- / Palliative care, since its inception over 60 years ago, has set the standard of how to care for people who are dying. Key features among these standards have been the professional development of clinical specialisms such as palliative medicine and palliative nursing; the essential addition of the multidisciplinary team to these two new specialisms that included social, spiritual and allied health workers—an outgrowth of the recognition that routine work with the dying, their carers, and the bereaved required more than solely clinical skills; and the unique partnership with communities that yielded the volunteer movement within palliative care. Professional, evidence-based symptom management and the importance of supportive care in its widest possible sense were and remain the cornerstones of the modern palliative care approach. However, the majority of people with terminal illnesses do not have access to palliative care teams, whose main focus of care remains patients with cancer. In the context outlined above this paper therefore poses two key questions: how can we provide an equitable level of care for all people irrespective of diagnosis and how can we increase the range and quality of non-medical/nursing supportive care in a context of diminishing resources? We argue that an important opportunity and solution can be found by adopting the principles of a public health approach to end-of-life care.

<p>This research examined the barriers and facilitators involved in the development and sustainability of palliative care teams using a shared care model. Shared care is established when interdisciplinary specialist palliative care teams (usually comprised of a palliative care physician, an advanced practice nurse, a psychosocial spiritual advisor, a bereavement counselor, a case manager and an administrator) form partnerships with primary care providers (usually frontline family physicians and home care nurses) to support the complex needs of terminally-ill patients and their family members in the home setting. Palliative care teams overcome gaps in the current health care system, such as: lack of palliative care specialists; poor coordination and integration of care, and; a health care workforce with insufficient training in palliative care. This type of service delivery model is common in medical specialties such as mental health and obstetrics, and various forms of palliative shared care have been implemented in other countries such as the US, Australia, UK, Italy and Spain, where it has been shown to be cost-effective. There are few palliative care teams working in a shared care model in Canada; this provided the impetus to investigate the process of how this integrated approach is developed and sustained within the context of specific populations and geographies. A longitudinal case study in a Local Health Integration Network (LHIN) area in Southern Ontario, comprised of urban and rural communities, was conducted in order to evaluate barriers and facilitators in using a shared care model from the perspective of team members, key-informants and stakeholders. The evaluation of barriers and facilitators informed recommendations to guide the sustainability of palliative care teams working in a shared care model.</p> / Doctor of Philosophy (PhD)