PCSSF 1

2
18
29
32
35
40
45
54
59
74
117
122
131
138
140
Fo re wo rd by C h a ir m a n
Facing illness and disease can be a distressing event, and even more so for patients with
life-threatening or life-limiting conditions such as cancer and end organ failure. Palliative care helps
in improving their quality of life along the disease progression till the last phase of their life journey.
Over the past years, there has been a steady development of palliative care services in the
Hospital Authority (HA). While the service was initially developed for cancer patients, it has been
extended to non-cancer patients in recent years to better address their needs.
In the context of a rapidly ageing population and growing chronic disease burden in Hong Kong,
there is a need to strengthen our healthcare services for supporting the various needs of patients
along the care pathway. In alignment with the Government policy on long-term care for the
elderly and the related ongoing initiatives and discussions on palliative and end-of-life care, it is an
opportune time for us to formulate this Strategic Service Framework for Palliative Care, to improve
the palliative care services in HA. It is also our duty to plan this service well, and empower our
colleagues to deliver palliative care alongside with other acute and curative services, so that
comprehensive healthcare services are provided to our population from cradle to grave.
My heartfelt gratitude goes to the wide range of clinical colleagues, patient representatives
and my fellow Board members for their support and contributions in formulating this Strategic
Service Framework. Successful implementation of the Framework requires collaborative effort
across disciplines, specialties and hospitals in HA for integrating palliative care into the care
continuum. With the commitment and dedication of all of us here in HA, I am confident that we
will raise the standards of our palliative care services to benefit all patients in need.
Prof John C Y LEONG

Chairman
Hospital Authority
2
Fore word by C hief E xecut ive
Life is a journey, with a beginning and also an end. As I mentioned in my speech at the 2016
Hospital Authority Convention, our mission of helping patients stay healthy is underpinned by a
strong belief in whole-life well being, from birth to death. As healthcare workers, our job is not
only about saving lives and treating illnesses, but also about providing care that is congruent to
the patients’ needs and preferences, and when the time comes, to help them live with dignity
and peace in the last stages of their life journeys.
Being the major provider of public healthcare services in Hong Kong, we are taking care of many
patients with life-limiting and life-threatening conditions who require palliative care. Palliative
care is not the ‘treatment option of last resort’. It is an integral part of the continuum of holistic
care for patients suffering from a serious illness, and should be provided early in the course of
the illness according to the patients’ needs. Patients should also have more opportunities to
participate in the planning of their care, so that their choices in the final stages of life are known
and respected for a better quality of life.
The Strategic Service Framework for Palliative Care is an overarching blueprint to guide
our clinicians and executives in aligning the palliative care service initiatives in our operation
planning. My sincere thanks go to all the staff and other stakeholders who have contributed to
the Framework’s development. To achieve our vision of better access to quality palliative care
services for all patients with a serious illness, there needs to be a fundamental shift in our culture
and in the way we understand and deliver palliative care. I look forward to working with you all
in striving for change, to bring better care to patients in need and their families/carers.
Dr P Y LEUNG
Chief Executive
Hospital Authority
3
The Strategic Service Framework for Palliative Care is going to guide the development of the
Hospital Authority (HA)’s palliative care services over the next five to ten years. It outlines our
strategic directions for building up a sustainable service model and system infrastructure, so as
to address the service gaps and improve the quality of our palliative care.
Under the Framework, focused efforts will be made to improve the governance and
organisation of our adult palliative care services, and strengthen the collaboration between
palliative care and non-palliative care teams. Emphasis is put on enhancing ambulatory and
community services so that patients can be taken care of in their usual place of residence.
At the same time, structured and family-centred paediatric palliative care is to be established in
our paediatric services network for addressing the needs of chronically or seriously ill children
and their families. Across HA, palliative care services are monitored for continuous quality
improvement, and key enablers are also identified to support the strategies.
4
Preface
We are delighted to see the active participation from a wide range of stakeholders during
the formulation of the Framework, including frontline clinical staff, Head Office and Cluster
executives, and patient representatives. Their views and aspirations have been most valuable
in shaping our future service development. In particular, we would like to express our gratitude
to the members of the Taskforce and Working Groups for their guidance and expert advice, as
well as the Subgroup members for developing the palliative care service plans for respective
Clusters. We would also like to extend our appreciation to everyone who provided suggestions
and feedback on the draft Framework. We look forward to your continuing support as we
implement the strategies in the years to come.
Dr Libby LEE Dr W L CHEUNG

Director, Strategy & Planning Division Director, Cluster Services Division
Hospital Authority Head Office Hospital Authority Head Office
5
Introduction
The Strategic Service Framework for Palliative Care (the Framework) is an overarching document
developed by the Hospital Authority (HA) to guide the development of adult and paediatric
palliative care services in the next five to ten years. It outlines the strategies and key enablers for
building up the service model and system infrastructure to address existing issues and improve
the service quality.
Patients with life-limiting conditions are in need of palliative care. They could be having different
diseases, in different hospitals or healthcare settings, and under the care of healthcare teams of
different specialties. Along the disease trajectories, patients may experience multiple symptoms
and distress requiring palliative care support at different time points. Therefore, concerted
efforts are required from each and every healthcare staff in supporting these patients and their
families/carers. Through this Framework, HA is moving towards the following vision:
All patients facing life-threatening and life-limiting conditions and their

families/carers receive timely, coordinated and holistic palliative care
to address their physical, psychosocial and spiritual needs, and are given
the opportunities to participate in the planning of their care, so as to improve their
quality of life till the end of the patients’ life journey.
The Framework is targeted at patients suffering from life-threatening and life-limiting conditions,
covering both adults and children with cancer or non-cancer diseases. Emphasis is placed
on the collaboration among different specialties along the care continuum from hospital to
community settings. While the focus is on palliative care services in HA, collaboration with
community partners and the welfare sector is also highlighted for supporting the patients and
their families/carers in the community.
6
E xecut ive S ummar y
Planning Process
The development of the Framework commenced in early 2016. Under the policy directions and
guidance of the Medical Services Development Committee (MSDC) and Directors’ Meeting, a
Taskforce was set up to oversee the formulation process. Working Groups were also formed to
advise on the future service models and system infrastructure for adult and paediatric palliative
care. Overall, a highly participative and broad engagement approach was adopted, with
contribution from frontline clinical staff, Cluster management, Head Office executives and patient
groups.
Literature review was conducted to understand the international development and service
models of palliative care. Situation analysis was carried out to evaluate the existing service
utilisation pattern in HA and identify service gaps and areas for improvement. It was
supplemented by hospital visits in the Clusters to observe the service operation and provision.
In addition, overseas experts shared their views and experience on palliative care in a Summit
which was attended by different key stakeholders including palliative care and non-palliative care
specialist doctors, nurses, allied health (AH) professionals, and executives. Themed discussions
were held during the Summit to gather ideas for developing the Framework. Moreover, regular
briefings and presentations were made to the relevant Coordinating Committees, Central
Committees and the Patient Advisory Committee to collect feedback.
Consultation on the draft Framework was conducted between 26 May 2017 and 22 June
2017. The responses and comments received were carefully considered and deliberated by the
Taskforce. Subsequently, the refined Framework was submitted to the Directors’ Meeting for
endorsement, followed by the MSDC for final approval.
7
Framework Strategies for Adult Palliative Care
In the Framework, there are four strategic directions for improving the governance and service
organisation, care coordination, place of care and performance monitoring of adult palliative care
services respectively, as follows:
1. Enhance governance by developing Cluster-based services with the collaboration of

medical and oncology palliative care specialists
2. Promote collaboration between palliative care and non-palliative care specialists through
shared care model according to patients’ needs
3. Enhance palliative care in the ambulatory and community settings to support patients
and reduce unnecessary hospitalisation
4. Strengthen performance monitoring for continuous quality improvement
Under each strategic direction, strategies are formulated with reference to the identified areas or
opportunities for improvement so as to address the service gaps and key issues.
8
1. Enhance Governance by Developing Cluster-based Services

with the Collaboration of Medical and Oncology Palliative Care
Specialists
Opportunities for Improvement

At present, adult palliative care services are mainly department or hospital-based, and are
provided by palliative care teams (PC teams) located in 16 hospitals. The teams are led by
palliative care specialists who are either from the Department of Medicine (medical PC teams)
or the Department of Clinical Oncology (oncology PC teams). Collaboration between different
PC teams is limited, resulting in variable service accessibility, particularly for hospitals without a
PC team. Overall, the palliative care coverage for non-cancer patients is lower than for cancer
patients. It is because both medical and oncology PC teams serve cancer patients, while
non-cancer patients are covered mainly by the medical PC teams. In addition to the Central
Committee on Palliative Care which oversees the palliative care services in HA at Head Office
level, Coordination Committees on Palliative Care Services have also been established in all the
Clusters. There is still room to further enhance the roles of these Cluster Committees in service
coordination and development.
Strategies
Enhancing the governance of adult palliative care services is the cornerstone of the overall
service development. The direction is set towards Cluster-based service organisation to
improve service accessibility and the coordination of care. Strategies include:
• Strengthening collaboration between medical and oncology palliative care specialists to

develop Cluster-based services. Palliative care services are delivered through a coordinated
network covering both cancer and non-cancer patients in all hospitals of the Clusters.
This enables the pooling of expertise and optimal use of resources and facilities for more
accessible palliative care
• Reinforcing the role of the Cluster Coordination Committees on Palliative Care Services to
support Cluster-based service organisation and improve the implementation, coordination
and monitoring of palliative care services at the Cluster level
9
2. Pro m o t e C o l l a b o r a t i o n b e t we e n Pa l l i a t i ve C a re a n d
Non-Palliative Care Specialists through Shared Care Model
according to Patients’ Needs

Care coordination is indispensable in palliative care given that patients requiring the service
are often under the care of different specialties. However, there is currently a heavy reliance
on palliative care specialists to deliver the service, while the parent teams of non-palliative
care specialists focus on providing disease management without much collaboration between
the palliative care and non-palliative care teams. Due to limited awareness and knowledge of
palliative care among non-palliative care specialists, referrals to PC teams are often made at the
very end stage of the patients’ disease trajectory, affecting the timeliness and accessibility of
palliative care.
Strategies
Enhanced collaboration between palliative care and non-palliative care specialists, and
integration of adult palliative care into the care continuum are promoted. Instead of simply
adding a layer of specialist palliative care for every patient with a life-threatening or life-limiting
illness, a shared care model is to be adopted, supported by training and skills transfer. The aim
is to ensure the provision of timely and appropriate care according to the needs of patients and
their families/carers. Strategies include:
• Stratifying patients according to their palliative care needs and disease complexity.
Patients whose palliative care needs are not complex are taken care of by the parent
teams. For cases with complex palliative care needs but still receive disease modifying
treatment, they are co-managed by both the parent teams and palliative care specialists
through consultative support, case conferences, etc. Only patients with complex palliative
care needs or difficult symptoms are managed by palliative care specialists in a palliative
care setting
• Integrating palliative care into the care pathway for early identification of patients in need
and initiation of advance care planning (ACP). With training and skills transfer, healthcare
staff working in non-palliative care settings are equipped to identify the palliative needs
of patients and their families/carers. ACP is conducted by the parent teams to address
patients’ and their families/carers’ needs and preferences regarding their care
• Strengthening specialist palliative consultative service in non-palliative care settings

is a key component of the shared care model, so as to support the parent teams in
providing palliative care to their patients
10
3. Enhance Palliative Care in the Ambulatory and Community Settings

to Support Patients and Reduce Unnecessary Hospitalisation

Patients approaching the end of life, especially in the last year of life, tend to have high utilisation
of hospital services such as Accident & Emergency attendances and acute admissions,
even though most of them prefer to be cared for at their usual place of residence. Acute
hospitalisation may be stressful to the patients or their families/carers if the goal of palliation
is unmet, and put significant pressure on the healthcare system inappropriately. Limitations of
palliative care services in the ambulatory and community settings may have accounted for the
situation. For instance, the provision of therapeutic procedures is available in only some of the
palliative care day settings; there are also considerable gaps and inconsistencies in palliative
home care service because it is organised separately by the medical and oncology PC teams.
Strategies
It is important to provide ambulatory and community palliative care support to patients and
their families/carers in order to facilitate care in place and reduce unnecessary hospitalisation.
The emphasis is on enhancing day care, home care, support to residential care homes, and
community partnership. Strategies include:
• Refining and aligning the palliative care day service model across Clusters, with the
service components being refocused to provide fast track support and therapeutic
procedures for symptom management
• Expanding palliative home care service with a Cluster-based arrangement and adopting
a case management approach for the home care teams to support both cancer and
non-cancer patients. There is also collaboration with Community Nursing Service under
the principle of shared care model
• Enhancing palliative care support to residential care homes for the elderly (RCHEs)
through expanding the end-of-life care programme provided by the Community Geriatric
Assessment Teams
• Enhancing medical-social collaboration with community partners such as

non-governmental organisations (NGOs), patient groups and volunteers, so as to better
mobilise community resources for supporting patients and families/carers
11
4. Strengthen Performance Monitoring for Continuous Quality
Improvement

At present, there are limited data on the performance and outcome of palliative care services
in HA. The services are mainly monitored on their service throughputs. With regard to quality
and performance monitoring, the data are captured manually and are not standardised. Quality
indicators are yet to be developed for systematic performance monitoring, benchmarking across
units and for informing service planning.
Strategies
Systematic monitoring of palliative care service quality is instrumental to drive service
improvement. Strategies include:
• Enhancing data collection with standardisation of data capture and alignment of

measurement tools
• Identifying key domains and developing indicators for the evaluation and monitoring of
clinical outcomes and service quality
Under the Framework, a new service model is envisioned for adult palliative care in HA, with the
integration of palliative care into the care continuum as illustrated in Figure 1 below.
Figure 1. Future Service Model of Adult Palliative Care in HA
12
Framework Strategies for Paediatric Palliative Care
In contrast to adult palliative care services, specialist palliative care is currently not available
in HA for paediatric patients. Children suffering from life-threatening or life-limiting illness
are being looked after by the respective paediatric subspecialty teams, which mainly deliver
disease management and may also look into the palliative care needs of their paediatric
patients if required. Community support for these patients is also generally limited even though
collaborations have been made in recent years between the paediatric departments and NGOs
to help bridge the service gap. Overall, the provision and development of paediatric palliative
care services is not carried out in a structured manner.
With the upcoming development of Hong Kong Children’s Hospital (HKCH), paediatric services
in HA will be reorganised into a coordinated service network. It is opportune to re-engine our
system to provide holistic care for paediatric patients ranging from acute curative to palliative
care.
13
Strategies
In the Framework, there are three strategic directions for establishing structured paediatric
palliative care services in HA to address the specific needs of children and their families through
a family-centred approach. The directions are as follows:
1. Establish Territory-wide Paediatric Palliative Care Services in HA

2. Promote Integrated and Shared Care with the Parent Teams
3. Enhance Community Support for Children and Families in Need of Palliative Care
Under the future service model for paediatric palliative care, territory-wide paediatric palliative care
services under a single clinical governance are established. A centralised paediatric PC team will
work with the designated care team of doctors and nurses at regional level to provide comprehensive
palliative care services for the needs of children. The latter plays a significant role in coordinating with
community partners, special schools and local paediatric sub-specialty teams; and in the provision of
palliative home care service in their local community. Overall, a continuum of paediatric palliative care
services is provided, covering inpatient, outpatient, home care, support to schools and bereavement
care. Community services are also strengthened through enhanced partnership with NGOs and
patient groups. The new service model is illustrated in Figure 2 below.
Figure 2. Future Service Model of Paediatric Palliative Care in HA
A centralised paediatric PC team works with the designated care team of doctors and nurses
at regional level to provide a continuum of territory-wide palliative care services
from hospital to community under a single clinical governance
14
Key Enablers
For effective implementation of the Framework strategies, various key enablers are required to
build up the system infrastructure for adult and paediatric palliative care.
Manpower and Training
A Cluster-based perspective of workforce planning and deployment is needed to support

the service models. A systematic approach is also to be adopted for training to drive cultural
change in integrating palliative care into the care continuum:
• Basic training for all healthcare staff to raise their general knowledge and awareness of
palliative care
• Advanced training for non-palliative care teams working directly with patients suffering from
life-threatening or life-limiting illnesses to build up their competency in implementing the
shared care model
• Specialist training for doctors, nurses and designated training for AH staff in the PC teams
Facilities
Physical designs for facilitating palliative care, including home-like, peaceful and soothing
environment are incorporated into the hospital development and redevelopment projects in HA.
In addition, capacity planning covering inpatient and ambulatory facilities for palliative care is to
be put in place to cope with the projected service demand and take into consideration changes
in the service model.
15
Logistic Support in Hospital Wards
The logistics and operations of the hospital wards should be designed to cater for the palliative
care needs of patients and their families/carers. Flexible visiting hours are introduced so that
patients can spend more time with their loved ones. Arrangement can also be made for
families/carers to stay overnight with the patients if hospital operation allows.
Information Technology (IT) Support
There is a need to enhance the IT system to support the workflow, communication and care
coordination across disciplines, specialties and care settings along the palliative care journey.
This includes building up a common platform for the documentation of ACP, and setting up
a palliative care database. The development of tele-care and mobile apps should also be
explored to support care in place.
Transportation
Transportation support for patients such as Non-emergency Ambulance Transfer Service needs
to be strengthened for improving patients’ access to palliative care day services as well as the
transfer of patients between hospitals or to RCHEs.
16
Implementation and Monitoring

