Commentary
Palliative care nursing in the virtual realm Simone Stenekes, Sarah Brown, Brenda Hearson, Shelly Cory
T
echnology has affected health-care delivery in many ways. Both the internet and consumer empowerment have evolved (Lober and Flowers, 2011), and the health-care environment is attempting to keep pace with these rapid changes. In Canada, 70% of home internet users search for medical or health-related information online (Statistics Canada, 2009). In the USA, 80% of internet users seek out health information, with 7% looking specifically for information about end-of-life decisions (Pew Research Center, 2011). In their search for knowledge, the general public and health professionals require trustworthy, relevant, and easily understood information that is based on research and empowers them as health-care consumers and providers. Along with changes in technology, there is also an increasing demand for palliative care. With the current resources in Canada, it is estimated that less than 30% of those who could benefit from palliative care services actually obtain them. Population ageing and a rising death rate will lead to an increasing demand for palliative care services in the next few years (Canadian Hospice Palliative Care Association, 2010; Carstairs, 2010). With this confluence of technological advances and the increasing demand for palliative care services, the health-care system is being challenged to use innovative methods to address the needs of patients at the end of life, their formal caregivers, and their families.
© 2014 MA Healthcare Ltd
Canadian Virtual Hospice In 2001 a group of palliative care leaders gathered to consider whether a web-based platform could address some of the gaps in palliative care in Canada. They recognised the benefits of having a central repository of evidence-based information that would be readily accessible regardless of time or geography, and envisioned a place where people could connect for peer-to-peer and professional support. Launched in February 2004, the Canadian Virtual Hospice (www.virtualhospice.ca and
International Journal of Palliative Nursing 2014, Vol 20, No 4
www.portailpalliatif.ca) provides support and personalised information about palliative and end-of-life care, loss, and grief to people with life-limiting illness, family members, health-care providers, researchers, health-care administrators, and educators. The information on the website is developed and reviewed by an inter disciplinary clinical team of palliative care experts. The site is evidence-informed, up-to-date, relevant, and accessible 24/7. Content is extensive and includes information on all aspects of palliative and end-of-life care, from physical symptoms to the emotional, spiritual, and financial issues that result from illness and the latest research. Content is continually evaluated, revised, and developed. Presently there are over 6000 pages of content on the website, which averages 1200–1400 visits per day. The bilingual site (available in English and French) is accessed by people in almost every country in the world, with the USA, UK, Australia, and France being key drivers of traffic. Canadian Virtual Hospice also leverages social media channels such as YouTube, Vimeo, Facebook, Twitter (@VirtualHospice), and Google+ for crowd sourcing and knowledge dissemination.
Ask A Professional When www.virtualhospice.ca was launched in 2004, it was the first web-based platform in the world to provide the public with direct online access to a clinical team. This interdisciplinary team comprises experts in palliative care, who lead the development of content and respond to questions posted in the Ask a Professional section of the website. Canadians who pose a question will receive an individualised response within 3 business days. Forty per cent of the Ask a Professional questions come from health-care providers seeking guidance on complex or difficult cases. Sixty per cent come from patients, families, and friends. The Ask a Professional service provides access to palliative care specialists including clinical
Simone Stenekes, Sarah Brown, and Brenda Hearson are Clinical Nurse Specialists, and Shelly Cory is Executive Director, Canadian Virtual Hospice Correspondence to: [email protected]
161
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 27, 2015. For personal use only. No other uses without permission. . All rights r
Commentary
Questions from health-care providers ● What
is the best opioid to use in a patient with renal impairment?
● When
caring for patients with advanced disease our team struggles with knowing how to initiate conversations related to palliative and end-of-life care. Can you offer any suggestions?
●
I am a nurse working in the oncology department. Can you suggest some resources for a teenager whose mother is dying?
● What
do you suggest for a patient with constant nausea?
● Are
there resources for supporting a schoolteacher and classmates who have a child in the classroom who is living with an advanced illness?
●
Does oxygen therapy have a physical effect during the final hours when a person is dying?
●
Can you recommend a bereavement assessment form for bereaved families?
●
I am a nurse who lives in a rural area. I care for a patient in the community with end-stage cardiac disease. He would like to die at home. What can I expect and how can I prepare?
Questions from patients, friends, family, caregivers, or others ●
My brother is dying of brain cancer. What can we expect as he gets closer to death?
