Palliative Care for Cancer Patients
A Community Health Nursing Perspective
Comprehensive nursing notes for healthcare professionals
Table of Contents
1. Introduction to Community Palliative Care 2. Core Principles of Palliative Care 3. Comprehensive Assessment in Palliative Care 4. Symptom Management Approaches 5. Holistic Care Approaches 6. Family and Caregiver Support 7. Cultural and Ethical Considerations 8. Care Coordination in Community Settings 9. Global Best Practices in Community Palliative Care 10. ConclusionIntroduction to Community Palliative Care
Community health nurse providing palliative care to a cancer patient at home with family support
Community palliative care focuses on improving the quality of life for cancer patients and their families through the prevention and relief of suffering. As defined by the World Health Organization (WHO), palliative care addresses physical, psychosocial, and spiritual issues, with the goal of enhancing quality of life rather than solely focusing on disease management or cure.
Key Concept: Community Palliative Care
Community palliative care involves providing specialized palliative services in non-hospital settings, including patients’ homes, residential care facilities, and outpatient clinics. This approach allows patients to receive care in familiar surroundings while maintaining connections to their community and support networks.
As community health nurses, we play a pivotal role in delivering palliative care to cancer patients outside hospital settings. We serve as the frontline healthcare providers, often being the first point of contact for patients and families navigating the complexities of serious illness in the community.
Significance of Community Palliative Care for Cancer Patients:
- Allows patients to remain in familiar surroundings
- Reduces hospitalization rates and emergency department visits
- Improves symptom management and quality of life
- Provides tailored support to both patients and caregivers
- Enables culturally appropriate care delivery
- Facilitates collaborative care with interdisciplinary teams
- Promotes patient autonomy and choice in care decisions
The integration of community palliative care into oncology practice represents a paradigm shift from the traditional dichotomy of curative versus end-of-life care. Instead, it encourages the simultaneous delivery of disease-modifying treatments alongside symptom management and supportive care from the time of diagnosis through the entire illness trajectory.
Core Principles of Palliative Care
Effective community palliative care is guided by fundamental principles that ensure comprehensive and person-centered approaches to care. These principles form the foundation for all palliative interventions in community settings.
COMFORT Principles of Palliative Care
Use this mnemonic to remember the core principles of palliative care:
- C – Comprehensive assessment and management of symptoms
- O – Open and honest communication with patients and families
- M – Multidisciplinary team approach to care
- F – Family and caregiver support and inclusion
- O – Ongoing reevaluation of care plans and goals
- R – Respect for patient autonomy and dignity
- T – Tailored care to individual needs and preferences
WHO Principles of Palliative Care
- Provides relief from pain and other distressing symptoms
- Affirms life and regards dying as a normal process
- Intends neither to hasten nor postpone death
- Integrates psychological and spiritual aspects of care
- Offers a support system to help patients live as actively as possible
- Offers a support system to help families cope
- Uses a team approach to address needs
- Enhances quality of life and may positively influence illness course
Ethical Principles in Palliative Care
- Autonomy: Respecting patients’ right to make informed decisions
- Beneficence: Acting in the best interest of patients
- Non-maleficence: Avoiding harm; balancing benefits and burdens
- Justice: Equitable distribution of resources and care
- Fidelity: Maintaining commitment to patients throughout illness
- Veracity: Truthfulness in communication
- Confidentiality: Protecting private information
In community palliative care, these principles take on unique applications as care is delivered in diverse and often less controlled environments compared to hospital settings. Community health nurses must adapt these principles to home-based care contexts while navigating resource limitations and geographical challenges.
The 6S Model for Person-Centered Palliative Care
The 6S Model provides a framework for ensuring comprehensive, person-centered care:
- Self-image: Understanding the patient’s perception of themselves
- Self-determination: Supporting patient autonomy and choices
- Symptom relief: Managing physical and psychological symptoms
- Social relationships: Maintaining meaningful connections
- Synthesis: Creating coherence and meaning in life
- Strategies: Developing approaches to achieve goals of care
Comprehensive Assessment in Palliative Care
Thorough assessment forms the foundation of effective community palliative care. Community health nurses must utilize appropriate tools and approaches to comprehensively evaluate patient and family needs across multiple domains.