Successful implementation of the Framework will require the joint effort of Clusters, hospitals
and frontline clinical staff. The process of change should start now, led by clinical leaders,
Cluster management and HA Head Office. The strategies will be implemented by phases
according to the priority of service needs and readiness of key enablers at both the clinical and
Cluster levels. Some of the strategies do not require additional resources, while others will incur
resources which could be sought through the HA annual planning process.
The implementation process will be monitored at different levels, including the existing
mechanism of annual plan programme monitoring, progress review of the operational plans at
the Cluster and corporate levels, and the development of HA-wide quality indicators on palliative
care services.
Conclusion
Palliative care is an integral part of the care continuum. Quality palliative care makes a significant
difference in helping adult and paediatric patients and their families/carers cope with the distress
of serious illness and anticipating death. The Framework not only highlights the future service
models that HA aspires to deliver, it also calls for a fundamental shift in our culture, so that all
healthcare workers are aware that good patient care is not only about saving lives, but also
about helping patients live with comfort, dignity and peace till the last phase of their life journey.
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PART O NE : S ett in g the S cen e
Introduction
Setting the Scene for Development of the Strategic Service Framework
for Palliative Care
According to the World Health Organisation (WHO), palliative care is an approach that improves
the quality of life of patients (adults and children) facing life-threatening or life-limiting illness
and their families/carers. It prevents and relieves suffering of the patients through early
identification, assessment and treatment of pain and other physical, psychosocial or spiritual
problems1. A team approach is used in palliative care to support the patients to live as actively
as possible until the last moment, and support their families/carers during the process as well as
bereavement.
Palliative care is required by patients who suffer from life-limiting conditions, commonly from
cancer and other serious chronic diseases such as kidney failure, chronic respiratory diseases,
cardiovascular diseases and neurological diseases. There is often a misconception that
palliative care means end-of-life (EOL) care and equals to “giving up”2, and it is only for patients
at the last stage of their illness. On the contrary, palliative care should be provided along with
the curative treatment to support the patient at any stage in a serious illness. It aims at relieving
the symptoms of both the disease and the treatment, such as pain, fatigue, shortness of breath,
nausea, depression, etc. In fact, palliative care is most effective when considered early in the
course of the illness, which not only improves quality of life for the patients but also reduces
unnecessary hospitalisation3.
1 World Health Organisation (WHO). WHO Definition of Palliative Care. Available at: www.who.int/cancer/palliative/definition/en
2 Chung, R. et al. (2017). Knowledge, attitudes, and preferences of advance decisions, end-of-life care, and place of care and death in Hong Kong. A population-based
telephone survey of 1067 adults. Journal of the American Medical Directors Association; 18(4):367.e19-367.e27.
3 World Health Organisation. Fact Sheet No. 402: Palliative Care. Available at: www.who.int/mediacentre/factsheets/fs402/en
29
In the perspective of quality healthcare, palliative care should be regarded as an integral part of
the care continuum. It is clearly distinct from the historical development of hospice care which
focuses on the very end of life period or after curative care has been exhausted (Figure 1).
The concept of palliative care advocates an integrated approach, with palliative care provided
alongside the curative and disease-modifying treatment to support the various needs of patients
and their families/carers (Figure 2).
Figure 1. Concept of Hospice Care
Hospice
Curative care
care
Diagnosis Death
Time
Figure 2. Concept of Integrated Palliative Care
Curative and disease modifying

treatment
Palliative care
Diagnosis Death
End-of life care Bereavement

care
Time
30
Providing palliative care is considered an ethical duty for healthcare professionals according to
WHO. The provision of care should not be confined to the palliative care specialists. A quality
and accessible palliative care system needs to be integrated into primary, community and
home-based care4. Specialist palliative care is but one component of palliative care service
delivery, where the palliative care specialists work together with healthcare professionals in other
specialties to support patients suffering from life-limiting conditions.
Currently, HA is providing a spectrum of palliative care services ranging from inpatient,

ambulatory to community care and bereavement services. The overall service development is
overseen by the Central Committee on Palliative Care (CC(Palliative Care)) at the Head Office
level. Palliative care teams (PC teams) in 16 hospitals are providing palliative care services to
adult patients with over 360 palliative care beds. There are recent initiatives to enhance the
palliative care services by extending the support from cancer patients to non-cancer patients,
strengthening the delivery of psychosocial care as one of the core elements in palliative care,
and moving from hospital-based care to reaching out into the community for better support of
patients at home and in care homes.
Overall, healthcare service development is skewed towards technology advancement and

service provision in acute and curative care. Hong Kong is of no exception. In the face of an
ageing population and increase in chronic diseases, the Government is promoting primary and
community care, and also fostering collaboration between the medical and welfare sectors
to better meet patients’ needs. That includes the development of a long-term care policy
to improve the quality of life of the frail elderly, with ongoing initiatives and discussions on
palliative and EOL care, amongst others. In alignment, HA strives to address responsively and
adequately the various needs of patients and their families/carers along the care pathway, and
thus sees the need to develop and enhance palliative care. A Strategic Service Framework for
Palliative Care is therefore developed to shape the future palliative care services in HA.
31
Scope and Vision
What We Aspire and What the Framework is about
Patients with life-limiting conditions are in need of palliative care. They could be having different
diseases, in different hospitals or healthcare settings, and under the care of healthcare teams of
different specialties. Along the disease trajectories, patients may experience multiple symptoms
and distress requiring palliative care support at different time points. Therefore, palliative
care services should not be limited by any professional boundaries, and concerted efforts are
required from each and every healthcare staff in supporting the needs of patients facing serious
illness and their families/carers. With this principle in mind, the following paragraphs describe
our aspirations for palliative care services in HA and what the Framework is about.
Vision of HA Palliative Care Services

All patients facing life-threatening and life-limiting conditions and their families/carers receive
timely, coordinated and holistic palliative care to address their physical, psychosocial and
spiritual needs, and are given the opportunities to participate in the planning of their care, so as
to improve their quality of life till the end of the patients’ life journey.
Scope of the Strategic Service Framework for

Palliative Care
The Framework sets out the strategic directions that HA will pursue to realise our vision for
better quality palliative care services. It aims to guide the development of HA palliative care
services in the coming five to ten years. It is an overarching document outlining the strategies
and key enablers for building up the service model and system infrastructure, so as to address
existing issues and to improve the quality of our palliative care services.
32
The Framework is targeted at patients suffering from life-threatening and life-limiting conditions,
covering both adults and children with cancer or non-cancer diseases. In particular, the
Framework puts emphasis on the collaboration among different specialties along the care
continuum from hospital to community settings. While focus is given to the provision of palliative
care services in HA, the importance of collaboration with community partners and the welfare
sector is also highlighted for supporting patients and their families/carers in the community.
Meanwhile, in line with the long-term care policy for the elderly in Hong Kong, there are related
ongoing initiatives and discussion at the Government level on palliative and EOL care. In the
formulation of the Framework strategies, alignment has been made with the overall Government
policy direction as well as the established HA guidelines5,6,7 where appropriate. While advance
care planning (ACP) is included in the Framework in terms of its service model, the legal aspects
and Government policy issues on dying in place, advance directives (AD) and Do-Not-Attempt
Cardiopulmonary Resuscitation (DNACPR) are beyond the scope of this Framework.
5 Hospital Authority (HA), Hong Kong Special Administrative Region. (2015). HA Guidelines on Life-
Sustaining Treatment in the Terminally Ill.
6 Hospital Authority (HA), Hong Kong Special Administrative Region. (2016). HA Guidelines on Do-Not-
Attempt Cardiopulmonary Resuscitation.
7 Hospital Authority (HA), Hong Kong Special Administrative Region. (2016). Guidance for HA Clinicians
on Advance Directives in Adults.
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Advance Care Planning (ACP)a
ACP is a process of communication among a patient with advanced progressive diseases, the
healthcare providers, and the patient’s families/carers regarding the kind of care that will be
considered appropriate when the patient cannot make those decisions. It is an overarching
and preceding process for expressing preference and values for medical and personal care,
which in turn will shape the care for the patients thereafter and at the end of life. Through the
ACP process, a mentally competent and properly informed patient may express preferences for
future medical or personal care, or make an advance directive (AD) refusing futile life-sustaining
treatment. In HA, the term of ACP extends beyond communication with mentally competent
adult patients to include that with family members of mentally incompetent and minor patients,
by consensus building according to the best interest of the patient.
Advance Directives (AD)b
A mentally competent and properly informed adult patient can make an AD, explicitly expressing
his/her wish to refuse specified life-sustaining treatment (e.g. cardiopulmonary resuscitation
(CPR), artificial ventilation, artificial nutrition and hydration etc.) in pre-specified conditions when
he/she is in an end-stage condition and mentally incapable of making healthcare decisions. A
valid and applicable AD is legally binding under common law. In HA, standardised AD forms are
designed for use by HA patients to document the decision.
Do-Not-Attempt Cardiopulmonary Resuscitation (DNACPR)c
DNACPR is an elective decision not to perform CPR, made in advance, when cardiopulmonary
arrest is anticipated and CPR is against the wish of the patient or otherwise not in the best
interest of the patient. The decision encompasses respecting the view of the patient and the
family, the principle of futility of treatment and the best interests of the patient. Standardised
DNACPR forms are in place in HA for documenting the decision. DNACPR only means that
CPR is not to be initiated in the event of cardiopulmonary arrest. It does not automatically imply
forgoing other life-sustaining treatments, which should be individually considered.
Issued by HA Clinical Ethics Committee:

a HA Guidelines on Life-Sustaining Treatment in the Terminally Ill (2015)
b Guidance for HA Clinicians on Advance Directives in Adults (2016)
c HA Guidelines on Do-Not-Attempt Cardiopulmonary Resuscitation (2016)
34
Planning Context
Contextual Factors for Driving the System Change
There are some contextual factors that have provided the impetus for the development of the
Strategic Service Framework for Palliative Care in HA, such as the growing evidence of palliative
care, and the increasing need for palliative care as a result of an ageing population and the rising
burden of chronic diseases. These factors are the main drivers for change in the system and
are outlined in this chapter.
Escalating Demand for Palliative Care Due to

Population Ageing and Chronic Disease Burden
Hong Kong is challenged with an escalating demand for palliative care services due to an ageing
population and a rising prevalence of chronic diseases. According to the latest population
estimates and projections by the Census and Statistics Department, the proportion of elderly
people aged 65 and above will grow from 16% in 2016 to 31% in 2046. The overall Hong Kong
population will increase from 7.3 million to 8.2 million during the same period (Figure 3)8.
Figure 3. Hong Kong Population (2016 – 2046)
8 Census and Statistics Department, Hong Kong Special Administrative Region. 2016 Population By-census and Hong Kong Population Projections 2015-2064.
35
Elderly people contribute to the majority of the mortality in Hong Kong. In 2014 there were
approximately 46 000 deaths in Hong Kong9, among which nearly 80% were elderly people
aged 65 or above, and of whom around 40% were residents of residential care homes for the
elderly (RCHEs). While more elderly people live longer, the prevalence of chronic diseases is also
on a rising trend. According to the Census and Statistics Department, 75% of elderly people
suffered from one or more chronic conditions in 201410. Cancer and other chronic diseases of
the heart, respiratory, neurological and renal systems as well as diabetes mellitus accounted for
about 60% of the deaths in Hong Kong (Figure 4)11.
Elderly people require more healthcare services, particularly the public services which are highly
subsidised. For instance, elderly population aged 65 years or above accounted for around half
of all the patient days in HA. The chance of an elderly person being hospitalised is about four
times that of a non-elderly person, and the bed requirement in terms of general bed utilisation
rate for elderly people is about nine times that of non-elderly people. Therefore, with the
ageing population and chronic disease burden in Hong Kong, there will be a significant impact
on the service demand of HA ranging from acute and curative care to palliative care services
in supporting the various needs of patients along the care pathway. Concerted efforts on
enhancing the palliative care services in HA are needed to cope with the rising demand and to
ensure sustainability of the services.
Figure 4. Top Ten Causes of Deaths in Hong Kong (2014)
9 Immigration Department and Hospital Authority, Hong Kong Special Administrative Region.
10 Census and Statistics Department, Hong Kong Special Administrative Region. (2015). Thematic Household Survey Report No. 58.
11 Department of Health, Hong Kong Special Administrative Region. (2015). Tables on Health Status and Health Services 2014.
36
HA’s Unique Position in the Delivery of Palliative Care

As the major public healthcare provider in Hong Kong, HA is managing about 90% of the
inpatient services (in terms of the number of bed days) in Hong Kong. The majority of patients
suffering from a life-threatening or life-limiting illness are under the care of HA, which is
reflected by the fact that about 90% of the approximately 46 000 deaths in Hong Kong in 2014
presented to or occurred in HA. While palliative care is not restricted to dying patients, many
patients require palliative care support during the last phase of their life journey. Hence, the high
number of dying patients passing through the HA system has put HA in a unique position of
responsibility and opportunity to provide palliative care services to patients in need. Moreover,
tasked with the responsibility of training healthcare professionals, HA has an important role in
upholding the professional standard and building up a competent workforce for the delivery of
quality palliative care, in addition to serving as the major provider of palliative care services.
High Hospital Service Utilisation in Last Phase of Life

It is observed in local and international data that hospital service utilisation escalates in the last
year of life12,13,14. On analysis of HA data in 2014, substantial utilisation by patients in their last
year of life is noted in terms of Accident & Emergency (A&E) attendances, hospital admissions
and patient days. The rise started in the last 6 months with the surge being seen in the final
two months of life (Figure 5). This applied both to patients dying with cancers and those with
end-organ failure. In particular, the average number of A&E attendances and patient days
of elderly patients in their last year of life were five and ten times of other elderly patients
respectively.
However, higher utilisation of healthcare services is not necessarily associated with higher quality
of care15. Literature review shows that a significant number of seriously ill patients who would
prefer palliative care found their medical care was at odds with their preference16. With the
existing dominant focus on acute curative care in the system, it is crucial to reconsider whether
the current service delivery models can effectively and adequately address the various needs of
the patients and their families/carers along the care pathway of a serious illness.
12 Fassbender, K. et al. (2009). Cost trajectories at the end of life: the Canadian experience. Journal of Pain and Symptom Management; 38(1):75-80.
13 Menec, V. et al. (2004). Patterns of Health Care Use and Cost at End of Life. Winnipeg: Manitoba Centre for Health Policy.
14 Goldsbury, D.E. et al. (2015). Acute hospital-based services used by adults during the last year of life in New South Wales, Australia: a population-based retrospective cohort
study. BMC Health Services Research; 15:537.
15 Fisher, E. et al. (2009). Health Care Spending, Quality, and Outcomes: More Isn’t Always Better. The Dartmouth Institute for Health Policy & Clinical Practice.
16 Teno, J.M. et al. (2002). Medical care inconsistent with patients’ treatment goals: association with 1-year Medicare resource use and survival. Journal of the American Geriatrics
Society; 50(3):496-500.
37
Figure 5. Distribution of HA Hospital Service Utilisation in the Last Year of Life for Patients
who Died in 2014
Growing Evidence Supporting the Development of

Palliative Care
With the introduction and adoption of an integrated approach in palliative care, more and more
evidence is available supporting the development of palliative care services. Both overseas and
local studies show that palliative care can improve pain and symptom control17,18,19, as well as
the overall quality of life18,20 during the patient’s last stage of life. Greater patients’ participation
is enabled as there is a greater respect for patients’ preference on treatment options19,20. At the
same time, it can reduce sufferings while forgoing invasive yet futile interventions20,21 and the
unnecessary use of acute care services, such as visits to emergency departments, admission
to acute care wards, and admission to intensive care units20,21. Furthermore, early palliative care
services are beneficial to the families/carers in reducing their stress burden22.
Palliative care is therefore not simply a concept, and there is clear evidence demonstrating its
role at both the patient and system level. Development of palliative care services has been
regarded as one of the top priorities in the healthcare policy agenda worldwide23,24, as well as
locally in HA.
17 Smith, T.J. & Cassel, J.B. (2009). Cost and non-clinical outcomes of palliative care. Journal of Pain and Symptom Management; 38(1):32-44.
18 Mueller, P.S. (2014). Community based specialist palliative care teams lead to less use of acute care at the end-of-life. Journal Watch General Medicine; 34(14):109-10.
19 Higginson, I.J. et al. (2003). Is there evidence that palliative care teams alter end-of-life experiences of patients and their caregivers? Journal of Pain and Symptom
Management; 25(2):150-68.
20 Temel, J.S. et al. (2010). Early palliative care for patients with metastatic non-small-cell lung cancer. New England Journal of Medicine; 363(8):733-42.
21 Tse, D.M.W. et al. (2007). The impact of palliative care on cancer deaths in Hong Kong: a retrospective study of 494 cancer deaths. Palliative Medicine; 21(5):425-33.
22 Dionne-Odom, J.N. et al. (2015). Benefits of early versus delayed palliative care to informal family caregivers of patients with advanced cancer: outcomes from the enable III
randomised controlled trial. Journal of Clinical Oncology; 33(13):1446-52.
23 National Palliative and End of Life Care Partnership, England. (2015). Ambitions for Palliative and End of Life Care: A National Framework for Local Action 2015-2020.
24 Department of Health and Ageing, Australia. (2010). Supporting Australians to Live Well at the End of Life: National Palliative Care Strategy 2010.
38
Recognition of Palliative Care Needs in Paediatrics

Death and dying is not limited to elderly people or adults. There were around 260 deaths of age
less than 18 in 2014 in Hong Kong. 83% of them occurred in HA. Though it only accounted for
less than 1% among all the deaths, such infrequency does not suppress the need for developing
palliative care to support paediatric patients and their families. Caring for a chronically ill or dying
child is an enormous and complex task25. When a child dies, it is one of the most traumatic
events a family can experience, with lasting physical and emotional effects26. Difference in
disease spectrum and importance in addressing the developmental needs are recognised as the
unique considerations in caring for sick children. However, the existing palliative care services in
HA focuses on supporting adult patients, with no structured development of paediatric palliative
care. Designated planning and development of service model for paediatric palliative care is
therefore warranted.
In this context, there is a pressing need to have coordinated planning at the system level so as
to better equip healthcare staff to address the challenges and improve the quality of palliative
care services in HA. The overall background also helps in guiding the focus and informing the
scope for formulation of the Strategic Service Framework for Palliative Care with an aim to drive
system and cultural change.
25 Davies, B. et al. (1998). Development of paediatric palliative care. In: Doyle, D. et al. (editors) Oxford Textbook of Palliative Medicine. Second edition. Oxford: Oxford
University Press, pp. 1011-117.
26 McSherry, M. et al. (2007). Psychosocial and spiritual needs of children living with a life-limiting illness. Paediatric Clinics of North America; 54:609-29.
39
Planning Process
How We Developed the Strategic Service Framework for
Palliative Care
Project Governance
Under the policy directions and guidance of the Medical Services Development Committee
(MSDC) and Directors’ Meeting, a designated Taskforce was set up to oversee the development
of the Framework. The Taskforce was co-chaired by the Director of Strategy and Planning
Division and the Director of Cluster Services Division of HA. The terms of reference and
membership of the Taskforce are set out in Appendix 1.
Under the Taskforce, Working Groups (Appendix 2 to 4) were formed to advise on the
future service models and required system infrastructure for adult and paediatric palliative care.
Discussions from the Working Group on Palliative Care Day Service of CC(Palliative Care) were
also brought back to the Taskforce to inform the development of the Framework. Moreover, to
enhance the organisation of palliative care services at Cluster level, a Subgroup (Appendix 5) was
set up with representatives nominated from each of the seven Clusters to identify their service
gaps and formulate Cluster-specific plans for enhancing the palliative care services in their
respective Clusters.
40
A project team from the Strategy and Planning Division provided the overall executive support
for developing the Framework. The governance structure of the project is illustrated in Figure 6.
Figure 6. Project Governance Structure
41
Formulation Process
The development of the Framework commenced in early 2016. The process consisted of review
on existing palliative care services, engagement of stakeholders, formulation and prioritisation of
strategies, consultation and approval. A highly participative and broad engagement approach
was adopted with the involvement of frontline clinical staff, Cluster management and Head
Office executives, as well as patient groups.
During the formulation process, literature review was conducted so as to understand the
development and service models of palliative care internationally. The project team also worked
closely with clinical colleagues on statistical analysis to evaluate the existing utilisation pattern of
palliative care services in HA and identify potential service gaps.
A Summit was conducted in which overseas experts from United Kingdom and Australia
shared their views and experience on palliative care. The Summit was attended by around
40 key stakeholders involved in the planning and delivery of palliative care services in HA,
including palliative care and non-palliative care specialist doctors, nurses and allied health (AH)
professionals, as well as executives from Cluster and Head Office. Themed discussions were
42
held during the Summit to gather ideas for informing the Framework’s development. A trip to
Taiwan was also arranged to gain exposure to the care model and practice of their palliative
care services. In addition, a series of Working Group and Subgroup meetings were held for
detailed discussion on the service models of adult and paediatric palliative care. Detailed plans
were also formulated by the Clusters for enhancing their respective palliative care services with a
focus on service organisation at the Cluster level.
In parallel, hospitals visits were carried out in all Clusters, which included palliative care facilities
covering inpatient, ambulatory and community care. Prior to the visits, a survey was conducted
to systematically collect information on the current service arrangement and facilitate in-depth
discussions during the visits. Furthermore, briefings were made to relevant Coordinating
Committees (COCs), Central Committees (CCs) and the Patient Advisory Committee (PAC), to
update members on the progress of the Framework formulation and seek their views and input.
All the findings and recommendations were put forward to the Taskforce for formulating the
Framework. Reports were also made to the Directors’ Meeting and MSDC on a regular basis,
with direction and advice sought from members.
Consultation on the draft Framework was conducted between 26 May 2017 and 22 June
2017, to solicit feedback and suggestions from key stakeholders. These included senior
management, frontline clinical staff, relevant COCs, CCs, their sub-committees and working
groups, other relevant committees, the PAC
and related patient groups. The responses
and comments received were carefully
considered and deliberated by the Taskforce.
Subsequently, the refined Framework was
submitted to the Directors’ Meeting for
endorsement, followed by the MSDC for final
approval.
43
PART T WO : Ad ul t Pal l i at i ve Care S er vices
Overview of Adult Palliative