● What
type of funding and resources are available for someone who plans to die at home?
● When
is the right time to stop tube feeding for someone who has suffered a major stroke?
●
My friend’s mother is dying. What can I say to her family?
● What ●
can be expected with end-stage Alzheimer’s disease?
My father has been started on morphine for his advanced cancer pain. Is there anything I should know about this medication? I heard it causes hallucinations—is this true?
●
How long can someone live without food or water?
●
My wife just found out she has terminal cancer. How do we tell our young adult children?
nurse specialists (CNSs), physicians, social workers, spiritual care advisors, ethics advisors, and paediatric palliative care specialists. To date, more than 1800 questions from across Canada have been answered. Questions cover all aspects of end-of-life care, including physical symptoms, emotional and spiritual aspects of care, grief, and communication. Results from a survey sent to users were overwhelmingly positive. Eighty nine per cent of users were ‘very satisfied’ with the response and also felt the information they received was provided in a thoughtful and respectful manner. Forty seven per cent planned to share the response with others. The questions posed to Ask a Professional range from broad and general to detailed and specific. Box 1 highlights the types of questions that users have submitted. To ask a question, users only have to supply an email address so that they can be notified that their answer is waiting for them in a secure email box on the Virtual Hospice server and a postal code so that links to local resources can be provided. The limited information collected assists in protecting personal health information. The person is asked to identify whose health issue they are inquiring
162
about from a drop-down menu to help the team provide an appropriate response.
The clinical nurse specialist role The CNS role in Canada was developed in the 1960s. Together with the nurse practitioner role, it is one of the advanced practice nursing roles recognised by the Canadian Nurses Association (CNA). It has five key components: clinician, consultant, educator, researcher, and leader (CNA, 2009a). The CNS role at the Canadian Virtual Hospice is unique in Canada and an innovative response that uses technology to enhance palliative care (CNA, 2009b). From the inception of the role, the provincial regulatory body for nursing has been supportive and encouraging in forging new and innovative ways to practise nursing in the technological realm. CNSs are key members of the Canadian Virtual Hospice clinical team. While working with the Virtual Hospice, the CNS is also employed with a regional palliative care consultation team assessing patients and families across community and institutional settings of care. This experience enriches and balances the two clinical practice roles. The online role requires the CNS to triage the questions submitted to Ask a Professional and engage the team members best qualified to develop the response. The CNS also researches and responds to questions, either independently or in collaboration with other team members depending on the expertise required to provide a comprehensive answer. The team does not encourage ongoing dialogue with the questioner and should not be perceived to be directing care. Other components of this unique online nursing role include evaluating trends in the questions asked and the feedback obtained in order to identify new content for the website. This content may include developing answers to frequently asked questions from health-care providers for the Asked and Answered section (Box 2). The CNS also solicits other palliative care specialists to contribute articles on best practice or research projects. They also identify and assess tools from across the country for an interdisciplinary repository on the website called Tools for Practice. The role also includes participating in marketing initiatives, increasing awareness through social media, redeveloping the website, supporting the discussion forums community manager, and contributing to the development of proposals for funding opportunities. The role is varied and unique, providing many challenges and rewards. The major challenge of working in the virtual realm is the limited feedback received to
© 2014 MA Healthcare Ltd
Box 1. Example Ask A Professional questions
International Journal of Palliative Nursing 2014, Vol 20, No 4
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 27, 2015. For personal use only. No other uses without permission. . All rights r
Commentary
responses to Ask a Professional questions. Working virtually does not allow the luxury of gaining the context of the situation from nonverbal cues or information one obtains in the clinical environment by communicating directly with a colleague, patient, or family member/carer. Sometimes it can be difficult to determine what the person is asking because of a lack of specificity. Where information provided in the question is limited or the question not explicit, intuition and a strong background in palliative care are required to identify the information the questioner is seeking. Other questions include detailed clinical information and background about the situation that allow for an equally detailed and specific response. Developing a response to a written question requires a delicate communication style that balances evidence-informed content with understanding and compassion. It is not within the scope of an online response to provide specific treatment recommendations to patients. Therefore, with questions posed by patients or family members, the response from the CNS often includes the suggestion to communicate with local health-care providers to obtain further information. The CNS possesses the background required to address clinical questions posed by a variety of health-care providers. In developing a response, the CNS may need to evaluate the contextual issues of a situation and include relevant resources or address specific system concerns. Nurses constitute the largest professional user group of the Ask a Professional service. They often ask questions on behalf of a larger team, and in these circumstances the response will consider the context of that team. A benefit of working in the virtual realm is how easily the information gleaned from providing responses on the website can be used by the CNS in other areas of clinical practice and the overall positive impact this has on their future interactions and communication with patients and families.
