Palliative Care Toolbox

Diagnosis, Treatment, either Recovery/Survivorship or End-of-Life Care.

Adapted from Cancer Care Ontario's online Palliative Care Toolkit.

Palliative care aims to improve a person's quality of life through improved symptom management while addressing psychosocial, emotional and spiritual issues. It is care that is appropriate at all stages of a person's illness. An interdisciplinary care team may involve medical oncologists, radiation oncologists, family physicians, palliative care physicians, social workers, dietitians, nurses, spiritual care workers and other health professionals (Cancer Care Ontario, 2013).

This web page is designed with the primary care provider in mind, as a resource in navigating the provision of palliative care in the MHCW regions, with links to best practice tools and local resources. Tools are organized according to the 3-step model of best practice proposed by the Gold Standards Framework (GSF): Identify, Assess, and Plan.
To view a detailed map of the standard of care and support that all cancer patients and their families should receive, please refer to Cancer Care Ontario's Psychosocial Oncology/Palliative Care Pathway.


Identify persons who may benefit from a palliative approach early in the illness trajectory, and flag this in their health record. Learn more about Step 1.

Step 2: ASSESS

Assess patient and family’s current and future needs across all domains of care (i.e. disease management, physical, psychosocial, spiritual, practical, grief/loss, goals of care, end of life care) using validated screening tools, and through an in depth history, physical exam and relevant laboratory/imaging tests.  Type and timeliness of assessment will depend on severity, interference with life, urgency and complexity of issues identified. Learn more about Step 2.

Step 3: PLAN

Plan and collaborate ongoing care to address needs identified during assessment, including prompt management of symptoms and coordination with other care providers. Learn more about Step 3.

Still Need Help?

As a primary care provider you will participate as a member of the primary level palliative care team.  The majority of patients should be cared for by the primary level care team with specialist support as needed (See MH LHIN Model of Hospice Palliative Care - PDF (145 KB). If patient/family needs are more complex or support is needed, consider the role of secondary level palliative care specialists (i.e. consultation, collaborative care/shared care, direct care).

Are we missing something? Please contact your Regional Palliative Care Lead for feedback and suggestions.