Care Services in HA
What We Are Doing Now
Adult palliative care services in Hong Kong was first started by Our Lady of Maryknoll Hospital
in 1982. Between 1986 and 1988, another four hospitals, namely the Ruttonjee Sanatorium,
Haven of Hope Hospital, United Christian Hospital and Nam Long Hospital, also set up their
adult palliative care services. After the establishment of HA in 1991, there was a steady growth
of adult palliative care services in various public hospitals. Professional development also
advanced with the establishment of professional societies, including the Hong Kong Society
of Palliative Medicine and the Hong Kong Hospice Nurses Association in 1997, as well as
the accreditation of the subspecialty of Palliative Medicine under the Hong Kong College of
Physicians (HKCP) in 1998 and the Hong Kong College of Radiologists (HKCR) in 200227.
Currently, adult palliative care services in HA are mainly provided by PC teams in 16 hospitals.
The teams are led by palliative care specialists who are either working in the Department of
Medicine (medical PC teams) or the Department of Clinical Oncology (oncology PC teams).
Traditionally, oncology PC teams serve cancer patients only. Medical PC teams also used to
serve cancer patients, but they have been extending their services to non-cancer patients in
recent years due to patients’ needs. The list of PC teams in the different Clusters is shown in
the table below (Table 1).
27 Chan, K.S. (2002). Two decades of palliative care. Hong Kong Medical Journal; 8(6):465-466.
45
Table 1. PC Teams in HA
Oncology PC Team Medical PC Team
Hong Kong East Pamela Youde Nethersole Eastern Ruttonjee & Tang Shiu Kin Hospitals
Cluster (HKEC) Hospital (PYNEH) (RTSKH)
Hong Kong West Queen Mary Hospital (QMH) Grantham Hospital (GH)
Cluster (HKWC)
Kowloon Central Queen Elizabeth Hospital (QEH) Hong Kong Buddhist Hospital (HKBH)
Cluster (KCC) Our Lady of Maryknoll Hospital (OLMH)*
Tung Wah Group of Hospitals Wong Tai
Sin Hospital (WTSH)*
Kowloon East Cluster - United Christian Hospital (UCH)

(KEC) Haven of Hope Hospital (HHH)
Kowloon West Cluster Princess Margaret Hospital (PMH) Caritas Medical Centre (CMC)
(KWC)
New Territories East Prince of Wales Hospital (PWH) Bradbury Hospice (BBH)
Cluster (NTEC) Shatin Hospital (SH)
New Territories West Tuen Mun Hospital (TMH)

Cluster (NTWC)
* Re-delineated from KWC to KCC with effect from 1 December 2016
Both medical and oncology PC teams are available in all Clusters except KEC, in which
oncology service is yet to be fully provided. The oncology PC team of KCC is providing
cross-Cluster palliative care support to KEC patients. NTWC is the only Cluster where both
the medical and oncology PC teams are located in the same hospital. With the re-delineation
of Cluster boundary between KWC and KCC effective from 1 December 2016, the medical PC
teams in OLMH and WTSH have been regrouped from KWC to KCC.
46
Governance Structure
At the Head Office level, CC(Palliative Care) oversees the palliative care services in HA
and provides advice on service development. It comprises palliative care specialists, AH
representatives, nursing representatives and Head Office executives. Its membership and terms
of reference are set out in Appendix 6.
At the Cluster level, Cluster Coordination Committees on Palliative Care Services have been
established in all Clusters since 2013 to coordinate their respective palliative care services
according to the policy overlay set by CC(Palliative Care). Each Cluster Committee is led either
by the respective Cluster Chief Executive (CCE), Hospital Chief Executive or a Cluster Palliative
Care Service Coordinator nominated by the CCE. Medical representatives from palliative care
specialists (i.e. specially trained physicians and oncologists), nurses as well as AH professionals
are key members of the Committees. In some Clusters, representatives of non-palliative care
background, such as senior doctors from Medicine, Surgery and Anaesthesiology specialties,
are also involved in the Committees.
Key Members in Service Delivery

The provision of palliative care services in HA adopts a multi-disciplinary team approach to
address the multi-faceted needs of patients and their families/carers. Doctors, nurses, medical
social workers, clinical psychologists, physiotherapists, occupational therapists, dietitians, other
AH professionals, spiritual workers and volunteers work as a team to provide holistic care. As at
May 2016, there were over 40 doctors, 300 nurses and 60 AH full-time equivalent staff providing
specialist palliative care services in HA. This includes seven Nurse Consultants (NCs) who are
responsible for ensuring the nursing standards and protocols in palliative care in the respective
Clusters.
47
Service Scope
The scope of HA palliative care services
covers the continuum of care from hospital
to community settings. There are four main
service components, including inpatient and
consultative, ambulatory, community and
bereavement care.
Inpatient and Consultative

Palliative Care Service
As at 31 December 2016, there were over

360 palliative care beds in HA. Palliative care
inpatient services mainly provide services
to patients with complex symptoms and
psychosocial problems that require day-to-
day medical intervention. It also provides
services for the imminently dying patients.
Since many terminally ill patients in need

of palliative care are admitted to other
specialties (e.g. Medicine, Surgery) for
treatment, palliative care specialists also
provide palliative consultative service in
the wards of other departments for these
patients and their families/carers. Palliative
consultative services cover patients
hospitalised in other departments with
advanced progressive diseases, who have significant symptoms or complex psychological
problems that require palliative care but still under the care of the parent team.
48
Ambulatory Palliative Care Service
Ambulatory palliative care service includes

specialist outpatient clinics (SOPCs) and
day care services. It plays an important
role in facilitating early discharge of patients
and reducing unnecessary or avoidable
readmissions.
Specialist outpatient care is one of the important

pillars of palliative care. The outpatient clinics
provide support to terminally ill patients living in
the community with the presence of symptoms
that require specialist care for symptom
palliation and complicated psychosocial
problems relating to their disease.
M o re o v e r, H A h a s s e t u p a n u m b e r o f
palliative day care centres to strengthen
the different modalities of physical and psychosocial support for terminally ill patients and
their families/carers, including interventional therapeutic procedures and consultation, pain
management programme and psychosocial support programme. Working in partnership with
non-governmental organisations (NGOs), volunteers and the Patient Resource Centres (PRCs),
the palliative day care centres also organise a wide array of activities and provide volunteering
services to suit different needs of patients and their families/carers and improve their overall
well-being.
49
Community Palliative Care Service
Patients facing terminal illness and living in the

community often have difficulties commuting
to the hospital/clinic to receive ambulatory
treatment. They may also prefer to spend their
last stage of life in their familiar environment. In
this context, palliative home care service has
been playing a vital role to support patients
in the community and reduce unnecessary
hospitalisation. Palliative home care team is
an integral part of the HA palliative care services, providing outreach symptom management
and monitoring, psychosocial and spiritual care, ACP, care coordination, counselling and
bereavement support to patients in the community setting.
In addition to the support for patients living at home, in recent years HA has also strengthened
palliative care for elderly patients living in RCHEs through the Community Geriatric Assessment
Team (CGAT) service. Starting from 2015-16, an EOL care programme has been piloted by
CGATs to provide better support for terminally ill residents living in RCHEs. CGATs work in
partnership with the hospital PC teams, and collaborate with RCHEs and NGOs to enhance
the medical and nursing care of elderly residents facing terminal illness and to provide training
to RCHE staff. The programme started with four CGATs (RTSKH, FYKH, SH, TMH) in 2015-16,
and was extended to the CGATs of QEH/KH as well as CMC in 2016-17.
50
The EOL care programme is a tripartite collaboration among healthcare professionals, patients
and their families/carers, and RCHE staff. Suitable RCHE residents are identified by CGAT or
RCHE staff for CGATs’ assessment on the readiness of patients and/or their families/carers
for ACP discussion. The goals and preferences of care options for the patients’ final stages of
life are discussed with the patients and their families/carers during the ACP process. They are
documented in the RCHEs’ as well as the patients’ clinical records by the CGATs, with regular
reviews especially when there is a change in the patients’ condition. This facilitates communication
with stakeholders in different settings to provide care according to patients’ wish as far as
practicable. There is also coordination among HA departments (e.g. A&E and inpatient services)
and RCHEs so as to enable support at appropriate settings.
Evaluation of the programme has shown positive outcomes, with high adherence to the patients’
preference on care options according to ACP, including 95% adherence for DNACPR and 100%
adherence for refusal of tube feeding and ventilator support. Coordinated admission was also
arranged for around 60% of the patients from RCHEs where needed.
51
Psychosocial Care and Bereavement Service
HA has improved palliative care psychosocial services for terminally ill patients as well as
bereavement services for their families/carers by introducing a stepped-care service model in
2012-13, and strengthening services provided by medical social workers and clinical psychologists.
This involves early identification of patients and families/carers at higher risk of suffering from severe
psychosocial distress, and the provision of professional psychosocial and emotional intervention (e.g.
crisis intervention, psychotherapy, in-depth counselling, adjustment and coping empowerment).
Patients and families/carers’ needs are addressed and assessed using standardised assessment
measures throughout the patient journey, with attention given to those points known to be
particularly challenging, such as from curative to non-curative phase, at EOL/dying phase, and
after death (for families/carers). Practical and emotional support is offered according to their
needs. Those assessed to be of high risk will be referred to clinical psychologists for specialist
psychological intervention (e.g. psychotherapy, cognitive behavioural therapy). Families/carers
who require assistance with their bereavement will receive psychosocial support to facilitate a
normal grieving process and to prevent the occurrence of complicated grief or other detrimental
consequences of bereavement.
52
Other Supportive Services
Indispensable partners of the PC teams are volunteers, who generously offer their time, talents
and endless energy to support our patients. With appropriate training, they offer friendship
and practical help that improves the quality of life of adults and children living with a life-limiting
illness, and their families/carers. The social and emotional support they provide carries a
significant impact to the patients and their families/carers. Activities include experience sharing,
support groups, social functions (e.g. festival events, birthday party), visits to ward or home, etc.
HA regularly organises training programmes for volunteers so as to improve their knowledge and
skills in supporting terminally ill patients.
There are also various NGOs and patient groups actively supporting the provision of palliative
care. Examples of their services include recreational activities (e.g. game activities, family photo
taking, outing), promoting life and death education, complementary therapy (e.g. art therapy,
music therapy), organising various training workshops, as well as providing community support
for terminally ill patients and bereavement care for their families/carers.
53
Key Areas Identified for
Improvement in the Current Practice
What We Need to Improve on
A comprehensive review has been conducted on the adult palliative care services in HA to
identify areas for improvement, so that strategies could be formulated in the Framework to
address the issues. The process involved structured analysis of hospital survey return, a series
of hospital visits and Cluster-based discussion, as well as Working Groups and Subgroup
meetings. Four key areas for improvement have been identified: (i) governance and organisation
of service; (ii) care coordination; (iii) place of care; and (iv) performance monitoring.
Governance and Organisation of Service
Organisation of Palliative Care Services
At present, adult palliative care services are mainly department or hospital-based and are
divided into medical and oncology PC teams, which are usually located in different hospitals.
Cross-support between departments and hospitals is suboptimal under this service
organisation, which has led to variable access to palliative care services among hospitals as
well as among different types of patients. For hospitals that do not have their own PC team,
patients’ access to palliative care services is relatively limited.
Even for hospitals with a PC team, the coverage is limited by whether the team is led by the
medical or oncology department. For example, in a hospital with only an oncology PC team,
patients suffering from non-cancer diseases (i.e. non-cancer patients) and thus are not under the
care of the oncology department are less likely to receive palliative care services. Overall, the
palliative care coverage for non-cancer patients is lower than for cancer patients. According to
service data in 2012-13, around 68% of cancer patients had received palliative care, compared
to around 44% of patients suffering from end-stage renal failure (ESRF) who had received the
relevant service. This is because both medical and oncology PC teams serve cancer patients,
but non-cancer patients are covered mainly by the medical PC teams.
54
Moreover, the setup among different PC teams varies in terms of manpower establishment and
facilities. Cross-support and collaboration between PC teams are not common, which limits
the service development. For example, both the medical and oncology PC teams organise their
own home care teams as well as manage their own day care facilities. As such, patients under
the care of a medical PC team without day facilities cannot receive services provided in the day
centre operated by an oncology PC team in the same hospital/Cluster. Nursing manpower also
varies among the home care teams, leading to different levels of care provision to patients with
the same needs.
Role of Cluster Coordination Committee on Palliative Care

Services
Although Cluster Coordination Committees on Palliative Care Services are established in all the
Clusters, there is room to further enhance their roles in service coordination and development.
Some Cluster Committees are more active than the others, and demonstrate better linkage
between the Cluster Committees and CC(Palliative Care) at the corporate level. The service
development is usually better aligned with the policy direction in these Clusters.
Composition of the Committees varies among different Clusters. For instance, in some Clusters
the Committees have not involved the NC(Palliative Care) and AH professionals, who are
important players in the palliative care service. The Cluster management team or representation
from different hospitals within a Cluster is sometimes not involved in the Committees. It is
believed that the composition of the Cluster Coordination Committees has contributed to the
observed differences in palliative care services across different hospitals of the Clusters.
55
Care Coordination
Not all patients with life-limiting and life-threatening conditions who require palliative care are
under the care of palliative care specialists. In fact, the patients are mostly taken care of by
healthcare teams in other specialties, for example the surgical team in the management of
colorectal cancer patients; renal physicians in the management of chronic renal failure patients,
etc. These non-palliative care specialists are commonly referred to as the “parent team” of the
patients. Hence, care coordination is indispensable in the delivery of palliative care to meet the
patients’ needs, particularly between the palliative care and non-palliative care specialists.
Collaboration between Palliative Care and Non-Palliative Care

Specialists
Adult palliative care services in HA currently relies heavily on palliative care specialists, while
the majority of the non-palliative care specialists focus on providing curative care in managing
the disease conditions of their patients. Awareness and knowledge of palliative care are limited
among the non-palliative care specialists and they often hold on to the traditional hospice
concept, thinking that palliative care is a last resort to be provided at the last phase of life
when possible curative means are exhausted. This affects the timeliness and accessibility of
palliative care for patients requiring the service, including the initiation of discussion on ACP to
address patients’ needs and preference along the disease progression. Instead of integrating
palliative care in their practice, referrals are often made by the parent teams to the palliative
care specialists at the very end stage when curative or disease-modifying treatment is no longer
effective for a patient, and are mostly aimed at handing the patient over to the PC team for EOL
care. Meanwhile, due to limited service capacity, the PC teams have to prioritise their services
to cater for patients with more complex or imminent needs.
Collaboration between palliative care and non-palliative care specialists is only at the starting
phase in HA. Successful examples of recent initiatives include collaboration with renal physicians
on palliative care service for patients with ESRF, and the EOL care programme in RCHEs
through collaboration with the CGATs led by geriatricians. Other collaboration formats include
PC teams working with the surgical specialties to support cancer patients, and conducting joint
pain clinic with pain specialists or anaesthetists. Overall, there are still considerable gaps in the
service coverage and accessibility of palliative care, particularly for patients with non-cancer
conditions other than ESRF, such as cardiac, pulmonary and neurodegenerative diseases, and
dementia. The situation urges the development of a structured service model and key enablers
for better coordinated care.
56
Place of Care
Most of the patients prefer to be cared for at their usual place of residence where they can
take comfort in a familiar environment and being surrounded by their loved ones28. However,
service data shows that there are repeated A&E attendances and acute hospital admissions for
patients in their last year of life, especially during the last six months of life. Acute hospitalisation
may be stressful to the patients or their families/carers if the goal of palliation is unmet, and
put significant pressure on the healthcare system inappropriately. Limitations of palliative care
services in the ambulatory and community settings may have accounted for the high hospital
utilisation.
Day Care Setting
Although palliative day care services are available in all the Clusters, the target groups of patients
and service components are not aligned among them, resulting in variation in service provision.
While they all provide multi-disciplinary support for patients and their families/carers covering
their physical and psychosocial needs, some of the palliative day care centres put more focus
on the social and recreational aspects, such as educational activities and birthday or festival
celebrations. Meanwhile, the provision of therapeutic procedures such as abdominal tapping
and blood transfusion is available in only some of the palliative care day settings, because only
some of the hospitals have designated day beds for palliative care. Patients requiring these
procedures in the other hospitals will have to be admitted to the inpatient wards. There is a
need to delineate the roles of palliative day care service in the care pathway in order to allow
patients to continue staying in the community with their loved ones and reduce unnecessary
hospitalisation.
Community Setting
Both the medical and oncology PC teams organise their own home care teams, which limits
any possible synergistic effect, such as sharing of expertise and pooling of manpower. This
arrangement also affects the level of support and service coverage for patients with cancer or
non-cancer conditions residing in different parts of the Clusters.
28 Chung, R. et al. (2017). Knowledge, attitudes, and preferences of advance decisions, end-of-life care, and place of care and death in Hong Kong. A population-based telephone
survey of 1067 adults. Journal of the American Medical Directors Association; 18(4):367.e19-367.e27.
57
Meanwhile, there are some duplication between the existing palliative home care service and
the Community Nursing Service (CNS), which provides support to the discharged patients
requiring nursing care and treatment. The same patient may receive home visits made by both
the palliative home care nurse and CNS nurse. Therefore, there is a need to develop a clear
role delineation and collaborative model for patient-centred, coordinated and sustainable service
delivery.
The EOL care programme provided by CGATs in the RCHEs has shown positive outcomes
according to an evaluation, but barriers have also been identified, particularly the acceptance
and readiness of hospital staff, RCHE staff, patients and their families/carers with regard to
palliative care. Enhancement, such as education to raise awareness and knowledge of palliative
care, is required for expanding the programme.
Apart from the EOL care programme in RCHEs, there is generally a lack of structured
partnership with the social sector to provide palliative care support for patients in the community.
Although there are some collaboration with community partners, such as NGOs, patients groups
and volunteer services, the degree of linkage varies among PC teams, resulting in variable level
of support available to patients and families/carers. For instance, some PC teams provide the
information for patients and families/carers to access the community resources on their own,
while others link up patients with community resources through palliative care nurses or medical
social workers. More structured collaboration is required to better mobilise the community
resources and support patients in the community.
Performance Monitoring
Another key area for improvement relates to the systematic monitoring of palliative care services
in terms of quality and performance. Currently, the available data in our system are generally
quite inadequate for identifying service gaps and for benchmarking across units. The palliative
care services are mostly monitored on their service throughputs on a regular basis. With regard
to quality and performance monitoring, the PC teams use their local database on service
utilisation and outcome measurement of patients under their care, which are not aligned or
standardised across HA, and the data are captured manually. Moreover, different measurement
tools are adopted by different teams on symptom severity and functional performance.
Although CC(Palliative Care) has coordinated clinical audits and programme evaluation for the
service, standardised quality indicators have yet to be developed for systematic performance
monitoring and for informing service planning.
58
Strategic Service Framework for