© 2014 MA Healthcare Ltd
Future innovations The Canadian Virtual Hospice is continually expanding content and resources, and looking for new ways to connect those with a need or passion for palliative and end-of-life care. Recent additions to the website include The Gallery, which offers professional development videos on end-of-life care, grief and bereavement, and caregiving, as well as a revitalised Discussions Forum providing peer-to-peer support for patients, families/carers, and friends. With these new initiatives, busy health-care providers can use the latest evidence-
International Journal of Palliative Nursing 2014, Vol 20, No 4
Box 2. Example Asked and Answered question and response How long can someone live without food or water? Estimating how long someone may live is very difficult. It is usually discussed in terms of ranges; that is, hours to days, days to weeks, or weeks to months. It’s important to realise that every situation is different, that many factors are involved, and that everyone responds differently. Fluid intake has the biggest effect on immediate survival. Our bodies tend to have several weeks’ worth of reserve energy from food stores, but lack of fluid causes problems with kidney function within a few days. When someone is no longer taking in any fluid, and if he or she is bedridden (and so needs little fluid) then this person may live as little as a few days or as long as a couple of weeks. In the normal dying process people lose their sense of hunger or thirst. In addition, they may not be alert enough to swallow safely. This is a sign that body systems are starting to shut down. Death may be days or hours away. The patient may feel more comfortable if the mouth is moistened, but this is to relieve a dry mouth, not to satisfy thirst. When a decision is made to discontinue life-sustaining treatments such as artificial feeding or intravenous fluids, then a patient’s remaining time depends on how sick he or she is at that point, and whether there are complications such as pneumonia. Commonly, even after intravenous fluids are stopped the patient may take sips of fluids, ice chips, or swabs to moisten the mouth. This may provide more fluid than people realise, and it may extend survival time. All these unique health factors affect how someone experiences the total burden of the illness and how long she or he will live. Some people believe that a person’s will to live also affects a person’s burden of illness and so may also affect life expectancy. Families and health-care providers may be uncomfortable when someone refuses artificial food and fluids, as this seems like basic nurturing.Yet, legally and ethically artificial nutrition and hydration are considered health-care treatment, just like surgery, dialysis, or other medical interventions. People have the right to decline medical treatments, and others must respect this decision. There is no way to predict when someone’s condition may change suddenly. Therefore, it’s important to address any issues that need attention before the patient becomes too weak to do so. Things that need to be done or said should happen sooner rather than later.
based information to provide quality care and JPN tools to support patients and families. I● Declaration of interests The authors are paid employees of Virtual Hospice Canada. They have no other conflicts of interest to declare. Canadian Virtual Hospice receives operating funding from the Winnipeg Regional Health Authority and Project funding from a variety of sources. Canadian Hospice Palliative Care Association (2010) Policy Brief on Hospice Palliative Care: Quality End-of-Life Care? It Depends on Where You Live …and Where You Die. http://bit.ly/1koqpQx (accessed 1 April 2014) Canadian Nurses Association (2009a) Position Statement. Clinical Nurse Specialist. http://bit.ly/1iW3Pzr (accessed 1 April 2014) Canadian Nurses Association (2009b) Registered Nurses: On the Front Lines of Wait Times. http://bit.ly/QClVgx (accessed 1 April 2014) Carstairs S (2010) Raising the Bar: A Roadmap for the Future of Palliative Care in Canada. http://bit.ly/1mvXprH (accessed 1 April 2014) Lober WB, Flowers JL (2011) Consumer empowerment in health care amid the internet and social media. Semin Oncol Nurs 27(3): 169–82. doi: 10.1016/j. soncn.2011.04.002 Pew Research Centre (2011) Health topics. http://bit. ly/1pHQf3y (accessed 1 April 2014) Statistics Canada (2009) Canadian internet use survey. http://bit.ly/1gY3g9M (accessed 1 April 2014)
163
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 27, 2015. For personal use only. No other uses without permission. . All rights r
Palliative care nursing in the virtual realm Simone Stenekes, Sarah Brown, Brenda Hearson, Shelly Cory
T
echnology has affected health-care delivery in many ways. Both the internet and consumer empowerment have evolved (Lober and Flowers, 2011), and the health-care environment is attempting to keep pace with these rapid changes. In Canada, 70% of home internet users search for medical or health-related information online (Statistics Canada, 2009). In the USA, 80% of internet users seek out health information, with 7% looking specifically for information about end-of-life decisions (Pew Research Center, 2011). In their search for knowledge, the general public and health professionals require trustworthy, relevant, and easily understood information that is based on research and empowers them as health-care consumers and providers. Along with changes in technology, there is also an increasing demand for palliative care. With the current resources in Canada, it is estimated that less than 30% of those who could benefit from palliative care services actually obtain them. Population ageing and a rising death rate will lead to an increasing demand for palliative care services in the next few years (Canadian Hospice Palliative Care Association, 2010; Carstairs, 2010). With this confluence of technological advances and the increasing demand for palliative care services, the health-care system is being challenged to use innovative methods to address the needs of patients at the end of life, their formal caregivers, and their families.
