient and family; refer to appropriate bereavement resources as necessary; contact family after death of the patient to express condolences
Flexible, attentive, patient-led and family-centred
Provide team-based careCommunicate regularly with other members of the treating team (eg, oncologists, family physicians and home care nurses) to provide a cohesive, team-based approach to care
Ensure consistency and availability of careProvide regular follow-up at 1-month intervals, with the same palliative care physician; ensure 24/7 access to palliative care team members
  • *Core domains are listed for each task, although other domains may also be relevant. All tasks are enacted according to the principles of care: flexible, attentive, patient-led and family-centred; tasks that are related specifically to these principles are also delineated.

  • ECOG, Eastern Cooperative Oncology Group performance status; PPS, Palliative Performance Status.