Adult Palliative Care Services
What We Are Going to Do
Based on the key areas identified for improvement, and with reference to international practice
and local experience, a comprehensive strategic service framework is formulated for adult
palliative care. It is aimed at achieving the vision that all patients facing life-threatening and
life-limiting conditions and their families/carers will receive timely, coordinated and holistic palliative
care to address their physical, psychosocial and spiritual needs, and are given the opportunities
to participate in the planning of their care, so as to improve their quality of life till the end of the
patients’ life journey.
Strategic Framework
There are four strategic directions in the Framework. Under each direction, strategies are
formulated to address the existing issues and improve adult palliative care services in HA. Key
enablers are also identified to facilitate effective implementation of the Framework. The table
below summarises the Framework, while details of the strategic directions and strategies are
outlined subsequently in this chapter.
59
Areas for Improvement Strategic Directions Strategies
(What we can do better) (Where we are going) (How we will get there)
Governance and Enhance governance

• Strengthen collaboration between
Service Organisation by developing Cluster-
medical and oncology palliative care
based services with the
specialists to develop Cluster-based
collaboration of medical
services
and oncology palliative
care specialists • Reinforce the role of Cluster
Coordination Committee on Palliative
Care Services to support Cluster-
based service organisation
Care Coordination Promote collaboration

• Stratify patients’ palliative care needs
between palliative care
for shared care
and non-palliative care
specialists through • Integrate palliative care into the care
shared care model pathway for early identification of
according to patients’ patients in need and initiation of ACP
needs • Strengthen specialist palliative
consultative service in non-palliative
care settings
Place of Care Enhance palliative care

• Refine and align palliative care day
in the ambulatory and
service
community settings to
support patients and • Expand palliative home care service
reduce unnecessary • Enhance palliative care support to
hospitalisation elderly patients in care homes
• Enhance medical-social collaboration

to support palliative care in the
community
Performance Strengthen
• Enhance data collection with
Monitoring performance monitoring
standardisation of data capture and
for continuous quality
alignment of measurement tools
improvement
• Identify key domains and develop
indicators for evaluation and
monitoring of clinical outcomes and
service quality
60
Strategic Direction 1:
Enhance Governance by Developing Cluster-based Services
with the Collaboration of Medical and Oncology Palliative Care
Specialists
Enhancing the governance of adult palliative care services is the cornerstone of the overall
service development. The direction is set towards Cluster-based service organisation with
collaboration between medical and oncology palliative care specialists. This is in accordance
with the corporate direction outlined in HA Strategic Plan 2017-2022, which promotes the
development of Cluster/network-based services to improve collaboration between specialties
for more streamlined care, as well as to support the concentration of expertise and optimal use
of facilities. Key strategies are outlined below.
Strengthen Collaboration between Medical and Oncology Palliative Care

Specialists to Develop Cluster-based Services
In contrast with the existing department-based service arrangement, which is bounded by
specialty and hospital, a Cluster-based service organisation is envisioned for palliative care in
HA under the Framework. It is underpinned by collaboration between medical and oncology
PC teams, with clinical leadership from the palliative care specialists to support both cancer
and non-cancer patients in all hospitals of the Clusters. This enables the pooling and sharing of
expertise as well as optimal use of facilities and resources between the medical and oncology
PC teams for more accessible palliative care at the Cluster level.
In each Cluster, a coordinated service network covering inpatient, ambulatory and community
palliative care services is put in place to support all patients and families/carers in need. It is to
be facilitated through common clinical management protocols and multi-disciplinary guidelines,
regular sharing sessions between teams in terms of case conferences or joint ward rounds,
and joint training activities on palliative care for healthcare staff from different specialties and
hospitals in the Clusters.
61
Reinforce the Role of Cluster Coordination Committee on Palliative Care
Services to Support Cluster-based Service Organisation
While CC(Palliative Care) continues its role in overseeing the overall palliative care services at
the corporate level, its membership has to be reviewed to adopt Cluster-based representation
instead of the existing hospital-based composition. Structured linkage should also be
established between CC(Palliative Care), the Coordination Committees on Palliative Care
Services in the Clusters, as well as COCs/CCs of other relevant specialties and services to
coordinate the overall palliative care services in HA.
The existing Cluster Coordination Committees on Palliative Care Services have to be

empowered, with roles and accountability strengthened for the development of Cluster-based
services. The enhanced governance structure is aimed at improving the access to palliative care
for both cancer and non-cancer patients under the care of different specialties and hospitals in
the Clusters. The Committees are responsible for coordinating the service planning, resources
bidding, implementation and monitoring of palliative care services of their respective Clusters.
The membership of the Committees should therefore be reviewed and enhanced with
the inclusion of all relevant key stakeholders from the various disciplines and specialties,
including palliative care specialists, NC(Palliative Care) and AH professionals. In particular, the
involvement of Cluster management in the Committees is essential to facilitate the execution
of Cluster-based services in terms of governance, resources management and administrative
support. Representatives from hospitals with no PC teams, as well as other non-palliative care
specialties such as medical and surgical stream specialties, A&E and pain specialists should
also be considered. Meetings should be held regularly so that the roles and functions of the
Committees can be executed effectively.
62
Promote Collaboration between Palliative Care and Non-Palliative Care
Specialists through Shared Care Model According to Patients’ Needs
There is growing evidence worldwide supporting the partnership between palliative care and
non-palliative care specialists for the delivery of sustainable, timely and accessible palliative
care29. Moreover, capacity building is required through their collaboration using a shared care
model in order to cope with the escalating service demand. Instead of simply adding a layer of
specialist palliative care for every patient with a life-threatening or life-limiting illness, a needs-
based approach is advocated by matching the appropriate level of service response to the needs
of patients and with the participation of non-palliative care specialists30. Key strategies relating to
the shared care model are outlined below.
Stratify Patients’ Palliative Care Needs for Shared Care

Patients are stratified for shared care between palliative care and non-palliative care specialists
according to their level of needs, their disease complexity and the professional competency of their
care teams in palliative care, as illustrated in Figure 7.
Figure 7. Shared Care Model between Palliative Care and Non-Palliative Care Specialists
Coordinated, timely and

appropriate palliative care Specialist palliative care through
Care by holistic and multi-disciplinary
Stratify patients according to: palliative care approach
• Level of needs specialists
(Medical & Oncology)
• Disease complexity
• Professional competence
Input from palliative care
Shared care by specialists to support parent
palliative care and teams for patient care
non-palliative care specialists
Disease management with

palliative care approach
• Identify palliative care needs
Care by non-palliative • Initiate advance care
care specialists planning
29 Quill, T.E. et al. (2013). Generalist plus specialist palliative care – creating a more sustainable model. New England Journal of Medicine; 368:13.
30 Palliative Care Australia. (2005). A Guide to Palliative Care Service Development: A Population Based Approach.
63
Under the shared care model, majority of
the patients whose palliative care needs
a re n o t c o m p l e x a re c o n t i n u e d t o b e
taken care of by the parent teams for the
basic management of pain, other physical
symptoms and psychosocial problems. For
cases with complex palliative care needs
but still requiring active input from the parent
teams on managing the disease conditions
and hence have to remain under the care of non-palliative care specialists, they are co-managed
by both the parent teams and palliative care specialists for holistic care through consultative
support, case conferences, and joint clinics or ward rounds. Only patients with highly complex
palliative care needs or difficult symptoms are taken care of by the palliative care specialists
in a palliative care setting. This way, timely and appropriate level of service is provided to all
patients requiring palliative care at any stage in a serious illness, ranging from symptom control,
psychosocial support, care at the end of life, to bereavement support for families/carers.
Dynamic changes occur in the patients’ condition as well as their level of needs. The model
acknowledges these changes and stresses the importance of stratification to the appropriate
care team according to the patients’ changing needs. This is enabled by structured referral
mechanism and detailed referral criteria. Link nurses are identified in the non-palliative care
settings as a contact point to facilitate care coordination and the integration of palliative care into
the practice of different specialties.
Integrate Palliative Care into the Care Pathway for Early Identification of
Patients in Need and Initiation of ACP
For the shared care model to work, palliative care has to be integrated into the care pathway
of patients suffering from a life-threatening or life-limiting illness regardless of the specialties of
their care team. According to WHO, it is an ethical duty for healthcare professionals to provide
palliative care for patients in need31. With training and skills transfer, all healthcare professionals
working in non-palliative care settings, especially the parent teams who are managing the
patients’ disease conditions should be able to identify the palliative care needs of patients and
their families/carers. Clinical triggers such as the surprise question (i.e. “would you be surprised
64
if this patient were to die in the next six to 12 months?”), general indicators of decline in terms
of deteriorating physical conditions and functional performance, as well as disease-specific
indicators for cancer and end-organ failure conditions are important tools to help proactive
identification and triggering of palliative care support32.
It is also the responsibility of the parent team to initiate ACP discussion with patients and
their families/carers. The ACP facilitates communication on the anticipated progression and
prognosis of the disease, discussion on available treatment options, and expression of wishes
and preferences by the patients and families/carers for future medical or personal care, such as
place of care, treatment and feeding options as well as AD on refusal of life-sustaining treatment.
Positive outcomes of ACP include improved patient satisfaction, reduced unnecessary
sufferings, and enhanced concordance with patient and family wishes33. Documentation with
regular reviews and ongoing discussion is required along the care journey.
Strengthen Specialist Palliative Consultative Service in Non-Palliative Care

Settings
Palliative consultative service by specialist PC teams has to be strengthened as a key
component of the shared care model. It is instrumental to provide proper support to the parent
teams when they encounter difficulty in managing patients with palliative care needs. It has
been shown to be effective in improving patient experience, reducing readmission and facilitating
hospital discharge34,35.
The PC consultative team consists of palliative care specialist, palliative care nurse and
AH professional, in particular medical social worker. They serve as a mobile team for the
co-management of patients with the parent teams in non-palliative care settings. The scope
of consultative services includes symptom management, joint ACP, discharge planning with
coordination of post-discharge care, anticipatory prescribing at end of life and carer support for
relatively complex cases.
It is a priority to provide palliative consultative service to those hospitals with no PC teams

and for those patients with non-cancer conditions such as end-stage organ failure in order to
address the existing service gaps.
32 Thomas, K. et al. (2011). Prognostic Indicator Guidance. Shrewsburg: The Gold Standards Framework Centre in End of Life Care Community Interest Company.
33 Henry, C. et al. (2007). Advance Care Planning: A Guide for Health and Social Care Staff. London: Department of Health.
34 Gade, G. et al. (2008). Impact of an inpatient palliative care team: a randomised controlled trial. Journal of Palliative Medicine.
35 Hospital Authority Convention. (2015). Nurse Consultant Consultative Services to Yan Chai Hospital.
65
Enhance Palliative Care in the Ambulatory and Community Settings
to Support Patients and Reduce Unnecessary Hospitalisation
It is important to provide palliative care support to patients and their families/carers in the
community in order to facilitate care in place and reduce unnecessary hospitalisation, which
helps to relieve the stress of both patients/carers and the healthcare system. The emphasis
is on enhancing day care, home care, support to residential care homes, and community
partnership, with strategies as outlined below.
Refine and Align Palliative Care Day Service

Palliative care day service provides one-stop integrated and multi-disciplinary care. Its service
model is aligned within and across Clusters in order to better support both cancer and
non-cancer patients living in the community. Its service components are also refocused to
provide interventional therapeutic procedures and programme-based services. Examples of
the therapeutic procedures include administration of intravenous fluid and medication, blood
transfusion, as well as chest and abdominal tapping. Protocol-based programmes that are
developed with defined selection criteria and discharge mechanism include those for symptom
control such as pain, dyspnea and fatigue management; and for rehabilitation purpose such as
metastatic spinal cord compression. By providing timely and fast track support to patients with
symptoms and needs that can be handled in day settings, palliative care day service enables
patients to stay in the community, avoiding unnecessary hospitalisation.
66
Expand Palliative Home Care Service

Palliative home care service should be
expanded to cope with the growing
service demand in the continuity of care
for discharged patients who have relatively
complex palliative care needs and are not
fit to attend ambulatory care programmes.
A case management approach is adopted
with palliative home care nurses as the care
coordinators. Patients are triaged using
standard assessment before appropriate
services are arranged, with the level of care defined in terms of the frequency and duration
of home visits. Services such as on-site assessment and intervention, carer support, phone
consultation and coordinated admission are provided according to patient needs.
The home care teams are organised as Cluster-based teams to support both cancer and
non-cancer patients residing in different districts of the Clusters. The teams are supported by
palliative care specialists and AH professionals for the delivery of trans-disciplinary care. There
is also collaboration between palliative home care nurses and CNS nurses, with role delineation,
bi-directional skills transfer and close cooperation under the principle of shared care model as
set out previously. Referral mechanism and structured communication platforms are needed
to facilitate cross-support between the palliative home care nurses and CNS nurses for the
provision of coordinated and appropriate care to discharged patients.
Enhance Palliative Care Support to Elderly Patients in Care Homes

The plan is to further expand the CGAT EOL care programme to more RCHEs, so that it is
extended to cover more patients in all the Clusters. To address the barriers identified during the
pilot, collaboration between CGAT and PC teams as well as coordination within the hospitals
needs to be strengthened. This includes skills transfer from the PC teams to CGAT and RCHEs
staff through structured training, clinical attachment and on-site coaching. Referral mechanism
should also be established for the management of complex cases through regular case
conference and joint visits.
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Enhance Medical-social Collaboration to Support Palliative Care in the
Community
Community resources should be better
mobilised to complement the palliative care
services in HA. This is carried out through
enhanced collaboration with community
partners such as NGOs, patient groups
and volunteers to support patients and
families/carers in the community, especially
with regard to personal and social care,
patient and carer empowerment, and public
education. Examples of support services provided by community partners include escort
service, equipment loan, respite care, haircut, bathing, meal preparation, celebration activities
(e.g. birthday and festival celebrations), practical help in funeral proceedings, peer support
groups and other psycho-spiritual support.
In addition to linkage through palliative

care nurses and medical social workers,
the role of PRCs in HA hospitals should
also be strengthened to act as a bridge
between the clinical teams and community
partners in helping patients and families/
carers to access the community resources.
Building on the experience from the EOL
care programme in RCHEs, more structured
collaboration with NGOs and Social Welfare Department is to be developed to promote
coordination between the medical and social sectors at the system level.
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Strengthen Performance Monitoring for Continuous Quality
Improvement
Systematic monitoring of the quality and outcomes of palliative care services is instrumental to
drive service improvement. Strategies include enhancing data collection and developing quality
indicators for continuous performance monitoring.
Enhance Data Collection with Standardisation of Data Capture and

Alignment of Measurement Tools
Along the palliative care pathway, there are various data concerning the structure, process,
output and outcome of the service. Apart from throughputs data, other useful parameters
for performance monitoring should also be deliberated and agreed upon for systematic data
capture. Standardisation of data definition and collection mechanism is crucial to ensure high
quality of source data for further analysis. Instead of relying on local manual return, automated
system should be put in place to facilitate systematic data collection. For those parameters
requiring measurement tools, such as symptoms severity and performance status, alignment of
measurement tools is required so as to allow benchmarking across HA.
Identify Key Domains and Develop Indicators for Evaluation and Monitoring
of Clinical Outcomes and Service Quality
Key domains should be identified for the evaluation and monitoring of clinical outcomes and
service quality, taking reference to local and international guidelines on outcome monitoring
of palliative care services. Examples include patient and carer satisfaction, symptoms control
and functional performance, service utilisation as well as coverage of and compliance to ACP.
Benchmarking of these parameters helps to avoid inconsistency in service provision among
Clusters. When the measuring parameters and tools are mature and widely adopted, they could
be developed as quality indicators for outcome monitoring at both the Cluster and corporate
level.
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The Future Service Model for Adult Palliative Care
Under this Framework, HA is moving towards the vision of providing timely, coordinated and
holistic palliative care to patients and families/carers in need. Specialist adult palliative care
services will be organised in a Cluster-based arrangement, with strengthened governance
through closer collaboration between medical and oncology PC teams. Timely and coordinated
palliative care is achieved through shared care between palliative care and non-palliative care
specialists. And palliative care is integrated into the care pathway of patients suffering from a
life-threatening or life-limiting illness regardless of the specialties of their care team. Moreover,
ambulatory and community palliative care services are enhanced to support care in place and
reduce unnecessary hospitalisation. Overall, performance monitoring is strengthened to facilitate
service improvement. The new service model of adult palliative care in HA is illustrated in
Figure 8 below.
Figure 8. Future Service Model of Adult Palliative Care in HA
Cluster-based service with enhanced governance and collaboration

between medical and oncology palliative care specialists
Identification of
Coordinated Care in place with
patients with Advance care palliative care support from
palliative care planning through shared hospital to
needs by parent
care approach community
teams
Palliative care as an integral part of the care continuum to support patients and their families/carers
Underpinned by strengthened performance monitoring
Key Enablers
Various key enablers are identified to facilitate the development of the above service model and
support effective implementation of the Framework strategies. These include manpower and
training, facilities, logistic support in hospital wards, information technology (IT) support, and
transport.
70
Manpower and Training

Training is fundamental to drive system and cultural change in integrating palliative care into the
care continuum. It has to be conducted through a system approach and by targeting healthcare
staff from both palliative care and non-palliative care settings, with the collaboration among HA,
academic and professional organisations.
Firstly, basic training for all healthcare staff across disciplines and specialties is needed to raise
their general knowledge and awareness of palliative care. It covers the basic principles and
ethical concepts of palliative care and ACP, as well as communication skills and practical care for
supporting patients along the disease trajectories. It can be in the form of seminars, tutorials and
workshops for introducing and explaining the concept to both professional and supporting staff.
Secondly, there is advanced training for non-palliative care teams working directly with patients
who are suffering from life-threatening or life-limiting illnesses. It is aimed at skills transfer
to build up competency of the teams in implementing the shared care model. It focuses on
skill-sets for ACP discussion, symptom management and bereavement care through clinical
attachment, rotation, direct coaching and case conference.
Thirdly, specialist training programmes will be continued to consolidate the provision of specialist
palliative care services in the system. They are provided by the HKCP and the HKCR for
medical and oncology palliative care subspecialty training respectively. For nurses, the Institute
of Advanced Nursing Studies in HA organises Post-registration Certificate Course in Palliative
Care Nursing. As regards AH professionals, designated training programmes are developed
and coordinated by HA’s Institute of Advanced Allied Health Studies for staff working in palliative
care settings.
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At the same time, detailed workforce planning for doctors, nurses and AH professionals is vital
to meet the escalating service demand. A Cluster-based perspective of workforce planning and
deployment is required to support the Cluster-based model. Manpower reference for inpatient,
ambulatory and community palliative care has to be developed to inform service planning and
resources allocation. Apart from manpower strength, the reporting line and career path for
professional development are also important areas to be worked out.
Facilities
Physical design for facilitating the delivery of palliative care is incorporated into the hospital
development and redevelopment projects in HA. Home-like, peaceful and soothing environment
are the general design principles for palliative care facilities to relieve stress and improve
perception of care. This can be achieved by paying attention to the quality of lights, use of
colour, selection of furniture, and the needs of different religions and beliefs. Provisions of
facilities for families/carers, sensory gardens and social space are also some of the important
physical elements, which allow various social activities and events to be held for patients and
their families/carers during patients’ hospitalisation.
Single rooms offering choice for patients approaching end of life with more privacy, as well as
interview rooms where patients and families/carers can engage in more intimate discussion
should be made available in both palliative care and non-palliative care settings of all hospitals.
The design of mortuaries is another area to be improved on, which will affect the experience and
memories of patients’ families/carers. In particular, the design for the circulation areas, viewing
72
rooms and ceremony rooms in the mortuaries should convey a sense of reverence and respect
for life. Modernisation of the overall design of mortuaries is also required to better suit the
operational workflow and the needs of families/carers.
In addition to the design, capacity planning covering inpatient and ambulatory facilities for
palliative care is to be put in place to cope with the projected service demand and take into
consideration changes in the service model. In view of the existing variation across hospitals in
HA, it is advisable to categorise palliative care beds as “convalescent/rehabilitation” bed type in
the system when opening new palliative care beds. CC(Palliative Care) will work with the Cluster
management for the alignment in future planning.
Logistic Support in Hospital Wards