© 2014 MA Healthcare Ltd
Canadian Virtual Hospice In 2001 a group of palliative care leaders gathered to consider whether a web-based platform could address some of the gaps in palliative care in Canada. They recognised the benefits of having a central repository of evidence-based information that would be readily accessible regardless of time or geography, and envisioned a place where people could connect for peer-to-peer and professional support. Launched in February 2004, the Canadian Virtual Hospice (www.virtualhospice.ca and
International Journal of Palliative Nursing 2014, Vol 20, No 4
www.portailpalliatif.ca) provides support and personalised information about palliative and end-of-life care, loss, and grief to people with life-limiting illness, family members, health-care providers, researchers, health-care administrators, and educators. The information on the website is developed and reviewed by an inter disciplinary clinical team of palliative care experts. The site is evidence-informed, up-to-date, relevant, and accessible 24/7. Content is extensive and includes information on all aspects of palliative and end-of-life care, from physical symptoms to the emotional, spiritual, and financial issues that result from illness and the latest research. Content is continually evaluated, revised, and developed. Presently there are over 6000 pages of content on the website, which averages 1200–1400 visits per day. The bilingual site (available in English and French) is accessed by people in almost every country in the world, with the USA, UK, Australia, and France being key drivers of traffic. Canadian Virtual Hospice also leverages social media channels such as YouTube, Vimeo, Facebook, Twitter (@VirtualHospice), and Google+ for crowd sourcing and knowledge dissemination.
Ask A Professional When www.virtualhospice.ca was launched in 2004, it was the first web-based platform in the world to provide the public with direct online access to a clinical team. This interdisciplinary team comprises experts in palliative care, who lead the development of content and respond to questions posted in the Ask a Professional section of the website. Canadians who pose a question will receive an individualised response within 3 business days. Forty per cent of the Ask a Professional questions come from health-care providers seeking guidance on complex or difficult cases. Sixty per cent come from patients, families, and friends. The Ask a Professional service provides access to palliative care specialists including clinical
Simone Stenekes, Sarah Brown, and Brenda Hearson are Clinical Nurse Specialists, and Shelly Cory is Executive Director, Canadian Virtual Hospice Correspondence to: [email protected]
161
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 27, 2015. For personal use only. No other uses without permission. . All rights r
Commentary
Questions from health-care providers ● What
is the best opioid to use in a patient with renal impairment?
● When
caring for patients with advanced disease our team struggles with knowing how to initiate conversations related to palliative and end-of-life care. Can you offer any suggestions?
●
I am a nurse working in the oncology department. Can you suggest some resources for a teenager whose mother is dying?
● What
do you suggest for a patient with constant nausea?
● Are
there resources for supporting a schoolteacher and classmates who have a child in the classroom who is living with an advanced illness?
●
Does oxygen therapy have a physical effect during the final hours when a person is dying?
●
Can you recommend a bereavement assessment form for bereaved families?
●
I am a nurse who lives in a rural area. I care for a patient in the community with end-stage cardiac disease. He would like to die at home. What can I expect and how can I prepare?
Questions from patients, friends, family, caregivers, or others ●
My brother is dying of brain cancer. What can we expect as he gets closer to death?