ASSESS Mnemonic for Palliative Assessment
- A – Analyze symptoms (physical, psychological, social, spiritual)
- S – Screen for distress and unmet needs
- S – Study functional status and performance
- E – Evaluate family/caregiver capacity and needs
- S – Survey goals of care and preferences
- S – Search for cultural and spiritual considerations
Holistic Assessment Approach
Physical Domain Assessment
- Pain assessment (location, intensity, quality, exacerbating/relieving factors)
- Respiratory assessment (dyspnea, cough, respiratory effort)
- Gastrointestinal assessment (nausea, vomiting, constipation, appetite)
- Neurological assessment (confusion, drowsiness, alertness)
- Skin assessment (integrity, wounds, pressure areas)
- Functional status and mobility assessment
- Sleep pattern evaluation
Psychological Domain Assessment
- Screening for depression and anxiety
- Assessing coping mechanisms
- Evaluating fear and concerns
- Identifying sources of distress
- Assessing body image concerns
- Determining cognitive function
- Evaluating impact of illness on identity
Social Domain Assessment
- Family structure and dynamics
- Primary caregiver identification and capacity
- Available support networks
- Financial concerns and resources
- Housing and environmental safety
- Access to transportation
- Communication patterns within family
Spiritual Domain Assessment
- Sources of meaning, hope, and strength
- Religious practices and preferences
- Existential concerns
- Unresolved relationships or issues
- Cultural beliefs about illness and death
- Rituals or practices of importance
- Concepts of afterlife or transcendence
In community palliative care, assessment is an ongoing, dynamic process rather than a one-time event. Regular reassessment is essential as patient conditions and family circumstances change. Community health nurses must be skilled in adapting assessment approaches to home environments and integrating findings into practical, achievable care plans.
Symptom Management Approaches
Effective symptom management is a core component of community palliative care for cancer patients. Community health nurses must be skilled in assessing, managing, and monitoring a wide range of physical and psychological symptoms that affect patients’ quality of life.
RELIEVE Approach to Symptom Management
- R – Recognize the symptom and its impact
- E – Evaluate thoroughly (cause, severity, impact)
- L – Listen to patient’s experience and concerns
- I – Implement evidence-based interventions
- E – Educate patient and family on management strategies
- V – Validate effectiveness of interventions
- E – Evaluate and adjust plan as needed
Management of Common Symptoms in Cancer Patients
| Symptom | Assessment Considerations | Pharmacological Approaches | Non-pharmacological Approaches | Community Nursing Interventions |
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| Pain |
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| Dyspnea |
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| Nausea/Vomiting |
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Special Considerations for Symptom Management in Community Settings
Medication Management
- Simplified regimens to improve adherence
- Medication storage and security concerns
- Alternative routes when oral route not viable
- Teaching family to administer medications
- Monitoring for side effects remotely
- Ensuring access to needed medications
Resource Limitations
- Adapting interventions to available resources
- Creative problem-solving with household items
- Identifying community support services
- Telehealth for monitoring symptoms
- Emergency planning for symptom crises
- Building capacity of family caregivers
Emergency Situations
- Clear protocols for urgent symptoms
- 24/7 phone support availability
- Crisis medication kits in the home
- Decision-making guides for families
- Advance care planning for expected issues
- Coordinating with emergency services
The Role of Anticipatory Prescribing
Anticipatory prescribing is a proactive approach in community palliative care where medications for common end-of-life symptoms are prescribed and available in the patient’s home before they are needed. This approach ensures timely symptom management without delays in obtaining prescriptions during crises.
Common medications included in anticipatory prescribing:
- Analgesics for pain (e.g., morphine)
- Anxiolytics for agitation/anxiety (e.g., midazolam)
- Antiemetics for nausea/vomiting (e.g., haloperidol)
- Anticholinergics for respiratory secretions (e.g., hyoscine)
- Anticonvulsants if history of seizures
In community palliative care, symptom management requires a flexible, creative approach adapted to each unique home environment. Community health nurses must empower patients and families with knowledge and skills while providing regular support and reassessment to ensure optimal symptom control.
Holistic Care Approaches
Community palliative care embraces a holistic approach that addresses the whole person, not just their physical symptoms or disease. This comprehensive approach recognizes the interconnectedness of physical, emotional, social, spiritual, and practical dimensions of a person’s experience with serious illness.