The logistics and operations of the hospital wards should be designed to cater for the needs
of patients and their families/carers. Consideration should be given to individual patients’
conditions, including their psychosocial and emotional needs, especially during their last phase
of life. Flexible visiting hours are introduced so that patients can spend more time with their
loved ones. Arrangement can also be made for families/carers to stay overnight with the
patients if hospital operation allows.
IT Support
IT support is required to enable implementation of the Framework. There is a need to enhance
the IT system to support the workflow, communication and care coordination across disciplines,
specialties and care settings along the palliative care journey, especially between palliative care
and non-palliative specialists, as well as between home care teams and CGAT. Building up a
common platform for the documentation of ACP is also important for clinical communication
and ongoing reviews. A database of palliative care patients has to be set up to facilitate the
identification of patients, care management as well as performance monitoring at both clinical
and system level. Furthermore, the development of tele-care, mobile apps and website support
should be explored to support care in place and empowerment of patients and families/carers.
Transport
Along with the development of ambulatory care, transportation support for patients such as
Non-emergency Ambulance Transfer Service is required to be strengthened. This way, patients
can attend the day care programme in a more accessible manner, and the day service is
more optimally utilised. Moreover, transportation support is also important to facilitate hospital
discharge and the transfer of patients between hospitals or to RCHEs.
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To address the challenges and improve the quality of adult palliative care services,
each Cluster has formulated a service plan in accordance with the overall strategic
directions of this Framework. The plans set out the Clusters’ local priorities to
facilitate implementation of the strategic directions, with a focus on enhancing service
delivery through Cluster-based organisation.
Sequence of the Plans

• Hong Kong East Cluster
• Hong Kong West Cluster
• Kowloon Central Cluster
• Kowloon East Cluster
• Kowloon West Cluster
• New Territories East Cluster
• New Territories West Cluster
74
Hong Kong East Cluster

Current Palliative Care Services Arrangement
2 4
3
Eastern 1
Wan Chai
Islands (excluding Lantau Island)
1. Pamela Youde Nethersole Eastern 4. Tung Wah Eastern Hospital 7. Wong Chuk Hang Hospital
Hospital + 5. St. John Hospital + Hospitals with A&E service are marked with the
2. Ruttonjee Hospital + 6. Cheshire Home, Chung Hom Kok symbol +
3. Tang Shiu Kin Hospital
Palliative care services in the Hong Kong East Cluster (HKEC) are provided by the oncology
PC team of Pamela Youde Nethersole Eastern Hospital (PYNEH) and the medical PC team of
Ruttonjee & Tang Shiu Kin Hospitals (RTSKH). The scope of services is shown in the table below:
Service Scope of PC Teams in HKEC

PYNEH RTSKH
Service Type
Inpatient
Consultative
Outpatient
Day
Home
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There are no PC teams in the other hospitals of HKEC, namely Tung Wah Eastern Hospital
(TWEH), St. John Hospital (SJH), Cheshire Home, Chung Hom Kok (CCH) and Wong Chuk
Hang Hospital (WCHH). Patients of these hospitals can access palliative care services through
the parent teams’ referral to the PC teams in PYNEH and RTSKH.
Palliative Care Day Centre in PYNEH
Palliative Care Ward in RTSKH
Key Challenges in Palliative Care Services Arrangement
Currently, the provision of palliative care services in HKEC mainly focuses on cancer patients.
Palliative care support for patients with non-cancer conditions is generally limited. Structured
palliative care service programme is only available for renal patients in PYNEH and RTSKH, while
a pilot service for pulmonary disease patients in RTSKH has been initiated recently. Palliative
care day services are provided to both cancer and non-cancer patients in RTSKH, but the
access is limited for non-cancer patients in PYNEH as the relevant services are serving cancer
patients only. The coverage of palliative care services for other hospitals in HKEC is very limited
due to the lack of outreaching services under the current service arrangement.
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Strategies
Governance: Cluster-based Service Organisation with Collaboration between

Medical and Oncology Palliative Care Specialists
Governance under the HKEC Coordination Committee on Palliative Care Services will be
enhanced with the membership widened to include representatives from PYNEH medical
nursing staff, the A&E departments of PYNEH and RTSKH, and from TWEH. Regular
performance monitoring will also be carried out by the Committee.
The collaboration between the two PC teams will be strengthened. Joint guidelines and
protocols will be developed and shared at the website of the Cluster Coordination Committee
on Palliative Care Services. Joint case conference will be conducted to facilitate communication
and learning. Staff rotation and joint training arrangement, for example in nurse training, will be
strengthened.
Care Coordination: Collaboration between Palliative Care and Non-Palliative

Care Teams
The two PC teams will strengthen palliative care consultative service by establishing a
Cluster-based palliative care consultative team. In collaboration with the Departments of
Medicine of PYNEH and TWEH, link nurses will be identified in these departments to act as
contact point with the PC teams to support the implementation of shared care model. Staff
training will be enhanced to support this arrangement, for example, through clinical attachment
of nurses in the medical wards of Cluster hospitals to the RTSKH PC team.
Collaboration of PC teams with the A&E departments of PYNEH and RTSKH will be enhanced
for streamlining admission and facilitating the process of death certification of patients under
palliative care. Staff training for pain and symptom control at A&E will be conducted. There
will also be collaboration with SJH to better support the palliative care needs of patients who
are living in Cheung Chau or Islands. Follow-up care with medication support and procedures
could be arranged at SJH, with support provided by the PC teams so as to minimise travelling
of patients and families/carers especially at the end stage of life.
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Place of Care: Enhanced Ambulatory and Community Palliative Care
Cluster-based home care team covering cancer and non-cancer patients will be established.
There will be enhancement in collaboration via joint home care protocols and case conference.
Telephone support will be strengthened. Partnership with CNS and CGAT will be established
with structured communication channel, as well as guideline on logistics and shared care.
Access to palliative care day service will be improved, especially for non-cancer patients
in PYNEH. PRCs will be utilised as a platform for linking up the community resources and
empowerment of patients and families/carers, including education on ACP for patients with
organ failure, in collaboration with the Department of Medicine in PYNEH.
Prioritisation of Strategies
Priority Strategies
Short-term • Enhance governance by reviewing the membership of the HKEC

Coordination Committee on Palliative Care Services
• Develop and implement palliative care guidelines and protocols jointly

by the PC teams of PYNEH and RTSKH
• Conduct joint case conference, and staff training and rotation

between the PC teams of PYNEH and RTSKH
Medium-term • Provide basic palliative care training to the medical staff in PYNEH
and TWEH
• Identify link nurses in the medical wards of PYNEH and TWEH as

contact point with the PC team to support shared care model
• Establish Cluster-based palliative care consultative team and home

care team in HKEC
• Conduct patient education on ACP using PRCs as a platform
• Strengthen PC teams’ collaboration with A&E in PYNEH and RTSKH
• Enhance palliative care support for SJH
Long-term • Improve access to palliative care day service for non-cancer patients
in PYNEH
78
79
Hong Kong West Cluster
Central &
Western
4
1
5
Southern 3
1. Queen Mary Hospital + 4. Tung Wah Group of Hospitals Hospitals with A&E service are marked with the
Fung Yiu King Hospital symbol +
2. Tung Wah Hospital
3. Grantham Hospital 5. MacLehose Medical Rehabilitation
Centre
Palliative care services in the Hong Kong West Cluster (HKWC) are provided by the oncology PC
team of Queen Mary Hospital (QMH) and the medical PC team of Grantham Hospital (GH). The
scope of services is shown in the table below:
Service Scope of PC Teams in HKWC
QMH GH
Service Type
Inpatient
Consultative
Outpatient
Day
Home
80
There are no PC teams in the other

hospitals of HKWC, namely Tung
Wah Hospital (TWH), Tung Wah
Group of Hospitals Fung Yiu King
Hospital (FYKH), and MacLehose
Medical Rehabilitation Centre
(MMRC). Patients of these hospitals
can access palliative care services
through the parent teams’ referral to Multi-disciplinary PC Team in QMH
the PC teams in QMH and GH.
Multi-disciplinary PC Team in GH
The provision of palliative care services in HKWC is mainly focused in QMH and GH. There is a
need to strengthen the service coverage for other hospitals without a PC team. The palliative
care support to non-cancer patients in the Cluster is also limited, especially for renal, chronic
obstructive pulmonary disease (COPD) and chronic heart failure patients.
The palliative care day centre in QMH is currently utilised by cancer patients only. Enhancement
of day service provision in the Cluster is required to address patients’ needs. For palliative home
care, the service is currently provided by separate teams under the PC teams of QMH and
GH. Better arrangement is required to improve palliative home care support to patients in the
community.
81
Strategies

The HKWC Coordination Committee on Palliative Care Services comprises palliative care and
non-palliative care specialists, nursing and AH staff. To strengthen the governance and enhance
the executive and administrative support for service development, senior Cluster management
will also be included in the membership of the Committee.
To strengthen collaboration between the medical and oncology PC teams, clear role delineation
will be established on service coordination. The QMH oncology PC team will coordinate the
palliative care services for cancer patients as well as the palliative care day services. Palliative
care services for non-cancer patients and the home care services will be coordinated by the GH
medical PC team.
Service alignment among the PC teams will be further enhanced by joint protocols and
multi-disciplinary guidelines such as nursing guidelines on the care of terminally ill patients.
Regular case conferences will be conducted for discussion, and complicated cases will be
managed by joint ward round and consultative visits in both medical and oncology palliative care
wards. The PC teams will also have regular collaboration in training and patient empowerment.
To better meet the needs of non-cancer patients in the Cluster, palliative care outpatient services
in QMH will be expanded to support non-cancer patients.
In view of the redevelopment of GH which will include the establishment of a new cancer centre,
there will be joint planning and delivery of palliative care services by the QMH and GH teams, to
optimise the opportunity of these capital projects for meeting the service needs of the Cluster.
82

Care Teams
A Cluster-based palliative care consultative team will be set up in HKWC to extend the service
coverage to TWH, MMRC and FYKH. Regular Cluster case conference will also be conducted
for collaboration between palliative care and non-palliative care specialists, with involvement of
representatives from all hospitals in the Cluster.
To improve the care provision for patients in non-palliative care settings, link nurses will be
identified as the contact point for service coordination. Skills transfer and training will be
provided to non-palliative care teams and will be extended to the non-cancer specialties. The
training will also facilitate parent teams to make referrals to specialist palliative care according to
patients’ needs.
Currently, palliative care nurses in the consultative team are playing an important role in the
ACP programme. The programme will be enhanced to cover all hospitals in HKWC especially
for support to non-cancer patients including those with end organ failure. The team will also
provide consultative and specialist palliative care support to the link nurses, and conduct training
for non-palliative care staff.
83
Palliative home care services in HKWC will be provided by a Cluster-based team under the
coordination of the GH medical PC team. The home care service acts as a link between
hospital and community care, supporting both cancer and non-cancer patients in the Cluster.
The service provision will be arranged on a district basis, with collaboration with CNS and CGAT
to enhance the care coordination for patients according to their needs.
To better support patients staying in the community, telephone hotline support will be extended
beyond office hours. The PC team will provide information and authorise the arrangement of
admission to the ward of the parent team as required. Alignment and communication among
the home care team will be enhanced through regular case conferences, joint protocols
and training. There will also be discussion on pairing up logistics of home care nurses for
on-leave support. Regarding the provision of palliative care day services, Cluster-based service
arrangement will be adopted to ensure that it is accessible by both cancer and non-cancer
patients in all hospitals of the Cluster.
Priority Strategies
Short-term • Enhance Cluster-based governance with the involvement of Cluster

management and collaboration between the medical and oncology
palliative care specialists in GH and QMH
• Develop joint protocol and multi-disciplinary guidelines
• Conduct regular Cluster home care case conference
Medium-term • Develop Cluster-based home care team in HKWC, with collaboration

with CNS and CGAT
• Set up a Cluster-based consultative team and enhance coverage for

TWH, MMRC and FYKH, with palliative care nurse consultation and
palliative care link nurse to support service and training
• Arrange palliative care day services in a Cluster-based manner,

accessible by both cancer and non-cancer patients
• Strengthen service provision to non-cancer patients in the Cluster by

expanding palliative care outpatient services in QMH
Long-term • Conduct joint service planning and delivery between the medical and
oncology PC teams of GH and QMH, taking into account of the GH
redevelopment and establishment of a new cancer centre
84
85
Kowloon Central Cluster
6
5
Wong Tai Sin
2
Kowloon City
Yau Tsim Mong
1. Queen Elizabeth Hospital + 4. Kwong Wah Hospital + Hospitals with A&E service are marked with the
symbol +
2. Kowloon Hospital 5. Our Lady of Maryknoll Hospital
3. Hong Kong Buddhist 6. Tung Wah Group of Hospitals
Hospital Wong Tai Sin Hospital
Palliative care services in the Kowloon Central Cluster (KCC) are provided by the oncology
PC team of Queen Elizabeth Hospital (QEH) and the medical PC teams of Hong Kong
Buddhist Hospital (HKBH), Our Lady of Maryknoll Hospital (OLMH) and Tung Wah Group of
Hospitals Wong Tai Sin Hospital (WTSH). The PC teams of OLMH and WTSH were regrouped
from Kowloon West Cluster to KCC in December 2016 due to re-delineation of the Cluster
boundaries.
The Department of Medicine of QEH also provides palliative care services (including inpatient,
consultative, outpatient and day care services) which are supported by non-palliative care
specialists. The scope of services provided by the KCC PC teams is shown in the table below:
86
Service Scope of PC Teams in KCC
QEH HKBH OLMH WTSH

Service Type
Oncology PC Team Medical PC Team Medical PC Team Medical PC Team
Inpatient
Consultative
Outpatient
Day
Home
Life Celebration Party for Patients in QEH Multi-disciplinary PC Team Case Conference in HKBH
Quiet Room in OLMH Occupational Therapy Session in WTSH
There are no PC teams in the other hospitals of KCC, namely Kowloon Hospital (KH) and Kwong
Wah Hospital (KWH). Patients of these hospitals can access palliative care services through the
parent teams’ referral to the PC teams in QEH, HKBH, OLMH and WTSH.
87
Currently, there is limited palliative care consultative service in KCC, with no service provision to
KWH and KH. In QEH, the palliative care consultative service for patients in the medical wards
is supported by renal and respiratory specialists. There is also a need to enhance the palliative
care SOPC services in the Cluster, especially for non-cancer patients. Palliative care nurse
clinics are currently available in QEH and OLMH only.
Under the current service arrangement, there are multiple medical PC teams in KCC including
HKBH, OLMH and WTSH. However, they all have limited number of palliative care specialists,
and only OLMH has been accredited as a Palliative Medicine training centre under the HKCP at
the moment. Their service organisation needs to be improved in order to enhance collaboration
and facilitate the service and professional development of medical palliative care.
Strategies

The KCC Coordination Committee on Palliative Care Services comprises Cluster management,
palliative care and non-palliative care specialists, nursing and AH staff. Representatives from
OLMH, WTSH and KWH have been included in the membership recently to facilitate palliative
care service planning and development of the whole Cluster.
Over the years, KCC has adopted an integrated model for inpatient palliative care service which
is provided at HKBH by the medical and oncology palliative care specialists. Clinical guidelines
on palliative care are also shared among different PC teams. This integrated service model will
88
be further developed in the Cluster to promote close collaboration between the medical and
oncology palliative care specialists. Besides continuation of the integrated inpatient palliative
care service at HKBH, integrated grand round and case conferences will also be established
by PC teams in the Cluster. The medical and oncology palliative care specialists will jointly run
the Cluster-based SOPC services at KWH and WTSH. The PC teams will also provide Cluster-
based palliative care consultative services to the Cluster hospitals and set up palliative care
nurse clinics to improve the service coverage.
Medical palliative care services in KCC will be provided in a Cluster-based manner through the
pooling of teams in HKBH, WTSH and OLMH. The arrangement will also help in facilitating the
accreditation of training centre under HKCP to support professional development and sustain
the service development in the Cluster.