● What
type of funding and resources are available for someone who plans to die at home?
● When
is the right time to stop tube feeding for someone who has suffered a major stroke?
●
My friend’s mother is dying. What can I say to her family?
● What ●
can be expected with end-stage Alzheimer’s disease?
My father has been started on morphine for his advanced cancer pain. Is there anything I should know about this medication? I heard it causes hallucinations—is this true?
●
How long can someone live without food or water?
●
My wife just found out she has terminal cancer. How do we tell our young adult children?
nurse specialists (CNSs), physicians, social workers, spiritual care advisors, ethics advisors, and paediatric palliative care specialists. To date, more than 1800 questions from across Canada have been answered. Questions cover all aspects of end-of-life care, including physical symptoms, emotional and spiritual aspects of care, grief, and communication. Results from a survey sent to users were overwhelmingly positive. Eighty nine per cent of users were ‘very satisfied’ with the response and also felt the information they received was provided in a thoughtful and respectful manner. Forty seven per cent planned to share the response with others. The questions posed to Ask a Professional range from broad and general to detailed and specific. Box 1 highlights the types of questions that users have submitted. To ask a question, users only have to supply an email address so that they can be notified that their answer is waiting for them in a secure email box on the Virtual Hospice server and a postal code so that links to local resources can be provided. The limited information collected assists in protecting personal health information. The person is asked to identify whose health issue they are inquiring
162
about from a drop-down menu to help the team provide an appropriate response.
The clinical nurse specialist role The CNS role in Canada was developed in the 1960s. Together with the nurse practitioner role, it is one of the advanced practice nursing roles recognised by the Canadian Nurses Association (CNA). It has five key components: clinician, consultant, educator, researcher, and leader (CNA, 2009a). The CNS role at the Canadian Virtual Hospice is unique in Canada and an innovative response that uses technology to enhance palliative care (CNA, 2009b). From the inception of the role, the provincial regulatory body for nursing has been supportive and encouraging in forging new and innovative ways to practise nursing in the technological realm. CNSs are key members of the Canadian Virtual Hospice clinical team. While working with the Virtual Hospice, the CNS is also employed with a regional palliative care consultation team assessing patients and families across community and institutional settings of care. This experience enriches and balances the two clinical practice roles. The online role requires the CNS to triage the questions submitted to Ask a Professional and engage the team members best qualified to develop the response. The CNS also researches and responds to questions, either independently or in collaboration with other team members depending on the expertise required to provide a comprehensive answer. The team does not encourage ongoing dialogue with the questioner and should not be perceived to be directing care. Other components of this unique online nursing role include evaluating trends in the questions asked and the feedback obtained in order to identify new content for the website. This content may include developing answers to frequently asked questions from health-care providers for the Asked and Answered section (Box 2). The CNS also solicits other palliative care specialists to contribute articles on best practice or research projects. They also identify and assess tools from across the country for an interdisciplinary repository on the website called Tools for Practice. The role also includes participating in marketing initiatives, increasing awareness through social media, redeveloping the website, supporting the discussion forums community manager, and contributing to the development of proposals for funding opportunities. The role is varied and unique, providing many challenges and rewards. The major challenge of working in the virtual realm is the limited feedback received to
© 2014 MA Healthcare Ltd
Box 1. Example Ask A Professional questions
International Journal of Palliative Nursing 2014, Vol 20, No 4
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 27, 2015. For personal use only. No other uses without permission. . All rights r
Commentary
responses to Ask a Professional questions. Working virtually does not allow the luxury of gaining the context of the situation from nonverbal cues or information one obtains in the clinical environment by communicating directly with a colleague, patient, or family member/carer. Sometimes it can be difficult to determine what the person is asking because of a lack of specificity. Where information provided in the question is limited or the question not explicit, intuition and a strong background in palliative care are required to identify the information the questioner is seeking. Other questions include detailed clinical information and background about the situation that allow for an equally detailed and specific response. Developing a response to a written question requires a delicate communication style that balances evidence-informed content with understanding and compassion. It is not within the scope of an online response to provide specific treatment recommendations to patients. Therefore, with questions posed by patients or family members, the response from the CNS often includes the suggestion to communicate with local health-care providers to obtain further information. The CNS possesses the background required to address clinical questions posed by a variety of health-care providers. In developing a response, the CNS may need to evaluate the contextual issues of a situation and include relevant resources or address specific system concerns. Nurses constitute the largest professional user group of the Ask a Professional service. They often ask questions on behalf of a larger team, and in these circumstances the response will consider the context of that team. A benefit of working in the virtual realm is how easily the information gleaned from providing responses on the website can be used by the CNS in other areas of clinical practice and the overall positive impact this has on their future interactions and communication with patients and families.
