I'll start off with the home care visit. We work with nurses and the CCACs, which are now part of the lens because it's all at a provincial level. We are making a concerted effort to train as many nurses in that model as possible, going through the LEAP courses and the Pallium courses. This, of course, raises the standard that we should be measuring. We should have outcome measures of how many nurses qualified through LEAP this past year, how many volunteers, or how many physicians have managed to do the LEAP courses.
The nurse-doctor model is the ideal model. I think there is a role for nurse practitioners, specifically in areas in which there is no physician. I do not think that nurse practitioners need to do this on their own, taking the responsibility to actually behave like physicians. The job of a nurse and the job of a physician are not the same. Definitely, the dyad is the best. In areas in which you don't have a physician, then perhaps the nurse practitioner can take on the most responsible person role for the patient.
The Peel Memorial site is of course to enable more patients to get more care. This is one of the areas in which we as palliative care physicians will be involved. It's a nurse-led clinic looking at patients with chronic medical problems.
One of our goals over there is.... The “surprise” question is a gold standard framework question that is not ours. It's developed in the U.K., which, by the way, is the highest country on the quality of death index. The surprise question is asked when a patient comes into the emergency room: “Would you be surprised if this patient were alive in one year?” If you would be surprised if the patient were still alive, he needs to have a “goals of care” discussion. If you're not able to do that, find somebody who can do it because perhaps what you think is good for the patient, the patient or the family don't always think is good for the patient.
That's what I would say.