Designated Centres Application Form

Please submit a description (clearly addressing each of the sub points listed) of the manner in which each of the 13 criteria is met in the centre.
For each of the criteria, limit your description to no more than 3000 words.
A letter of intent must be uploaded and signed by the Director of the Oncology Service and the Hospital/Institute Director at the end of the application.

1. The centre is a cancer centre which provides closely integrated oncology and palliative care clinical services

1.1. Please describe the oncology department or cancer centre. *

1.2. Describe how oncologists and palliative medicine services interact. *

1.3. When complex needs are identified, describe how the oncologists and palliative medicine services share responsibilities for patient care. *

1.4. Describe the availability of oncologic care and evaluation for palliative care patients. *

2. The centre is committed to a philosophy of continuity of care and non-abandonment

2.1. Please present an overview describing how the centre provides continuity of care including, but not limited to, patients who are no longer benefiting from anti-tumor interventions. *

3. The centre incorporates expert medical and nursing care in the evaluation and relief of pain and other physical symptoms

3.1. Please provide details about the palliative care clinicians involved in the programme including their professional training and credentials in palliative care.*

4. The centre incorporates expert care in the evaluation and relief of psychological and existential distress

4.1. Please provide details about the clinicians involved in psychoncologic care including their professional training and credentials in palliative care. *

4.2. Please provide details about the staff involved in chaplaincy, pastoral care or spiritual care including their professional training and credentials in palliative care. *

5. The centre provides routine patient assessment of physical and psychological symptoms and social support and has an infrastructure that responds with appropriate interventions in a timely manner

5.1. Describe how physical and psychological symptoms of patients with advanced cancer are evaluated in outpatient and inpatient settings. *

5.1.1. Describe how severity of symptoms is recorded. *

5.1.2. When inadequately controlled symptoms are identified, describe the approach to evaluation and treatment.*

5.2. Describe how psychosocial problems or inadequate support of patients with advanced cancer are evaluated in outpatient and inpatient settings. *

5.2.1. Describe how these problems are recorded.*

5.2.2. When inadequately controlled psychosocial problems are identified, describe the approach to evaluation and treatment. *

6. The centre provides emergency care of inadequately relieved physical and psychological symptoms

6.1. Describe the availability and type of urgent care for inadequately controlled severe symptoms or psychosocial problems during office hours.*

6.2. Describe the availability and type of urgent care for inadequately controlled severe symptoms or psychosocial problems outside of office hours. *

7. The centre provides facilities and expert care for inpatient symptom stabilisation

7.1. Describe the criteria for admission for inpatient care of patients with poorly controlled symptoms in need of symptom stabilization. *

7.2. Describe where they are physically cared for (oncology ward, medical ward, palliative care ward). *

7.3. Describe who manages the care of patients needing symptom stabilisation. *

7.4. Describe how these aspects of care are monitored with ward rounds, case conferences etc. *

8. The centre incorporates programmatic support of family members

8.1. Describe how the needs of the family members of patients with advanced cancer are routinely evaluated and managed. *

8.2. Describe the psychological and social support available to family members. *

9. The centre provides high level home care with expert back-up and coordination of home care with primary cancer clinicians

9.1. Describe the availability of home care services and the expertise of the care providers. *

9.2. In the case that care is delivered by other community services:

9.2.1. Describe the services and their credentials. *

9.2.2. Describe the ongoing relationship to those services in the care of your patients. *

10. The centre provides respite care for ambulatory patients for patients unable to cope at home or in cases of family fatigue

10.1. Please describe the centres approach to situations where the patient and/or family request admission because either the patient is unable to cope at home or in situations of severe family fatigue. *

11. The centre provides facilities and expert care for inpatient end of life (terminal) care and is committed to providing adequate relief of suffering for dying patients

11.1. Describe the management approach to dying patients who are unable to manage at home.*

11.2. When inpatients are dying, describe how adequacy of comfort is monitored and documented. *

11.3. Describe the management approach to refractory symptoms at the end of life. *

11.4. Describe the supports offered to comfort the patient and family. *

12. The centre participates in basic or clinical research related to palliative care and the quality of life of cancer patients and their families

Please note that:

Quality of life evaluation as part of routine oncologic studies does not constitute palliative care research for purposes of recognition.
Research may be related to physical, psychological or social aspects of patient care.
Research may be related to quality assurance or improvement including models of care delivery.

12.1. Please describe open studies, completed studies and list all publications and presentations. *

13. The centre is involved in clinician education to improve the integration of oncology and palliative care

Please describe palliative cancer care teaching activities to:

13.1.1. Medical and nursing students *

13.1.2. House staff *

13.1.3. Oncology trainees *

13.1.4. Other health care staff*

13.2. Please describe any teaching publications. *

13.3. Pleases describe any conferences or symposia (post and planned). *

13.4. Please describe any other teaching activities. *

Guidelines for the letter of intent:

Written on institute/centre letterhead
A statement declaring the accuracy of the application
Signed by the the Director of Oncology Service and the Hospital/Institute Director

Letter of Intent*

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Section 1: Eligibility Criteria Checklist

Section 2: Background Information

Section 2: Narrative descriptions for accreditation criteria