© 2014 MA Healthcare Ltd
Future innovations The Canadian Virtual Hospice is continually expanding content and resources, and looking for new ways to connect those with a need or passion for palliative and end-of-life care. Recent additions to the website include The Gallery, which offers professional development videos on end-of-life care, grief and bereavement, and caregiving, as well as a revitalised Discussions Forum providing peer-to-peer support for patients, families/carers, and friends. With these new initiatives, busy health-care providers can use the latest evidence-
International Journal of Palliative Nursing 2014, Vol 20, No 4
Box 2. Example Asked and Answered question and response How long can someone live without food or water? Estimating how long someone may live is very difficult. It is usually discussed in terms of ranges; that is, hours to days, days to weeks, or weeks to months. It’s important to realise that every situation is different, that many factors are involved, and that everyone responds differently. Fluid intake has the biggest effect on immediate survival. Our bodies tend to have several weeks’ worth of reserve energy from food stores, but lack of fluid causes problems with kidney function within a few days. When someone is no longer taking in any fluid, and if he or she is bedridden (and so needs little fluid) then this person may live as little as a few days or as long as a couple of weeks. In the normal dying process people lose their sense of hunger or thirst. In addition, they may not be alert enough to swallow safely. This is a sign that body systems are starting to shut down. Death may be days or hours away. The patient may feel more comfortable if the mouth is moistened, but this is to relieve a dry mouth, not to satisfy thirst. When a decision is made to discontinue life-sustaining treatments such as artificial feeding or intravenous fluids, then a patient’s remaining time depends on how sick he or she is at that point, and whether there are complications such as pneumonia. Commonly, even after intravenous fluids are stopped the patient may take sips of fluids, ice chips, or swabs to moisten the mouth. This may provide more fluid than people realise, and it may extend survival time. All these unique health factors affect how someone experiences the total burden of the illness and how long she or he will live. Some people believe that a person’s will to live also affects a person’s burden of illness and so may also affect life expectancy. Families and health-care providers may be uncomfortable when someone refuses artificial food and fluids, as this seems like basic nurturing.Yet, legally and ethically artificial nutrition and hydration are considered health-care treatment, just like surgery, dialysis, or other medical interventions. People have the right to decline medical treatments, and others must respect this decision. There is no way to predict when someone’s condition may change suddenly. Therefore, it’s important to address any issues that need attention before the patient becomes too weak to do so. Things that need to be done or said should happen sooner rather than later.
based information to provide quality care and JPN tools to support patients and families. I● Declaration of interests The authors are paid employees of Virtual Hospice Canada. They have no other conflicts of interest to declare. Canadian Virtual Hospice receives operating funding from the Winnipeg Regional Health Authority and Project funding from a variety of sources. Canadian Hospice Palliative Care Association (2010) Policy Brief on Hospice Palliative Care: Quality End-of-Life Care? It Depends on Where You Live …and Where You Die. http://bit.ly/1koqpQx (accessed 1 April 2014) Canadian Nurses Association (2009a) Position Statement. Clinical Nurse Specialist. http://bit.ly/1iW3Pzr (accessed 1 April 2014) Canadian Nurses Association (2009b) Registered Nurses: On the Front Lines of Wait Times. http://bit.ly/QClVgx (accessed 1 April 2014) Carstairs S (2010) Raising the Bar: A Roadmap for the Future of Palliative Care in Canada. http://bit.ly/1mvXprH (accessed 1 April 2014) Lober WB, Flowers JL (2011) Consumer empowerment in health care amid the internet and social media. Semin Oncol Nurs 27(3): 169–82. doi: 10.1016/j. soncn.2011.04.002 Pew Research Centre (2011) Health topics. http://bit. ly/1pHQf3y (accessed 1 April 2014) Statistics Canada (2009) Canadian internet use survey. http://bit.ly/1gY3g9M (accessed 1 April 2014)
163
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 27, 2015. For personal use only. No other uses without permission. . All rights r
