Table 2.

Content of clinical practice of the Integrated Cancer and Palliative Care Services in the Orkdal region

	Clinical practice
Healthcare providers’ approach to care
All healthcare providers	Focus on  Functional status, symptom burden, and individual needs  Smooth transition between levels  Transfer of medical information  Availability of healthcare personnel with competence in palliative cancer care 24/7  Available symptom assessment tools  Support to carers
Fully integrated outpatient clinic for cancer and palliative care
Staff	Oncologists and cancer nurses trained in palliative care
Palliative care team	Oncologist, cancer nurse, physiotherapist, occupational therapist, dietician, social worker, and chaplain Weekly meetings to coordinate patients’ services and for educational purposes
Consultations	Medical history and physical examination Social and living conditions Assessment of  Symptoms using EAPC Basic Dataset [45]  Performance status using ECOG/WHO PS scale [55]  Weight and nutritional status  Side effects of anti-cancer treatment Need of referral to palliative care team? Need of contact with community care? Discussed with the patient:  Treatment intention, treatment plan, side effects, preferences  Action plan for follow-up and evaluation Patient receives information (also written) regarding:  Medication  Ongoing anti-cancer treatment and side effects  Resources available for the patient  Contact information 24/7 Joint consultation with oncologist and nurse when anti-cancer treatment is stopped Routine consultation with cancer nurse before start of anti-cancer treatment
Outpatient follow-up	Adapted to where the patient is in the disease trajectory, symptom burden, needs and if the patient has contact with community care services:  Visits at the Integrated Clinic  Telephone follow-up from an oncology/palliative care nurse  Referral to allied healthcare professionals  Ambulatory home visits
On-call service	24-h to Integrated Clinic or ward (local hospital or tertiary hospital) staffed with nurses and physicians trained in cancer and palliative care
Carers	Encouraged to accompany the patient Assessment of carer’s needs by use of The Carer Support Needs Assessment Tool (CSNAT) [56] Separate carer consultations Follow-up of carers 4–6 weeks after patients’ death
Hospital service
Inpatient care	Designated beds for palliative care
Inpatient staff	Ward cancer nurses trained in palliative care Ward rounds three times a week routinely and upon request by oncologist trained in palliative care
Palliative care team (same team as at the Integrated Clinic)	Weekly meetings to coordinate patients’ services and for educational purposes
Palliative care training	Nurses are part of the network of resource nurses in cancer and palliative care Oncologist teaches internal medicine physicians in palliative cancer care four times a year
Inpatient follow-up	Coordinated with follow-up from the outpatient clinic
Community care
Staff	GP, resource nurses with expertise in cancer and palliative care, home care nurses, nursing home nurses and nurse assistants who have attended educational courses in palliative cancer care
Community care access	Contact with community cancer nurses and/or home care is offered repeatedly to patients and carers Contact information is given
Communication between hospital and GP or physician at nursing home	Routine (written information) Emphasis on communication of what information the cancer patient and their carers have received from the oncologist Telephone contact when the patient has a high symptom burden
Communication between hospital and home care nurses	Routine, if applicable
Follow-up	Dependent on preferences, needs, symptom burden, geography and where the patient is in the disease trajectory:  Contact with GP  Contact with resource nurses in cancer and palliative care  Home nursing care