The Five Domains of Holistic Palliative Care
1. Physical Domain
Addressing physical symptoms and maintaining comfort and functional ability.
- Pain and symptom management
- Nutrition and hydration support
- Mobility and physical function
- Sleep quality enhancement
- Complementary therapies (massage, acupuncture)
2. Psychological Domain
Supporting emotional well-being and mental health.
- Counseling and psychotherapy
- Anxiety and depression management
- Coping strategies development
- Cognitive-behavioral interventions
- Meaning-making and life review
3. Social Domain
Maintaining connections and addressing social needs.
- Family relationship support
- Communication facilitation
- Community resource connection
- Financial and practical support
- Legacy work and meaningful activities
4. Spiritual Domain
Addressing existential concerns and spiritual needs.
- Spiritual counseling and support
- Religious rituals and practices
- Existential meaning exploration
- Hope and transcendence
- Cultural and religious considerations
5. Practical Domain
Managing everyday life challenges.
- Activities of daily living support
- Home environment modifications
- Financial and legal planning
- Care coordination
- Advance care planning
Integrative Therapies in Community Palliative Care
Mind-Body Approaches
- Meditation and mindfulness: Reducing anxiety and improving coping
- Guided imagery: Managing pain and promoting relaxation
- Deep breathing exercises: Alleviating dyspnea and anxiety
- Progressive muscle relaxation: Reducing tension and improving sleep
- Yoga: Gentle adaptations for maintaining mobility and promoting relaxation
Creative and Expressive Therapies
- Music therapy: Reducing pain, anxiety, and enhancing mood
- Art therapy: Expressing emotions and processing grief
- Journaling: Articulating thoughts and feelings
- Life review: Finding meaning and closure
- Legacy projects: Creating lasting mementos for loved ones
Physical Modalities
- Therapeutic massage: Relieving pain and promoting relaxation
- Aromatherapy: Managing symptoms and creating comforting environment
- Heat/cold therapy: Localized pain relief
- Gentle exercise: Maintaining function and improving mood
- Positioning therapy: Enhancing comfort and preventing pressure injuries
Community-Based Support
- Support groups: Connecting with others having similar experiences
- Volunteer visitors: Providing companionship and respite
- Faith community involvement: Spiritual support and community connection
- Pet therapy: Comfort and emotional support
- Community activities: Maintaining social engagement and purpose
WHOLE Person Care Approach
- W – Wellness focus despite serious illness
- H – Hope fostering in realistic contexts
- O – Openness to different coping strategies
- L – Listening deeply to patient narratives
- E – Engaging all dimensions of personhood
Implementing holistic community palliative care requires nurses to be attentive to all dimensions of a person’s experience with illness. By addressing the interconnected domains of physical, psychological, social, spiritual, and practical needs, community health nurses can help patients achieve comfort, dignity, and meaning even amid serious illness.
Family and Caregiver Support
In community palliative care, family members and other informal caregivers play a crucial role in providing day-to-day care for patients with cancer. Supporting these caregivers is essential for both patient well-being and caregiver health.
Caregiver Assessment
Comprehensive assessment of caregiver needs and capacity is essential for effective support.
Caregiver Preparedness
- Knowledge and skills for care tasks
- Confidence in managing symptoms
- Availability and time commitment
- Physical capacity for caregiving
- Previous caregiving experience
Caregiver Burden
- Physical strain and fatigue
- Emotional impact and distress
- Financial implications
- Social isolation and role changes
- Competing responsibilities
Caregiver Resources
- Social support network
- Coping mechanisms and resilience
- Financial resources
- Access to respite options
- Personal health status
Caregiver Education and Training
Providing caregivers with necessary knowledge and skills is fundamental to successful home-based care.