Care Teams
Collaboration between palliative care and non-palliative care teams in the Cluster will be
enhanced by adopting a shared care model between the palliative care consultative team and
the parent teams. The consultative service will be provided under the concept of joint ownership
of patients to ensure appropriate care according to patients’ needs. It will be extended to QEH
medical wards, KWH and KH in a stepwise approach. Furthermore, parallel clinics will be set up
with the KWH medical SOPC to enhance collaboration in the provision of care.
89
A Cluster-based palliative home care team will be set up in KCC with two sub-units located in
HKBH and OLMH. The home care team will serve both cancer and non-cancer patients in the
Cluster, supported by medical and oncology palliative care specialists. The sub-units in HKBH
and OLMH will be under the same reporting line. Common protocols will be shared and joint
training will also be organised to facilitate service collaboration and alignment. The telephone
hotline support provided by home care nurses will be strengthened, and direct clinical admission
by the home care team will be coordinated. Collaboration with CNS and CGAT will also be
enhanced to improve care coordination and avoid service duplication. For highly selected cases
after discussion at case conference, home visits could be provided by AH professionals and
doctors.
Regarding the provision of palliative day care services in KCC, improvements will be made in the
alignment of the services in QEH, WTSH and OLMH. The feasibility of an additional palliative
care day centre in HKBH will also be explored to cater for the service needs.
Priority Strategies
Short-term • Enhance inpatient palliative care consultative service at QEH through

Cluster-based consultative team
• Provide inpatient palliative care consultative service to KWH and KH
through Cluster-based team
• Set up palliative care SOPC sessions at KWH and WTSH
• Establish palliative care nurse clinic at HKBH and WTSH
• Apply for accreditation of palliative medicine training centre under
HKCP
Medium-term • Enhance palliative day care service in KCC

• Further extend palliative care outpatient service
• Extend Cluster-based palliative care consultative services to all
hospitals in the Cluster
Long-term • Review the implementation of the short and medium-term strategies

and bridge remaining gaps by full implementation of the
Cluster-based palliative care service structure
90
Case Illustration
91
Kowloon East Cluster
Sai Kung
2
1
3
Kwun Tong
1. United Christian Hospital + 3. Haven of Hope Hospital Hospitals with A&E service are marked with the
symbol +
2. Tseung Kwan O Hospital +
Palliative care services in the Kowloon East Cluster (KEC) are provided by the medical PC teams
of United Christian Hospital (UCH) and Haven of Hope Hospital (HHH). The scope of services is
shown in the table below:
Service Scope of PC Teams in KEC
UCH HHH
Service Type
Medical PC Team Medical PC Team
Inpatient
Consultative
Outpatient
Day
Home
92
There is no PC team in Tseung Kwan O Hospital (TKOH). The palliative care consultative and
outpatient services for TKOH are provided by an associate consultant of HHH and the home
care service is provided by the Cluster home care team.
Multi-disciplinary PC Team Case Conference in UCH
Garden of Palliative Care Ward in HHH
93
There is a substantial demand for palliative care services in TKOH. However, the service
provision in inpatient and outpatient settings is limited due to the absence of a PC team in
TKOH. A significant proportion of deaths in KEC occur in non-palliative care settings, hence
there is a need to enhance the knowledge and skills of parent teams in providing general
palliative care to patients, with support from the specialist palliative care consultative service for
managing complex problems.
Furthermore, the coverage of non-cancer palliative care service is low for patients in KEC other
than those with ESRF. Support to other non-cancer patients such as those with advanced
pulmonary, cardiac, liver and neurological diseases needs to be strengthened.
Strategies

The KEC Coordination Committee on Palliative Care Services comprises Cluster management,
palliative care and non-palliative care specialists and nursing staff. To enhance the coordination
of palliative care services among different healthcare disciplines, the Committee membership will
be reviewed for involving appropriate representative from the AH disciplines.
With the development of cancer service in KEC, a mechanism for collaboration between
medical and oncology palliative care specialists will be established to provide palliative care
services for cancer patients and to govern the service development. A Cluster-based palliative
care consultative team will be set up to extend the coverage of palliative care inpatient
consultative and outpatient services in all hospitals for supporting both cancer and non-cancer
patients. Also, through the UCH and HHH redevelopment projects in the coming years, further
enhancement in the capacity of inpatient palliative care services will be explored.
94

Care Teams
Collaboration between the palliative care and non-palliative care teams in KEC will be
strengthened to enhance the service provision in non-palliative care settings. Strategies include
collaboration with medical and surgical teams to enhance the workflow of hospital admission,
linkage and triage for palliative care service; collaboration with the Cluster pain team in pain
control; and collaboration with TKOH A&E Department for streamlined admission and facilitating
the process of death certification for patients under palliative care. Education, training and skills
transfer for healthcare workers in non-palliative care settings will also be continued and further
enhanced.

The existing home care team in KEC is Cluster-based. Further collaboration among the home
care nurses will be achieved through the establishment of Cluster-based home care service
guidelines and case conferences. Support to palliative care patients staying in the community
will be enhanced through extending the duration of telephone hotline support, improving the
logistics for clinical admission and enhancing the use of existing ambulatory centre to reduce
unnecessary hospital admissions. Collaboration with CNS, CGAT and Integrated Care Model
(ICM) services will be further strengthened to address the needs of patients with different
complexity levels of needs. The palliative care day centre in UCH will also be better utilised to
support patients in TKOH and HHH, while the establishment of another palliative care day centre
in HHH is being explored according to the service demand.
95
Priority Strategies
Short-term • Strengthen collaboration between palliative care and non-palliative

care teams to enhance service provision in non-palliative care
settings
• Establish Cluster-based palliative care consultative team
• Utilise UCH palliative care day centre to support TKOH and HHH
patients in need
• Develop Cluster-based guidelines and conduct case conferences for

home care nurses
• Strengthen collaboration with CNS, CGAT and ICM
• Collaborate with TKOH A&E to support patients under palliative care
• Improve arrangement for clinical admission of palliative care patients

in the community
Medium-term • Establish mechanism for further collaboration between medical and

oncology palliative care specialists along with the development of
cancer service in KEC
• Enhance collaboration with the Cluster pain team in TKOH
• Extend duration of telephone hotline support for palliative care

patients
Long-term • Enhance capacity of inpatient palliative care service in the Cluster

through UCH and HHH redevelopment projects
• Explore the feasibility of establishing a palliative care day centre in

HHH
96
97
Kowloon West Cluster
Tsuen Wan
3
Kwai 4
Tsing 1
2
Sham
Shui Po
Lantau Island
1. Princess Margaret Hospital + 4. Kwai Chung Hospital Hospitals with A&E service are marked
with the symbol +
2. Caritas Medical Centre + 5. North Lantau Hospital +
3. Yan Chai Hospital +
Palliative care services in the Kowloon West Cluster (KWC) are provided by the oncology PC
team of Princess Margaret Hospital (PMH) and the medical PC team of Caritas Medical Centre
(CMC). The scope of services is shown in the table below:
Service Scope of PC Teams in KWC

PMH CMC
Service Type
Inpatient
Consultative
Outpatient
Day
Home
98
There are no PC teams in the other hospitals of KWC, namely Yan Chai Hospital (YCH), Kwai
Chung Hospital (KCH) and North Lantau Hospital (NLTH). Patients of these hospitals can
access palliative care services through the parent teams’ referral to the PC teams in PMH and
CMC.
Palliative Care Day Centre in PMH
Multi-disciplinary PC Team in CMC
With the re-delineation of Cluster boundaries since 1 December 2016, the PC teams of OLMH
and WTSH have been moved from KWC to KCC. The inpatient palliative care beds of OLMH
and WTSH have been relocated to KCC. The inpatient service in KWC is therefore skewed
geographically, with palliative care beds only available in CMC. It presents a challenge to the
capacity of palliative care services in KWC, particularly on the accessibility of patients living in
Tsuen Wan, Kwai Tsing and Tung Chung. Moreover, palliative care beds in KWC focus primarily
on support to cancer patients, with limited support to non-cancer patients.
99
There is a low coverage of both cancer and non-cancer palliative care in the Cluster’s acute
hospitals, especially in YCH which does not have a PC team. Inter-hospital consultative
services are limited without a Cluster-based team for service provision. In PMH, intra-hospital
consultative service for cancer patients not under the Department of Oncology is currently
unavailable. There is also a need to enhance the palliative care services for non-cancer patients
in the Cluster, to better support patients with ESRF and extend the service to patients with other
organ failures.
Regarding palliative home care service, there are variable coverage and intensity of home visits
for patients of different hospitals in the Cluster. Enhancement of the home care service is
required to better support patients in the community.
Strategies

The KWC Coordination Committee on Palliative Care Services comprises Cluster management,
palliative care and non-palliative care specialists, nursing and AH staff. To enhance the
coordination of palliative care services among different AH disciplines, the Cluster AH
Coordinator will also be included in the Committee membership. The membership will also
be reviewed for involving the respective organ specialists when the palliative care services are
extended to cover advanced respiratory diseases and cardiac failure.
Following the re-delineation of Cluster boundaries, palliative care services in KWC are mainly
centralised in CMC and provided with Cluster-based arrangement. Inpatient services are
concentrated in CMC, which will be reviewed to cope with the service demand and be
incorporated into the planning of Phase II hospital redevelopment project of CMC. There will
be provision of palliative care outpatient services in PMH and YCH serving both cancer and
non-cancer patients through collaboration between CMC medical PC team and PMH oncology
PC team.
100

Care Teams
A Cluster-based multi-disciplinary consultative team will be established to enhance the
service provision and collaboration between palliative care and non-palliative care teams. The
consultative team will be based at CMC and serve all non-cancer patients in the Cluster as
well as cancer patients in CMC and YCH. Link nurses will be identified in the parent teams
as contact points for care coordination with the consultative team. In PMH, intra-hospital
consultative service will be established by the oncology PC team to support cancer patients.
Collaboration between palliative care and non-palliative care teams will also be strengthened
by setting up joint or parallel palliative care outpatient clinics in PMH and YCH as mentioned
above. The clinic service is provided through collaboration among palliative care specialists,
oncologists, organ specialists and pain specialists. The Cluster-based consultative team and
joint or parallel clinic services are platforms for palliative care specialists to provide skills transfer
to non-palliative care teams.
Besides, skills transfer and empowerment of staff in non-palliative care settings will also be
enhanced through Cluster-based rotation and training programmes. Trained nurses in the
parent teams of acute hospitals will act as link persons for better coordination with the PC team.
101
Palliative home care services in KWC will be optimised through Cluster-based home care team
based at CMC, covering both cancer and non-cancer patients. Collaboration with community
service providers including CGAT and CNS will be strengthened to improve care coordination
according to the stratification of patients’ palliative care needs. The collaboration with CGAT
team to enhance palliative care support for RCHEs shall be extended to YCH, following the
implementation in CMC and PMH. Referral criteria to palliative home care service, mechanism
of feedback collection and liaison with the referring teams will be standardised for better
alignment in care provision.
Utilisation of palliative care day centres in KWC will be optimised to better meet the service
demand in the Cluster. The palliative day care centre in CMC will mainly provide interventional
procedures for both cancer and non-cancer patients, while the day centre in PMH will mainly
provide Cluster-wide day programmes for palliative care.
Priority Strategies
Short-term • Enhance governance by reviewing the membership of the KWC

Coordination Committee on Palliative Care Services
• Set up Cluster-based multi-disciplinary palliative care consultative
team in KWC
• Set up joint or parallel palliative care clinics in YCH and PMH
Medium-term • Increase palliative care beds in CMC for both cancer and non-cancer
palliative care patients in KWC
• Enhance the capacity of palliative home care services and
collaboration with CNS and CGAT
• Provide training and skills transfer of basic palliative care knowledge
to doctors and nurses in acute hospitals
Long-term • Refine and enhance the scope of palliative care day service in PMH
and CMC
102
103
New Territories East Cluster
North
2
4
3
Tai Po
7
Sha Tin
6
5
1. Prince of Wales Hospital + 4. Tai Po Hospital 7. Cheshire Home, Shatin

2. North District Hospital + 5. Shatin Hospital Hospitals with A&E service are marked
3. Alice Ho Miu Ling Nethersole Hospital + 6. Bradbury Hospice with the symbol +
Palliative care services in the New Territories East Cluster (NTEC) are provided by the oncology
PC team of Prince of Wales Hospital (PWH) and the medical PC teams of Shatin Hospital (SH)
and Bradbury Hospice (BBH). The scope of services is shown in the table below:
104
Service Scope of PC Teams in NTEC

PWH SH BBH
Service Type
Oncology PC Team Medical PC Team Medical PC Team
Inpatient
Consultative
(serving the whole Cluster)
Outpatient
Day
Home
(serving the whole Cluster)
There are no PC teams in the other hospitals of NTEC, namely North District Hospital (NDH),
Alice Ho Miu Ling Nethersole Hospital (AHNH), Tai Po Hospital (TPH) and Cheshire Home,
Shatin (SCH). However, palliative care services (including consultative, outpatient, day and
home care services) are available in NDH, which are provided by a satellite medical PC team of
SH and BBH. Patients of AHNH, TPH and SCH, on the other hand, can access palliative care
services through the parent teams’ referral to the PC teams in PWH, SH and BBH.
Palliative Care Day Centre in PWH
Palliative Care Ward in SH Multi-disciplinary PC Team in BBH
105
NTEC has a large geographical coverage of catchment districts. Currently, the palliative
care support in the North and Tai Po districts of NTEC is limited. There is a need to enhance
palliative home care services in the northern region of the Cluster, as well as the consultative,
day and outpatient palliative services in NDH, AHNH and TPH.
Furthermore, there is a lack of out-of-hours support for palliative home care patients residing in
the community. Services such as hotline telephone support and direct admission arrangement
are needed, which can reduce unnecessary A&E attendances and admissions.
Strategies

To strengthen the governance of palliative care services in NTEC, there will be a revamp of
the NTEC Coordination Committee on Palliative Care Services. Clinical lead in medical and
oncology palliative care will be identified to lead the service development and collaboration
between the teams in the Cluster. The membership will be reviewed to enhance the involvement
of palliative care and oncology clinicians, nurses and AH staff. Palliative Care Committee will
also be set up in each acute hospital to facilitate implementation of the palliative care services
with participation by non-palliative care specialists.
Joint protocol and multi-disciplinary guidelines will be promulgated on topics such as pain and
symptom control. Regular consultative visits in both medical and oncology wards and case
conferences will be conducted. Collaboration in training will be enhanced with rotation of
trainees between palliative medicine and oncology, joint palliative care training for oncology and
palliative medicine trainees and nurses, as well as joint training for non-palliative care specialists,
nurses and AH staff.
106

Care Teams
Cluster-based consultative services will be outreached to various specialties and departments
using clinical triggers. The existing renal palliative care programme will be strengthened
with increased coverage in Tai Po and Northern District. Shared care model will also be
developed for non-cancer palliative care conditions in various hospitals of the Cluster, such as
neuro-degenerative disease programme in PWH, advanced COPD programme in PWH
and NDH as well as surgical palliative care in SH. Moreover, joint programme with the A&E
departments in acute hospitals will be in place to better support coordinated palliative care
admissions.
To support implementation of these strategies, training of palliative care link nurse will be
extended to the whole Cluster. There will be continued rotation of palliative medicine trainees to
the Departments of Medicine and Geriatrics for exposure and skills transfer.

Palliative home care service in NTEC will be enhanced through Cluster-based team arrangement.
The existing home care teams will be pooled under single governance and reporting line. The
Cluster-based home care team will be supported by both medical and oncology palliative care
specialists, and will serve cancer and non-cancer patients with enhanced support to the North
and Tai Po districts. Telephone support will also be strengthened through the palliative care day
centre, home care team and ward telephone hotline, but adequate trained and experienced
workforce is required to extend the hours of telephone support. Back up services such as
direct admission to palliative care wards, designated beds in acute and extended hospitals or
fast track service in A&E departments will be implemented in steps to ensure appropriate place
of care for palliative care patients.
Collaboration between the palliative home care team, CNS and CGAT will also be strengthened
with early identification of cases and enhanced communication. A collaboration model will be
developed to provide care according to patients’ needs. To increase palliative care support to
RCHEs, an integrated PC Team comprising the medical and oncology teams will continue to
collaborate with geriatricians through the CGAT EOL care programme.
107
To better address the Cluster’s needs for palliative day care services, the day centres of NDH,
SH and BBH will be further utilised to serve the other hospitals. Subject to the future service
demand, service model development and facility planning in the Cluster, including an additional
day centre at AHNH or TPH would be explored to enhance service accessibility.
Priority Strategies
Short-term • Enhance Cluster governance by revamping the NTEC Coordination

Committee on Palliative Care Services and identifying clinical lead in
medical and oncology palliative care
• Implement joint protocol and multi-disciplinary guidelines
• Conduct regular case conferences and consultative visits in oncology
and palliative care wards
• Enhance collaboration in training
• Enhance home care provision through Cluster-based team
• Establish Integrated PC Team with medical and oncology palliative
care and collaborate with other specialties
• Extend palliative care link nurse training to the whole Cluster, and
continue rotation of palliative medicine trainees to Medicine &
Geriatrics Departments
Medium-term • Extend Cluster-based consultative services in collaboration with

parent teams utilising clinical triggers
• Develop shared care model for non-cancer palliative care patients,
for example, neurodegenerative diseases, advanced COPD and
surgical palliative cases
• Expand renal palliative care programme with increased coverage in
Tai Po and Northern District
• Implement joint programme with A&E departments of PWH and NDH
to better support palliative care patients
Long-term • Strengthen telephone support and further facilitate coordinated

admission
• Strengthen collaboration with CNS and CGAT
• Utilise existing palliative care day centres to support patients in
AHNH, TPH and SCH, and consider to develop a new centre at
AHNH or TPH
• Consider providing inpatient palliative care services in the acute
hospitals of NTEC
108
109
New Territories West Cluster
Yuen Long
4 5
Tuen Mun
1. Tuen Mun Hospital + 4. Castle Peak Hospital Hospitals with A&E service are marked
with the symbol +
2. Pok Oi Hospital + 5. Siu Lam Hospital
3. Tin Shui Wai Hospital +
Palliative care services in the New Territories West Cluster (NTWC) are provided by the medical
and oncology PC teams of Tuen Mun Hospital (TMH). The scope of services is shown in the
table below:
Service Scope of PC Teams in NTWC

TMH
Service Type
Medical PC Team Oncology PC Team
Inpatient
Consultative
Outpatient
Day
Home
110
Palliative Care Day Centre in TMH Multi-disciplinary Medical PC Team in TMH
At the moment, there are no PC teams in the other hospitals of NTWC, namely Tin Shui Wai
Hospital (TSWH), Pok Oi Hospital (POH), Castle Peak Hospital (CPH) and Siu Lam Hospital (SLH).
TSWH is a new hospital that has commenced service in phases since January 2017, and the
provision of palliative care services is being planned to address the needs of patients in the Tin
Shui Wai district. Meanwhile, patients of POH, CPH and SLH can access palliative care services
through the parent teams’ referral to the PC teams in TMH.
Currently, palliative care services in the Cluster are mainly focused in TMH, with inadequate
coverage for the other hospitals. In particular, there is a need to strengthen the service provision
in POH which has a higher level of palliative care service needs compared to CPH and SLH.
There is also a limited number of palliative care specialists providing service to non-cancer
patients in the Cluster, resulting in low service provision of palliative care inpatient, consultative
and outpatient services for these patients.
111
Strategies

The NTWC Coordination Committee on Palliative Care Services comprises Cluster management,
palliative care and non-palliative care specialists, nursing and mortuary staff. To enhance the
coordination of palliative care services among different disciplines, medical social worker will be
included in the Committee membership.
Collaboration between the medical and oncology PC teams will be strengthened, with the
NC(Palliative Care) playing a key role in supporting both teams. Meanwhile, common clinical
protocols are being developed to align the service provision in the Cluster and affirm the concept
of Cluster-based service. Furthermore, the medical and oncology PC teams will organise joint
training and education sessions to facilitate information and skills sharing.
The opening of TSWH presents an opportunity for strengthening the palliative care services,
especially beyond Tuen Mun district. A palliative care SOPC will be set up in TSWH to serve all
palliative care patients under the joint care of medical and oncology PC teams.
112

Care Teams
In view of the limited palliative care support to POH, CPH and SLH, Cluster-based palliative care
consultative team will be set up to serve both cancer and non-cancer patients in all hospitals of
the Cluster.
At the same time, integration of palliative care into different specialties is essential for providing
timely and quality patient-centred care. Based on stratification of patients’ needs, shared
care between palliative care and non-palliative care teams will be provided through different
collaborative models. For patients with a general level of palliative care needs, the care will be
led by non-palliative care specialists with consultative and bereavement support from palliative
care specialists. Patients with more complex needs will be taken care of through joint clinic
and joint grand round between palliative care and non-palliative care teams. Moreover, the
PC teams will provide continuous education and skills transfer to build up the expertise and
skill-sets of the non-palliative care teams.

