I do home health, and generally, the focus for palliation is to keep the patient in the home as long as possible. If the burden on the family becomes too heavy, many hospitals in Ontario now have excellent palliative care units, where nurses and doctors are trained in the latest palliation drugs, treatments, etc.
There are also some live-in hospices, such as Casey House in Toronto for AIDS patients, and Hill House in Richmond Hill. I am familiar with both facilities, and they are top-notch.
Yee Hong Centre has a palliative care team which works in the community. They, too are excellent.
The main problem I have as a community nurse is the odd doctor who either wants to 'go it alone' for palliation, and doesn't have another doctor as knowledgeable for backup, OR the flip side of this coin, the family doctor who knows zip about palliation, is scared to give sufficient narcotics for pain control, AND does not make house calls!
All too often, in the above cases, the nurse is left holding the bag, and the patient may make an unnecessary trip to the ER if a crisis arises.
I had a situation last fall where an elderly lady (early 90's) had a gangrenous leg, and the decision had been made not to amputate, but to allow nature to take its course. The family doc. was really good, but unfortunately, he took off to the cottage for the weekend.
When I visited late Sunday night, the lady was in obvious pain, and having difficulty breathing. I upped her morphine pump dose (thank GOD the doc. had left titration orders!) until she was a little more comfortable, but she still seemed to be gasping for breath, and in a great deal of distress.
We called the doctor on call, and waited...and waited...and waited. Meanwhile, the PSW went off to the drug store, and got some scopolamine patches, to help dry up the saliva she was choking on.
Finally, the doc. answered his page. I don't recall his exact words, but it was something like this: "I don't know a thing about palliative care, and her MD said all I would have to do was pronounce her. I'm sorry, I can't give you an order for the morphine pump."
"That's okay," I said, gritting my teeth, and blessing her GP for that titration order, "I have an order for that, but she's in respiratory distress..."
"Well what would you normally give in a case like this?"
"Usually Ativan, to help relax her." (She was fully conscious, and obviously distressed.)
"I'm hesitant to do that, because it can depress respirations."
"I've seen this done many, many times."
"That may be, but it's my license on the line here, and I'm not comfortable with it."
Finally, he agreed to the script, but ONLY ONE TABLET!! (one mg.)
I told the daughter to give 2, if needed.
She settled right down with the one tablet, and went to sleep. She died peacefully 3 hours later.
It's times like this when I KNOW I've been able to make a difference, that make up for all the other c**p I have to put up with in community nursing. It's a good feeling to be able to help a client carry out his/her wish to die in the home.