Practical Skills Training
- Medication administration techniques
- Safe patient handling and positioning
- Personal care and hygiene assistance
- Feeding and nutrition support
- Use of medical equipment
Symptom Recognition and Management
- Identifying worsening symptoms
- Basic comfort measures
- When and how to use PRN medications
- Warning signs requiring medical attention
- Communication with healthcare team
Self-Care Education
- Setting realistic expectations
- Stress management techniques
- Importance of accepting help
- Maintaining own health needs
- Preventing caregiver burnout
CARE Approach for Family Support
- C – Communicate openly and regularly with family members
- A – Acknowledge the challenges and emotions of caregiving
- R – Resource connection and practical support provision
- E – Educate on care skills and self-care strategies
Support Interventions for Family Caregivers
Emotional Support
- Therapeutic listening and validation
- Grief counseling and anticipatory grief support
- Facilitating family meetings to address concerns
- Connecting to caregiver support groups
- Providing psychological counseling referrals
Practical Support
- Arranging respite care options
- Connecting to home health aide services
- Assisting with financial resource applications
- Coordinating volunteer services
- Facilitating meal delivery programs
Informational Support
- Providing disease and treatment information
- Explaining the dying process and what to expect
- Guiding through advance care planning
- Clarifying healthcare system navigation
- Offering guidance on insurance and benefits
Supporting Caregivers Through Transitions
Community palliative care involves supporting caregivers through various transitions in the patient’s illness trajectory. These transitions often represent periods of increased stress and uncertainty for family caregivers.
Key transition points:
- Initial diagnosis and treatment planning
- Hospital discharge to home care
- Disease progression or recurrence
- Shift from curative to palliative focus
- Transition to end-of-life care
- Bereavement period after death
Support strategies during transitions:
- Increased visit frequency around transitions
- Clear communication about changing care needs
- Anticipatory guidance about what to expect
- Reassessment of caregiver capacity and needs
- Enhanced coordination between care providers
- Emotional support for grief and adjustment
Caregiver Wellness Promotion
Self-Care Strategies for Caregivers
- Physical health maintenance: Regular health check-ups, adequate sleep, proper nutrition, physical activity
- Emotional well-being: Journaling, counseling, support groups, expression of feelings
- Social connection: Maintaining friendships, regular social activities, avoiding isolation
- Stress management: Relaxation techniques, mindfulness, deep breathing, meditation
- Respite planning: Scheduling regular breaks, accepting help from others
- Boundary setting: Recognizing limitations, saying no when necessary
- Personal identity: Maintaining hobbies and interests beyond caregiving role
- Spiritual practice: Engaging in personally meaningful spiritual or reflective practices
Family caregivers are essential partners in community palliative care, providing the majority of hands-on care for patients at home. By supporting caregivers’ emotional, practical, and educational needs, community health nurses enhance both patient care and caregiver well-being. A family-centered approach recognizes that the patient and family are a unit of care, and that caregiver health directly impacts patient outcomes.
Cultural and Ethical Considerations
Providing culturally sensitive and ethically sound community palliative care requires nurses to recognize and respect diverse beliefs, values, and practices related to illness, dying, and caregiving. Cultural humility and ethical awareness are essential components of quality palliative care.
Cultural Considerations in Palliative Care
Key Areas Influenced by Culture
Communication Patterns
- Directness vs. indirectness of communication
- Truth-telling and disclosure preferences
- Decision-making authority (individual vs. family)
- Non-verbal communication norms
- Use of interpreters and cultural mediators
Meanings of Illness and Suffering
- Explanatory models of disease causation
- Beliefs about the meaning of suffering
- Views on fate, karma, or divine will
- Traditional healing practices and remedies
- Expectations regarding pain expression
End-of-Life Rituals and Practices
- Religious rituals and spiritual practices
- Family roles during dying process
- After-death care of the body
- Mourning practices and expressions of grief
- Beliefs about afterlife and continuation
Cultural Humility in Nursing Practice
Core Principles
- Self-reflection and awareness of biases
- Recognition of power imbalances
- Openness to learning from patients
- Suspension of judgment
- Willingness to adapt care approaches
Cultural Assessment
- Asking about cultural/religious practices
- Exploring illness beliefs and expectations
- Identifying important traditions
- Understanding family structure and roles
- Learning preferred communication styles
Implementing Culturally Sensitive Care
- Accommodating religious practices and rituals
- Adapting care plans to cultural preferences
- Including family according to cultural norms
- Integrating traditional practices when safe
- Using culturally appropriate resources
DIVERSE Cultural Assessment Mnemonic
- D – Demographics and language preferences
- I – Ideas about illness causation and meaning
- V – Views on healthcare and treatment preferences
- E – Expectations for care and provider roles
- R – Religion and spiritual practices
- S – Support systems and family involvement
- E – End-of-life beliefs and preferences
Ethical Considerations in Community Palliative Care
Core Ethical Principles
Autonomy
Respecting patient’s right to make informed decisions about their care.