Currently, the palliative home care service of NTWC is provided by separate teams under
medical and oncology departments. A single Cluster-based home care team will be set up
to enhance service coverage through better coordination and manpower arrangement. The
home care team will be under the leadership of the NC(Palliative Care), with support from both
oncology and medical palliative care specialists for providing services to cancer and non-cancer
patients.
113
Moreover, telephone consultation and coordinated admission will be strengthened for better
patient support. Collaboration between the palliative home care team, CNS and CGAT will be
enhanced to provide appropriate care according to patients’ needs. To meet the increasing
palliative care needs of Tin Shui Wai district, a palliative care day centre will be set up in TSWH
to provide day services for cancer and non-cancer patients.
Priority Strategies
Short-term • Strengthen governance through the NTWC Coordination Committee

on Palliative Care Services and establish Cluster-based service
organisation with collaboration between medical and oncology
palliative care specialists in TMH
• Improve coverage of palliative home care service through formulation
of a Cluster-based home care team in NTWC
Medium-term • Set up Cluster-based consultative team covering cancer and

non-cancer patients in POH, TSWH, CPH and SLH
Long-term • Strengthen palliative care outpatient services through setting up

SOPC service in POH and TSWH
• Develop inpatient palliative care services and set up a palliative care
day centre in TSWH for serving cancer and non-cancer patients in
NTWC
114
115
PART T H REE : Paed i at r i c Pal l i at i ve Care S er vices
Current Situation of Paediatric

Palliative Care Services in HA
What We Are Doing Now
In contrast to adult palliative care services, specialist palliative care is currently not available in
HA for paediatric patients. The specialist PC teams in the 16 HA hospitals mentioned earlier
are providing palliative care to adult patients only. Children suffering from life-threatening or
life-limiting illness are under the care of different paediatric departments, and are being looked
after by the respective paediatric subspecialty teams which mainly deliver disease management.
The paediatric teams may also look into the palliative care needs of their paediatric patients if
required, but the service provision and development is not carried out in a structured manner.
Support for the chronically or seriously ill paediatric patients in the community is also very limited
because the existing paediatric services in HA focus on hospital care. Although paediatric
nurses from a few hospitals provide home visits, they mainly deliver technical support to patients
on ventilator and tube-feeding. Since many
of the children with serious chronic illness
are living in residential special schools, a
Children with Medical Complexity Community
Support Programme (CCSP) has recently been
developed to support them, with paediatric
nurses taking up the role as care coordinators.
However, the nurses are not well equipped with
the knowledge and skill-sets for addressing the
palliative care needs of these patients.
With limited support in the community, repeated admissions and prolonged hospitalisation
are not uncommon for these children. To alleviate the problem, paediatric departments are
collaborating with NGOs to support patients and families in need of palliative care, to help relieve
the service gap. The services provided by the NGOs include home visits, telephone support,
psychosocial activities, respite care, and family bereavement care.
117
Overall, structured paediatric palliative care services are yet to be developed in HA, and some
of the service needs are partly met by our community partners. A number of factors have led
to the relatively slow development of paediatric palliative care. This includes the uniqueness
of caring for sick children, the relatively low demand for paediatric palliative care compared to
adults, and the lack of specialised expertise and training.
Uniqueness of Caring for Sick Children

The cause and trajectory of paediatric illnesses as well as the needs of children are very different
from those of adult patients, making it very difficult (if at all feasible) to transfer the experience of
adult palliative care to the paediatric context.
First of all, the disease spectrum of children is substantially different from adults, and many of
the serious conditions, such as prematurity and genetic disorders, are unique to children. In
the case of inheritable diseases, there may be more than one affected child in a family. Even
illnesses that are seen in adults, like cancers and neurological disorders, can act differently in
children due to differences in anatomy and physiology between children and adults. Hence,
special expertise of paediatricians is required in providing age-appropriate medical care to
children.
The spectrum of serious paediatric illnesses

can be reflected in the data on deaths below
age 18. For instance, as shown in Figure 11,
in 2014 around half of the deaths below
age 18 in HA were of infants less than one
year of age, 75% of which were related to
perinatal conditions and congenital anomalies.
As regards young children and adolescents
of age one to 17, 37% of the deaths were
related to cancer, and 27% to cardiovascular,
neurological, respiratory and genitourinary conditions, which might be of various congenital,
genetic, metabolic or acquired diseases origins.
118
Figure 11. Principle Diagnosis of Inpatient/Day Inpatient Deaths Below Age 18 in HA (2014)
In addition, as they go through illness, paediatric patients are also growing and developing
physically, cognitively, socially and emotionally. As such, their medical conditions and
multifaceted needs as well as their understanding of the disease evolve and change quite
rapidly along the care journey36. Moreover, the duration of paediatric care journey often has a
longer span compared to adults, usually lasting many years37. Some of the patients may grow
into adulthood, especially with the advancement in life-prolonging options, and require transition
arrangement to adult healthcare services. All these special features increase the complexity in
developing paediatric palliative care services.
36 Williams-Reade, J. et al. (2015). Paediatric palliative care: a review of needs, obstacles and the future. Journal of Nursing Management; 23:4-14.
37 Association for Children's Palliative Care, England. (2003). A Guide to the Development of Children’s Palliative Care Services.
119
Relatively Low Demand for Paediatric Palliative
Care
The service demand for paediatric palliative care in HA is much lower than that of adults. It is
because serious illnesses are not common among children in a developed economy like Hong
Kong. This can be partly reflected by the data showing that less than 1% (around 260 cases) of
the deaths in Hong Kong in 2014 were of children/adolescents under 18 years old.
The relatively low demand limits the development progress of both service and expertise in
paediatric palliative care38. However, the rare occurrence of serious illness among children
makes such an encounter even more unanticipated and difficult to cope with, which may
generate palliative care needs that are more complex and intense than those of adult patients.
It is especially difficult for parents, siblings and other family members, as well as the healthcare
teams to face the imminent death of a child39, because children in our modern society are
expected to grow up and outlive their parents. Therefore, it is not unusual to pursue curative
and life-prolonging options aggressively for a seriously ill child40. This may be one of the reasons
that more than 50% of the deaths below age 18 in HA occurred in the intensive care settings,
which is a much higher rate than for adult patients.
Such an intensive focus on cure may have downplayed the importance of palliative care for
paediatric patients, causing the patients and families to endure unnecessary suffering and
emotional distress40. As healthcare decisions for children are usually made by their parents,
ethical dilemma will need to be resolved when there is a disagreement between a parent and
the healthcare team in deciding the course of action that is in the best interest of the sick child39.
38 Meier, D.E. et al. (2007). Paediatric palliative care offers opportunities for collaboration. Journal of Palliative Medicine; 10(2):284-89.
40 Rushton, C.H. (2005). A framework for integrated paediatric palliative care: being with dying. Journal of Paediatric Nursing; 20(5):311-25.
120
Lack of Specialised Expertise and Training

Studies have shown that family members reported less emotional distress and increased care
satisfaction when a PC team was involved in the care of a seriously ill paediatric patient 41.
However, there is no dedicated team formally set up in HA for this service. In general, there
is a lack of training to equip healthcare staff with the specialised knowledge and skill-sets for
providing palliative care to children and families, such as effective pain and symptoms control,
sensitive communication, conflict resolution, and management of ethical dilemma.
Unlike the establishment of adult palliative medicine as a recognised subspecialty, such a

status for paediatric palliative care is not yet developed in Hong Kong, impeding the cultivation
of clinical leadership in this service area. Contrary to the situation in the United Kingdom,
Australia and the United States, where palliative medicine for children has been introduced
as a paediatric subspecialty, training
programme for this subspecialty has yet
to be developed under the Hong Kong
College of Paediatricians. Nevertheless,
paediatric oncologists generally gather
more experience in providing palliative
care, since cancer is the leading cause of
death in children above one year of age.
There is also no coordinated training

for nurses and AH professionals in paediatric palliative care. Although there are initiatives in
some Clusters or hospitals for supporting a small number of staff to undergo overseas training
in paediatric palliative care, concerted strategies and designated resources for building up a
specialised workforce for this service are generally lacking in HA.
With the upcoming development of Hong Kong Children's Hospital (HKCH), paediatric services
in HA will be reorganised into a coordinated service network. It is a valuable opportunity to
re-engine our system to provide comprehensive and holistic care for paediatric patients, ranging
from acute curative to palliative care, so as to better support sick children and their families
along the care journey.
121
Strategic Service Framework for
Paediatric Palliative Care Services
What We Are Going to Do
After taking into consideration the service gaps and the factors contributing to the slow
development of paediatric palliative care, and with reference to overseas experience, a
dedicated framework has been formulated for establishing structured paediatric palliative care
services in HA. A key component of the framework is the development of a specialised PC
team under the paediatric specialty to address the palliative care needs of seriously ill children
and their families, which are substantially different from those of adult patients. The framework
is aimed at improving the accessibility and quality of palliative care for chronically or seriously ill
paediatric patients and their families, such that their quality of life could be enhanced.
In the context of paediatric palliative care, families include parents, siblings, carers and significant
others who matter to the patients42,43. As with adult patients, palliative care for paediatric
patients can take place at any stage of a serious illness, including from the point of diagnosis
as an integrated approach alongside active treatments that aim at cure or prolonging life, and
continue till the bereavement phase. It can also be provided in different settings, ranging from
tertiary care facilities to the patients’ home. An important emphasis is on compassionate,
sensitive and open communication to help patients and families understand the situation
they are facing, possible options available to them and the respective treatment goals. This
empowers them to have greater participation in the decision-making process44,45.
43 Australian Commission on Safety and Quality in Health Care, Sydney. (2016). National Consensus Statement: Essential Elements for Safe and High-quality Paediatric
End-of-Life Care.
44 Rushton, C.H. (2005). A framework for integrated paediatric palliative care: being with dying. Journal of Paediatric Nursing; 20(5):311-25.
45 Craig, F. et al. (2007). IMPaCCT: standards for paediatric palliative care in Europe. European Journal of Palliative Care; 14(3):109-14.
122
Strategic Framework
There are three strategic directions for paediatric palliative care in the Framework. Under
each direction, strategies are formulated for the development of structured paediatric palliative
care services in HA. Key enablers are also identified to facilitate effective implementation of
the Framework. The table below summarises the Framework, while details of the strategic
directions and strategies are outlined subsequently.
Strategic Directions Strategies

(Where we are going) (How we will get there)
Establish territory-wide • Set up a centralised paediatric PC team for coordinating the

paediatric palliative territory-wide service development
care services in HA
Promote integrated and • Integrate palliative care into paediatric services with a shared care
shared care with the approach to meet different levels of patient needs
parent teams
• Support local care to accommodate the preference of
patients and families
Enhance community • Develop paediatric palliative home care service

support for children
• Enhance palliative care support for special schools and residential
and families in need of
schools
palliative care
• Strengthen community partnership on paediatric palliative care
123
Establish Territory-wide Paediatric Palliative Care Services in HA
The direction is set towards establishing territory-wide paediatric palliative care services, under a
single clinical governance. A centralised paediatric PC team will work with the designated care
team of doctors and nurses at regional level to provide comprehensive palliative care services for
the needs of children. The latter plays a significant role in coordinating with community partners,
special schools, and local paediatric sub-specialty teams; and in the provision of palliative home
care service in their local community.
Set up a Centralised Paediatric PC Team for Coordinating the Territory-wide

Service Development
The centralised paediatric PC team is led by paediatricians to coordinate the development of
an age-appropriate and family-centred care to cater for the special needs of paediatric patients
facing life-limiting and life-threatening conditions, in the best interests of the children. These
include conditions for which curative treatment may be feasible but can fail (e.g. cancers),
conditions where intensive treatment may prolong life but premature death is inevitable (e.g.
severe muscular dystrophy on long term ventilator), conditions without curative options where
treatment is exclusively palliative (e.g. progressive metabolic disorder), and irreversible but
non-progressive conditions causing severe disability leading to susceptibility to complications
and premature death (e.g. severe cerebral palsy and spinal cord injury)46.
46 Australian Commission on Safety and Quality in Health Care, Sydney. (2016). National Consensus Statement: Essential Elements for Safe and High-quality Paediatric End-of-Life Care.
124
A multi-disciplinary approach is adopted, involving paediatricians with special interest and

expertise in palliative care, nurses and AH professionals such as social workers, clinical
psychologists, physiotherapists, occupational therapists and dietitians. A continuum of services
that includes inpatient, outpatient, home care, support to schools and bereavement care is
provided to address the physical, psychosocial and spiritual needs of patients and families.
Apart from symptom control and psychosocial support, the services also cover ACP especially
in complex cases, and offer bereavement care to families with complicated grief. For patients
who survive beyond the age of 18, collaboration with the relevant adult specialties is coordinated
by the PC team to facilitate the transition to adult healthcare services.
The centralised PC team is to be based in the HKCH upon its service commencement. With the
commissioning of HKCH, paediatric services in HA will be reorganised into a service network,
with HKCH as the tertiary referral centre for managing complex and rare conditions, while the
paediatric departments of other HA hospitals provide secondary and step-down care in the
respective local communities. Therefore, territory-wide paediatric palliative care services have to
be established under a single governance for coordinated care in the paediatric service network.
125
Promote Integrated and Shared Care with the Parent Teams
The paediatric PC team works closely as partners with paediatricians and other members in the
parent teams who are managing the patients’ condition. An integrated and shared care approach
is adopted to promote continuity of care. Leveraging on the established bonding between the
parent teams and the patients and families, the approach facilitates early introduction of palliative
care in a seamless and coordinated manner and through joint formulation of a care plan.
Integrate Palliative Care into Paediatric Services with a Shared Care

Approach to Meet Different Levels of Patient Needs
Palliative care should be embedded into the overall paediatric care to improve service
accessibility. While the paediatric PC team is equipped to take care of patients and families
with more complex palliative care needs, clinicians and other members of the parent teams
should also acquire basic knowledge and skills of paediatric palliative care in order to identify
and support patients in need, as well as address less complex needs. System has to be put in
place for accessing the paediatric PC team. Consultative services and joint outpatient clinics
are examples of shared care platform between the paediatric PC team and the parent team.
Support Local Care to Accommodate the Preference of Patients and Families

Under the territory-wide service model, local care is supported to fulfil the wish of many patients
and families to receive services at home or in the proximity of their homes. The paediatric PC
team will work with the designated care team of doctors and nurses at regional level to ensure
the continuity of palliative care in the paediatric service network. The designated care team is
formed by paediatricians and nurses with interest and training in palliative care. They work
closely with the centralised paediatric PC team and community partners to provide coordinated
care. For patients under the care of HKCH, there will be an option of receiving palliative care in
other HA hospitals closer to their home, especially towards the end of life.
126
Enhance Community Support for Children and Families in Need of
Palliative Care
Children often prefer to be cared for at home when they are sick and most families also opt to
care for their children at home if feasible47,48,49,50. School is another familiar environment to the
children, providing a sense of reassuring rhythm to normal life with education and social life48,49.
As such, community-based services are an integral part of paediatric palliative care. Support
and empowerment should be given to patients, their families, and their carers in schools to allow
patients to live as fully as possible in their communities.
Develop Paediatric Palliative Home Care Service

The paediatric PC team works with the designated care team of doctors and nurses at
regional level to provide palliative home care services. Through visiting patients and families
in their homes, their needs are assessed for the provision of appropriate support on the spot.
Moreover, families can access telephone support for consultation and advice when required.
48 Department of Health, Western Australia. (2009). Paediatric and Adolescent Palliative Model of Care.
49 Hynson, J.L. et al. (2003). The dying child: how is care different? Medical Journal of Australia; 179:S20-S22.
50 Vickers, J.L. et al. (2000). Choices and control: parental experiences in paediatric terminal home care. Journal of Paediatric Oncology Nursing; 17:12-21.
127
Enhance Palliative Care Support for Special Schools and Residential Schools
Support is provided to special schools and residential schools, leveraging on the existing CCSP.
There are also training and skills transfer for nurses serving as the care coordinators and for the
staff in special schools. Basic knowledge and skill-sets on paediatric palliative care have to be
built up in the school setting to address as far as possible the needs of chronically or seriously ill
children who are attending school, with backup from the paediatric PC team.
Strengthen Community Partnership on Paediatric Palliative Care

Relevant NGOs and patient groups are engaged to provide complementary support to
the patients and families. With their experience and resources in the community, they are
instrumental to the provision of personal care, social care and respite care to address different
social and practical needs.
The Future Service Model for Paediatric Palliative Care
Under this Framework, HA is moving towards the vision of providing timely, coordinated and
holistic palliative care to paediatric patients and families in need. A centralised multi-disciplinary
paediatric PC team is to be set up to coordinate the development of territory-wide palliative
care services through the HA paediatric service network under a single clinical governance. The
paediatric PC team works with the designated care team of doctors and nurses at regional level
to provide a continuum of comprehensive palliative care services from hospital to community for
the needs of children. The new service model of paediatric palliative care in HA is illustrated in
Figure 12 below.
128
Figure 12. Future Service Model of Paediatric Palliative Care in HA
A centralised paediatric PC team works with the designated care team of doctors and nurses
at regional level to provide a continuum of territory-wide palliative care services
from hospital to community under a single clinical governance
Key Enablers
To facilitate the implementation of the above service model and Framework strategies, various
key enablers are required for supporting the establishment of territory-wide paediatric palliative
care services in HA.
Structured referral guidelines, clinical protocols and clinical standards have to be developed by
the centralised paediatric PC team for the territory-wide service. Detailed workforce planning
covering multi-disciplinary staff is also crucial in supporting the service implementation by
phases. To ensure the quality and sustainability of the service model, appropriately trained
and skilled multi-disciplinary staff is required in all the paediatric departments so that palliative
care can be integrated into paediatric services. The training plans in this regard are to be
coordinated by the paediatric PC team. Similar to adult palliative care services, IT support,
facilities and transport are also important enablers for the effective implementation of paediatric
palliative care.
129
PART FO U R : Im pl em entat i o n an d Mon itor in g
Implementation and Monitoring

Realising the Plan - Our Short, Medium and Long-term Goals
The Framework set out in this document for the development of adult and paediatric palliative
care services is the blueprint that will steer HA towards achieving the vision of accessible
and high quality palliative care for our patients over the next five to ten years. Successful
implementation of the Framework will require the joint effort of Clusters, hospitals and frontline
clinical staff to develop operational plans according to the strategies. The process of change
should start now. And it should be led by clinical leaders, Cluster management and HA Head
Office.
In this chapter, the strategies outlined in the Framework are prioritised for phased
implementation across HA. Overall consideration is given to the service needs and the
readiness for implementation at both the clinical and Cluster management levels. Changes
could begin in clinical areas and Clusters that have greater service needs and are more ready
for implementation. Local priorities of the respective Clusters are already delineated in the
Cluster plans under Part Two of this document. Some of the strategies do not require additional
resources, while others will incur resources. The HA annual planning process is the mechanism
through which resources could be sought to support the implementation of the relevant
strategies.
131
Short Term
Strengthen Governance Structure

