Helping the primary care system identify, plan, and care for seriously ill, frail elderly

Canadians nearing the end-of-life (EOL) do not always receive the best care possible. This study seeked to help family doctors plan and care for older adults who are frail and may be approaching EOL.

Possible Research Results

Anticipated findings: (1) A valid identification rule to identify older adults at risk of declining health or dying; and (2) information to help move this tool into practice and to help family doctors engage patients in advance care planning (ACP).

Impact of findingsA tool to identify patients in family practices who are nearing EOL will assist and guide physicians on how to approach ACP conversations with patients. Frail older adults and their families are thus more likely to receive care that matches their goals and wishes, and have better care experiences at EOL.

About the Project

Doctors find it difficult to know when patients are nearing EOL. As a result, patients who would benefit from having conversations with their doctors about their goals and wishes for care (i.e. ACP) are often identified when it is too late for these to be met. This can lead to unwanted care for patients at EOL, and stress and anxiety for families.

The main objective of the study was to create an “identification rule” using information from the electronic medial records (EMR) of patients, to notify doctors when a patient is nearing EOL, as well as understanding how it could be integrated in doctors’ offices.

Project Team

Principal Investigator:

Robin Urquhart, PhD — Dalhousie University


Richard Birtwhistle, MD, MSc, CCFP, FCFP — Queen’s University

Fred Burge, MD, FCFP, MSc — Dalhousie University

Colleen Cash, BA, BBA, MSHA — Nova Scotia Hospice Palliative Care Association

Grace Johnston, BSc, MHSA, PhD — Dalhousie University

Jyoti Kotecha, BSc (Hons), MPA, PhD(c) — Queen’s University

Francis Lau, BSc, MSc, MBA, PhD — University of Victoria

Beverley Lawson, BSc (Hons), MSc — Dalhousie University

Doug Manuel, BSc, MD, MSc — University of Ottawa

Emily Marshall, BA, MSc, PhD — Dalhousie University

Nandini Natarajan, MD, CCFP, FCFP — Dalhousie University

Tara Sampalli, B.Eng, MASc (Biological Engineering), PhD — Capital District Health Authority

Peter Tanuseputro, BSc, MHSc, MD — Ottawa Hospital

Cheryl Tschupruk, BA (Hons), MSW, RSW — Cancer Care Nova Scotia

Knowledge Users and Partners:

Bill VanGorder — National Initiative for the Care of the Elderly

Nova Scotia Health Authority

Nova Scotia Health Research Foundation

Nova Scotia Hospice Palliative Care Association

Project Contact: Robin Urquhart —

SIG 2014F-09

Key words: frail; older adults; family practice; end-of-life; advance care planning 

Research Plan

(Nova Scotia & Ontario): (1) Identification rule development and validation using information from family doctors’ EMRs from across Canada. (2) Focus groups with family doctors to understand how the identification rule can be best put into practice in doctors’ offices. (3) Focus groups (with doctors, nurses and healthcare managers/administrators) and interviews (with older adults and family members) to understand views on using an identification rule and on how family doctors should start ACP conversations once a person is identified. (4) Stakeholder dialogues to obtain guidance about how to move forward with early identification in Canada.