- Informed consent processes
- Advance care planning facilitation
- Respecting refusal of treatments
- Supporting decision-making capacity
Beneficence
Acting in the best interest of the patient.
- Providing effective symptom management
- Weighing benefits vs. burdens of interventions
- Promoting quality of life
- Focusing on holistic well-being
Non-maleficence
Avoiding causing harm to patients.
- Preventing unnecessary suffering
- Avoiding futile interventions
- Managing medication side effects
- Balancing risks and benefits
Justice
Fair distribution of resources and access to care.
- Equitable access to palliative services
- Addressing healthcare disparities
- Advocating for underserved populations
- Fair allocation of nursing time and resources
Ethical Decision-Making Framework
- Gather relevant information: Clinical facts, patient preferences, cultural/religious factors, legal considerations
- Identify the ethical problem: Clarify the ethical principles in conflict
- Analyze the options: Consider possible actions and their consequences
- Make a decision: Choose the option that best upholds ethical principles
- Implement the plan: Act on the decision with sensitivity
- Evaluate the outcome: Reflect on the results and lessons learned
Common Ethical Challenges in Community Palliative Care
Autonomy vs. Beneficence Conflicts
- Patient wishes conflicting with clinical recommendations
- Family members disagreeing with patient choices
- Balancing safety concerns with patient preferences
- Cultural traditions that limit individual autonomy
Truth-telling and Communication
- Family requests to withhold diagnosis/prognosis from patient
- Balancing hope with realistic information
- Cultural norms against direct disclosure
- Communication with patients with cognitive impairment
Cultural and ethical considerations are interwoven throughout community palliative care. Community health nurses must develop cultural humility and ethical reasoning skills to navigate complex situations with sensitivity and integrity. By respecting diverse cultural perspectives while upholding ethical principles, nurses can provide care that honors patients’ values and dignity.
Care Coordination in Community Settings
Effective coordination of care is essential in community palliative care, as patients often receive services from multiple providers across different settings. Community health nurses play a central role in facilitating seamless, integrated care.
BRIDGES Approach to Care Coordination
- B – Build relationships with interdisciplinary team members
- R – Recognize roles and responsibilities of each provider
- I – Integrate care plans across settings and providers
- D – Document clearly and share information appropriately
- G – Guide patients and families through the healthcare system
- E – Evaluate outcomes and adjust plans accordingly
- S – Support transitions between care settings
Interdisciplinary Team Collaboration
| Team Member | Role in Palliative Care | Collaboration Strategies | Communication Methods |
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| Primary Care Provider |
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| Palliative Care Specialist |
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| Social Worker |
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Managing Care Transitions
Transition Points in Palliative Care
Hospital to Home
- Pre-discharge assessment and planning
- Medication reconciliation and education
- Home safety evaluation
- Equipment coordination
- First 24-48 hour support planning
Home to Hospital/Emergency Department
- Transfer of current care plan information
- Communication of goals of care
- Advance directive transmission
- Current medication list provision
- Family support during transition
Palliative to Hospice Care
- Timing discussion and preparation
- Explanation of service differences
- Transfer of care information
- Joint visits for smooth handover
- Emotional support during transition
Change in Care Location
- Home to nursing facility
- Moving to family member’s home
- Relocation to hospice facility
- Return to home from respite care
Care Transition Tools and Strategies
Documentation Tools
- Standardized transfer forms
- Medication reconciliation documents
- Portable medical records
- Advance directive summary forms
- Emergency care plans
Communication Strategies
- Warm handoffs between providers
- Case conferences before transitions
- Direct phone communication
- Secure messaging systems
- Follow-up verification of information receipt
Technology in Care Coordination
Technology plays an increasingly important role in coordinating community palliative care across providers and settings. Effective use of technology can enhance communication, documentation, and access to care.
Health Information Technology
- Electronic health records with shared access
- Health information exchanges
- Secure messaging platforms
- E-prescribing systems
- Patient portals for information access
Telehealth Applications
- Virtual visits for symptom assessment
- Remote patient monitoring
- Virtual team meetings
- Specialist consultation via telemedicine
- Videoconferencing for family meetings
Mobile Health Solutions
- Symptom tracking applications
- Medication reminder systems
- Point-of-care documentation tools
- Resource locator applications
- Caregiver support and education apps
As the central coordinator in community palliative care, the community health nurse must skillfully navigate complex healthcare systems while keeping the patient’s needs at the center of care. Effective care coordination ensures that all providers work together cohesively, information flows appropriately, and transitions are managed smoothly to provide seamless care across settings and over time.
Global Best Practices in Community Palliative Care
Around the world, innovative models of community palliative care are demonstrating effective approaches to supporting cancer patients in non-hospital settings. Learning from these global examples can enhance nursing practice and improve care delivery.
Kerala Neighborhood Network in Palliative Care (India)
A community-owned network where trained volunteers work alongside healthcare professionals to provide palliative care.
Key Elements:
- Community ownership and volunteer engagement
- Training local volunteers in basic care
- Home-based care delivery
- Integration with existing healthcare systems
- Focus on psychosocial and practical support
- Sustainable funding through community contributions
Application to Practice:
- Engaging community volunteers as extenders of care
- Building sustainable community-based support networks
- Empowering non-professionals to provide basic support
- Creating culturally sensitive approaches to care
Macmillan Nurse Program (United Kingdom)
Specialist nurses with advanced training in palliative care who work across settings to support cancer patients.
Key Elements:
- Advanced practice nurse-led model
- Specialized education and certification
- Bridge between hospital and community
- Expert consultation to other providers
- Direct patient care and care coordination
- Focus on complex symptom management
Application to Practice:
- Developing specialized nursing roles
- Creating pathways for advanced training
- Building consultation models
- Enhancing nurse autonomy in symptom management
Common Themes in Successful Community Palliative Care Models
Person-Centered Approach
- Individualized care planning
- Respect for personal preferences and values
- Focus on quality of life as defined by patient
- Shared decision-making processes
- Regular reassessment of needs and goals
- Flexible care delivery approach
Integration and Coordination
- Seamless transitions between care settings
- Clear communication channels between providers
- Shared documentation and care plans
- Defined roles and responsibilities
- Single point of contact for patients/families
- Integration of palliative and disease-modifying care
Accessibility and Equity
- Outreach to underserved populations
- Multiple access points to services
- Reduction of geographic barriers
- Cultural adaptation of services
- Affordability and financial accessibility
- Early identification of eligible patients
GLOBAL Best Practices in Community Palliative Care
- G – Goals of care should be clearly articulated and regularly reviewed
- L – Local resources and cultural contexts must be considered
- O – Optimal symptom management through evidence-based approaches
- B – Building capacity of both professional and non-professional caregivers
- A – Access to services must be equitable and timely
- L – Linkages between services and settings should be seamless
Learning from global best practices in community palliative care allows nurses to incorporate successful elements from diverse settings into their practice. By adapting these approaches to local contexts, community health nurses can enhance the quality and effectiveness of palliative care for cancer patients in their communities.
Conclusion
Community palliative care for cancer patients represents a vital and evolving area of nursing practice. As community health nurses, we have the unique opportunity to support patients and families through one of life’s most challenging journeys, providing compassionate, holistic care that honors dignity, preferences, and quality of life.
The complex nature of community palliative care requires nurses to develop expertise across multiple domains: comprehensive assessment, skilled symptom management, effective communication, cultural sensitivity, ethical reasoning, care coordination, and family support. By integrating these competencies, nurses can provide truly person-centered care that addresses the multidimensional needs of patients with advanced cancer.
As models of community palliative care continue to evolve globally, community health nurses remain at the forefront of innovation, adapting approaches to meet the unique needs of their communities and the individuals they serve. Through continued learning, collaboration across disciplines, and commitment to evidence-based practice, we can ensure that patients with cancer receive the highest quality palliative care in the community settings they call home.
Key Takeaways
- Community palliative care focuses on improving quality of life through comprehensive symptom management and holistic support.
- Comprehensive assessment across physical, psychological, social, spiritual, and practical domains forms the foundation for effective care planning.
- Skilled symptom management requires both pharmacological and non-pharmacological approaches adapted to home settings.
- Family caregivers are essential partners who require education, support, and care to fulfill their vital role.
- Cultural sensitivity and ethical awareness are necessary for providing respectful, person-centered care.
- Effective care coordination ensures seamless integration of services across providers and settings.
- Global best practices offer valuable insights that can be adapted to enhance local community palliative care delivery.