A robust governance of palliative care services is essential in successfully leading the
implementation of the Framework across HA. As a key initial step, the governance will be
enhanced at both the corporate and Cluster levels. At the corporate level, the membership of
CC(Palliative Care) will be reviewed to adopt Cluster-based representation instead of the existing
hospital-based composition. Linkage with other relevant COC/CCs will also be strengthened,
such as by setting up joint working groups, to enhance collaboration in the development of
palliative care service models and training for different specialities. Meanwhile, governance at
the Cluster level will be enhanced by reviewing the membership of the Cluster Coordination
Committees on Palliative Care Services to include representatives from the Cluster management
and other important stakeholders. The Cluster Committees will also be empowered for
overseeing the service development and execution of the Clusters’ operational plans according
to the strategies set out in this Framework.
Develop Cluster-based Service Model with Collaboration between Medical

and Oncology Palliative Care Specialists
Collaboration between medical and oncology PC teams in the respective Clusters should be
enhanced in the short term, so that their adult palliative care services can be organised in a
Cluster-based manner. Apart from the development of common protocols and guidelines,
Cluster-based home care teams and consultative service teams will also be set up to support
all the hospitals in the Clusters, covering both cancer and non-cancer adult patients. There will
also be collaborative activities between the teams, e.g. case conference, joint training and staff
rotation.
132
Promote Shared Care Model through Strengthening Palliative Care

Consultative Services and Skills Transfer for Non-Palliative Care Specialists
Many adult patients who need palliative care are admitted to and under the care of other
specialities. To cope with the rising service demand and provide appropriate care, it is imminent
to build up a culture of shared care between palliative care and non-palliative care teams and to
integrate palliative care into the management of all patients in need. Enhancement of palliative
care consultative services is a starting point for fostering collaboration and skills transfer.
Through providing mobile palliative care services to other specialities, the PC teams support the
parent teams to address patients’ palliative care needs and provide skills-transfer in the process.
In the short term, consultative services will be strengthened with priority given to hospitals with
no PC teams and support for patients with non-cancer conditions.
Expand Palliative Home Care Service and Enhance Support to RCHEs

Palliative home care is pivotal in facilitating care in place by helping patients to stay in the
community and reduce unnecessary hospital admissions. The home care service will expand in
phases to improve service quality and support more patients in need. Collaboration with CNS
will also be established with structured communication platform and cross-support to ensure
coordinated and appropriate care is provided according to the patients’ stratified needs.
The palliative care needs of old age home residents are also acknowledged with plans to
increase support through the CGAT EOL care programme. In the coming years, the programme
will be further expanded to cover more patients in RCHEs according to the service needs and
readiness of different CGATs and PC teams.
133
Establish Structured Paediatric Palliative Care Services for Territory-wide
Support
In parallel, structured development of paediatric palliative care should be carried out in the
short term. Given the commissioning of HKCH and reorganisation of paediatric services, it is
opportune to start the systematic development of paediatric palliative care services. It is of
high priority to build up the service model for meeting the palliative care needs of paediatric
patients. As the first step, a centralised paediatric PC team will be set up in HKCH to provide
territory-wide services in the HA paediatric service network, including inpatient, outpatient, home
care, support to schools and family bereavement care.
Strengthen Training for Staff in Non-Palliative Care Settings

The sustainability of palliative care services depends on our staff’s competency and awareness.
To drive the culture change and build up the service capacity, there is a need to strengthen the
training of staff working beyond palliative care settings. Priority will be given to nurses in view of
their key role in providing daily patient care and communication with families/carers. Particularly
for those working in clinical areas of high service needs such as Medicine, Geriatrics and CNS,
structured training through clinical attachment and skills transfer will be conducted. Nurses
who have undergone the relevant training could act as link persons to liaise with PC teams for
implementing the shared care model. In general, basic training programmes will be arranged
for both professional and supporting staff to raise their awareness and knowledge on palliative
care. Collaboration with community partners and relevant stakeholders will also be explored to
support the training needs.
134
Medium Term
Refine and Align Palliative Care Day Service

In the medium term, adult palliative day care services will be enhanced through refining the
service model and standards. With a refocus on therapeutic procedures and programme-based
services, palliative day care can provide better symptom management for patients living in the
community, and reduce unnecessary hospital stay by providing fast-track support.
Strengthen Community Partnership

HA treasures the collaboration with community partners to support our palliative care patients
and families in the community. Medical-social collaboration will help complement our services
and provide comprehensive palliative care especially on the aspects of personal and social
care, psycho-spiritual support and empowerment of patients and families/carers. In the coming
years, we will continue to work with NGOs, patient groups and volunteers on these areas. The
role of PRCs will also be strengthened for linking up the clinical teams and community resources
in meeting our patients’ needs. Structured collaboration with the welfare sector will also be
explored to promote coordination between the medical and social sectors at the system level.
Enhance Data Collection and Develop Quality Indicators for Performance

Monitoring
To enhance performance monitoring, there will be continued review of service statistics on
palliative care across HA, so as to achieve standardisation in the data definition, data collection
and reporting mechanism. Subsequently, suitable quality indicators will be identified and
developed for continuous monitoring and improvement of our palliative care services.
Increase Transportation Support

Transportation support is an essential enabler to support patients’ access to ambulatory
palliative care services and to facilitate transfer between hospitals for inpatient care. Through
reviewing HA’s transport service arrangement and enhancing the capacity, we will be in a better
position to meet the service needs in the medium term.
135
Enhance IT Support
IT has an indispensable role to play in the successful implementation of many of the strategies
outlined in the Framework. For example, IT systems can support ACP documentation for
information sharing and care planning, data capture for performance monitoring as well as
other innovative IT solutions for care support and empowerment of patients and families/carers.
Enhancement of IT support should be initiated immediately and carried out by phases as one of
the medium-term goals, with consideration of the readiness of system technologies in meeting
the user requirements.
Moreover, a one-stop web-based information platform on palliative care will be developed to provide
easily accessible information to healthcare staff, patients, families/carers and the general public.
Long Term
Enhance Physical Capacity and Design for Palliative Care in Hospital Capital
Projects
In the long run, physical design and facilities for supporting the delivery of palliative care will be
incorporated into hospitals that are undergoing redevelopment as well as future new hospitals in
HA. For example, single rooms, interview rooms and family areas will be included, with design
features to foster a caring environment and meet the needs of patients at the end of life and
their families/carers. The design of mortuaries will also be improved taking into account the
operational workflow and perception of the patients’ families/carers.
136
Monitoring
The implementation of this Framework is a continuous process of developing and improving our
palliative care services. Monitoring the process is the key to ensuring proper implementation
of the strategies and effective use of resources. The success of the strategies in achieving the
goals of service improvement will be evaluated. The monitoring will be carried out at several
levels, as follows:
• Service deliverables tied in with resources bidding through the HA annual planning process
will be monitored through the existing mechanism.
• Progress on the key implementation milestones mapped out in the operational plans of the
Framework will be regularly reviewed over the next five to ten years at both the Cluster and
corporate level.
• Quality indicators will be developed for benchmarking, accountability reporting and

continuous quality improvement of the overall palliative care services in HA.
137
Palliative care is an integral part of the care continuum. Quality palliative care makes a significant
difference in helping patients and their families/carers cope with the distress of serious illness
and anticipating death.
We envisioned that all patients facing life-threatening or life-limiting conditions and their families/
carers can receive timely, coordinated and holistic palliative care to address their needs. They
can have greater participation in planning their care, are aware of the choices they can make,
and have the best possible quality of life till the end of the patients’ life journey.
This Framework sets out the strategies to achieve this vision. Improvements are to be
made in the governance and organisation of our adult palliative care services. Collaboration
between palliative care and non-palliative care teams is highlighted to improve service quality
and build up the capacity for meeting the growing needs. Emphasis is put on the place of
care by enhancing ambulatory and community services. At the same time, structured and
family-centred paediatric palliative care is to be established in our paediatric services network
for addressing the specific needs of chronically or seriously ill children and their families. Across
HA, palliative care services are monitored for continuous quality improvement, and key enablers
are developed to support implementation of the strategies.
138
PART FIVE : Con c lusion
The quality of palliative care in HA relies on more than changing our practice of delivering the service.
This calls for a fundamental shift in our culture, so that all healthcare workers are aware that good
patient care is not only about saving lives, but also about helping patients live with comfort, dignity
and peace in the last phase of their life journey. The provision of palliative care should be integrated
into the management of every patient suffering from life-threatening or life-limiting illness, spanning
from hospital to community care. Although the process of building this culture takes time, many
changes have already begun and will continue with the momentum generated from developing this
Framework, and through the concerted efforts of all of us here in HA.
139
Abbreviations
A&E Accident & Emergency
ACP Advance Care Planning
AD Advance Directives
AH Allied Health
CC Central Committee
CC(Palliative Care) Central Committee on Palliative Care
CCE Cluster Chief Executive
CCSP Children with Medical Complexity Community Support Programme
CGAT Community Geriatric Assessment Team
CNS Community Nursing Service
COC Coordinating Committee
COPD Chronic Obstructive Pulmonary Disease
CPR Cardiopulmonary Resuscitation
DNACPR Do-Not-Attempt Cardiopulmonary Resuscitation
EOL End-of-life
ESRF End-stage Renal Failure
HA Hospital Authority
HKCP Hong Kong College of Physicians
HKCR Hong Kong College of Radiologists
ICM Integrated Care Model
IT Information Technology
MSDC Medical Services Development Committee
NC Nurse Consultant
NGO Non-governmental Organisation
PAC Patient Advisory Committee
PC Team Palliative Care Team
PRC Patient Resource Centre
RCHE Residential Care Home for the Elderly
SOPC Specialist Outpatient Clinic
WHO World Health Organisation
140
PART S IX : Ab b re v i at i o ns an d Ap p en dices
Appendix 1: Taskforce on the HA Strategic

Service Framework for Palliative Care
Terms of Reference
• To review the current and future service needs for palliative care in HA
• To advise on the future service model(s) and system infrastructure for addressing the existing
and anticipated gaps in HA palliative care services over the next five to ten years
• To identify priority areas and develop strategies to enhance the quality and outcome of HA
palliative care services
• To formulate a strategic service framework for HA palliative care services for consideration by
the members of the Directors’ Meeting and MSDC
Membership (as at May 2017)

Co-chairs
Dr S V LO Director (Strategy & Planning), HA Head Office (up to 31 October 2016)
Dr Libby LEE Director (Strategy & Planning), HA Head Office (from 1 November 2016)
Dr W L CHEUNG Director (Cluster Services), HA Head Office
Members
Dr K S LAU Chief of Service (Integrated Medical Services) & Consultant (Respiratory

Medicine & Palliative Care), Ruttonjee & Tang Shiu Kin Hospitals –
Representative of CC (Palliative Care)
Dr Doris TSE Deputising Cluster Chief Executive & Clinical Stream Coordinator (Medical),
Kowloon West Cluster / Hospital Chief Executive, Caritas Medical Centre –
Dr Rebecca YEUNG Chief of Service (Clinical Oncology), Pamela Youde Nethersole Eastern Hospital
– Representative of COC (Clinical Oncology)
Dr S H LO Consultant (Clinical Oncology), Tuen Mun Hospital – Representative of

CC (Cancer Service)
Dr K S CHAN Deputy Hospital Chief Executive & Chief of Service (Medicine), Haven of Hope
Hospital – Representative of COC (Internal Medicine)
141
Members
Dr Elsie HUI Cluster Coordinator (Community Geriatric Assessment Team), New Territories
East Cluster / Chief of Service (Medicine & Geriatrics), Shatin Hospital –
Representative of COC (Internal Medicine)
Dr Harold LEE Consultant (Medicine & Geriatrics), Princess Margaret Hospital –

Dr David YONG Associate Consultant (Medicine & Geriatrics), Caritas Medical Centre –
Dr H T LEONG Chief of Service (Surgery), North District Hospital / Alice Ho Miu Ling
Nethersole Hospital – Representative of COC (Surgery)
Dr H P CHUNG Chief of Service (Surgery), Tung Wah Hospital / Consultant (Surgery), Queen
Mary Hospital – Representative of COC (Surgery)
Dr H B CHAN Chief of Service (Paediatric & Adolescent Medicine) & Service Director
(Information Technology & Telecommunications), United Christian Hospital –
Representative of COC (Paediatrics)
Ms Eva LIU Cluster General Manager (Nursing), Kowloon Central Cluster / General
Manager (Nursing), Queen Elizabeth Hospital – Representative of Nursing
Grade
Ms C H CHAN Nurse Consultant (Palliative Care), New Territories West Cluster –

Representative of Nursing Grade
Ms Margaret SUEN Cluster Coordinator (Medical Social Work), Kowloon West Cluster / Department
Manager (Medical Social Work / Health Resource Centre & Volunteer Service
Coordinator), Caritas Medical Centre – Representative of Allied Health Grade
Mr Hercy LI Clinical Stream Coordinator (Allied Health), Hong Kong East Cluster / Allied
Health Coordinator & Department Manager (Occupational Therapy), Ruttonjee
& Tang Shiu Kin Hospitals – Representative of Allied Health Grade
Dr Libby LEE Chief Manager (Strategy, Service Planning & Knowledge Management),
HA Head Office (up to 31 October 2016)
Dr Leo WAT Chief Manager (Strategy, Service Planning & Knowledge Management),
HA Head Office (from 19 April 2017)
Dr Christina MAW Chief Manager (Primary & Community Services), HA Head Office
Ms Ivis CHUNG Chief Manager (Allied Health), HA Head Office
Ms Susanna LEE Manager (Nursing) / Chief Nursing Officer, HA Head Office – on behalf of Chief
Manager (Nursing) / Chief Nurse Executive, HA Head Office
Ms Eva TSUI Chief Manager (Statistics & Workforce Planning), HA Head Office
Dr Sharon WONG Senior Manager (Strategy & Service Planning), HA Head Office – Secretary
142
Appendix 2: Working Group on Palliative

Care Service Model
Terms of Reference
• To identify strength and weakness of current HA palliative care services along the care pathway
• To advise on future service model and related system infrastructure for HA palliative care
services, particularly the service collaboration between PC teams, with non-palliative care
specialists as well as among hospitals in Clusters
• To report the recommendations to the Taskforce on the HA Strategic Service Framework for
Palliative Care for consideration and formulation of strategies for addressing the existing and
anticipated gaps in HA palliative care services over the next five to ten years

Co-chairs
Members
Kowloon West Cluster / Hospital Chief Executive, Caritas Medical Centre –

– Representative of COC (Clinical Oncology)
Dr S H LO Consultant (Clinical Oncology), Tuen Mun Hospital – Representative of COC

(Clinical Oncology)
Dr C B LAW Deputy Hospital Chief Executive (Clinical Services), Princess Margaret Hospital
/ Chief of Service (Medicine & Geriatrics), Princess Margaret Hospital / North
Lantau Hospital – Representative of COC (Internal Medicine)
143
Members
Dr H T LEONG Chief of Service (Surgery), North District Hospital / Alice Ho Miu Ling
Nethersole Hospital – Representative of COC (Surgery)
Dr K L TSUI Consultant (Medicine), Pamela Youde Nethersole Eastern Hospital –

Representative of CC (Cardiac Service)
Dr Maureen WONG Clinical Services Coordinator & Chief of Service (Medicine & Geriatrics /
Intensive Care Unit), Caritas Medical Centre – Representative of CC (Chronic
Obstructive Pulmonary Disease)
Dr David YONG Associate Consultant (Medicine & Geriatrics), Caritas Medical Centre –
Representative of Central Renal Committee
Prof Gilberto LEUNG Honorary Consultant (Surgery) & Director (Trauma Services), Queen Mary
Hospital – Representative of COC (Neurosurgery)
Dr M C CHU Consultant (Anaesthesia), Pamela Youde Nethersole Eastern Hospital –

Representative of Head Office Committee on Pain Management Service
Dr James LUK Consultant (Geriatrics), Tung Wah Group of Hospitals Fung Yiu King Hospital –
Representative of Geriatrics Subcommittee
Ms Ellen YEUNG Nurse Consultant (Palliative Care), Hong Kong East Cluster – Representative of
Nursing Grade
Ms Candic TANG Department Operations Manager (Medicine & Geriatrics), Princess Margaret
Hospital – Representative of Nursing Grade
Dr Damaris HUNG Clinical Psychologist in-charge (Clinical Psychology), Grantham Hospital /

Clinical Psychologist & Communication Ambassador, Queen Mary Hospital –
Representative of Allied Health Grade
Ms Ellie TANG Department Manager (Physiotherapy), Tung Wah Group of Hospitals Wong Tai
Sin Hospital – Representative of Allied Health Grade
Ms Susanna LEE Manager (Nursing) / Chief Nursing Officer, HA Head Office
Dr Sharon WONG Senior Manager (Strategy & Service Planning), HA Head Office
Dr Tony HA Senior Manager (Elderly & Palliative Care), HA Head Office
144
Appendix 3: Working Group on Place of

Care
Terms of Reference
• To identify strength and weakness of current HA palliative care services at home/care home
• To advise on support to patients and their families/carers on palliative care and EOL care
beyond hospital, with particular focus on the care provision at patients’ home and care
home, as well as on community partnership
anticipated gaps in HA palliative care services over the next five to ten years

Co-chairs
Members
Hospital – Representative of CC (Palliative Care)
Dr K H WONG Consultant (Clinical Oncology), Queen Elizabeth Hospital – Representative of

CC (Palliative Care)
Dr Elsie HUI Cluster Coordinator (Community Geriatric Assessment Team), New Territories
East Cluster / Chief of Service (Medicine & Geriatrics), Shatin Hospital –
Representative of Geriatrics Subcommittee
Ms Cecilia KWAN Nurse Consultant (Palliative Care), New Territories East Cluster / Bradbury
Hospice – Representative of Nursing Grade (Palliative Care Nurse)
Ms S H LEUNG Nurse Consultant (Community), Kowloon East Cluster – Representative of

Nursing Grade (Community Nursing Service)
145
Members
Ms Donna TSE Ward Manager (Community Geriatric Assessment Team), Ruttonjee & Tang
Shiu Kin Hospitals – Representative of Nursing Grade (Community Geriatric
Assessment Team Nurse)
Coordinator), Caritas Medical Centre – Representative of Allied Health Grade
(Social Worker)
Mr Hercy LI Clinical Stream Coordinator (Allied Health), Hong Kong East Cluster / Allied
Health Coordinator & Department Manager (Occupational Therapy), Ruttonjee
& Tang Shiu Kin Hospitals – Representative of Allied Health Grade (Occupational
Therapist)
Dr Cissy CHOI Senior Manager (Rehabilitation & Patient Empowerment), HA Head Office
146
Appendix 4: Working Group on Paediatric

Palliative Care
Terms of Reference
• To identify strength and weakness of current HA paediatric palliative care services along the
care pathway
• To advise on future service model and related system infrastructure for HA paediatric
palliative care services
anticipated gaps in HA paediatric palliative care services over the next five to ten years

Co-chairs
Members
Representatives of COC (Paediatrics)
Prof Godfrey CHAN Chief of Service (Paediatrics & Adolescent Medicine), Queen Mary Hospital
/ Commissioning Service Coordinator (Paediatric Cardiology), Hong Kong
Children's Hospital
Dr K S LUN Deputy Chief of Service (Paediatric Cardiology) & Consultant (Paediatric

Cardiology), Queen Mary Hospital
Dr S L LEE Consultant (Paediatrics & Adolescent Medicine), The Duchess of Kent

Children’s Hospital at Sandy Bay
Dr S P WU Consultant (Paediatrics), Queen Elizabeth Hospital
Dr H B CHAN Chief of Service (Paediatric & Adolescent Medicine) & Service Director
(Information Technology & Telecommunications), United Christian Hospital
147
Representatives of COC (Paediatrics)
Dr Lilian LEE Associate Consultant (Paediatric & Adolescent Medicine), United Christian
Hospital
Dr S C LING Consultant (Paediatrics & Adolescent Medicine), Princess Margaret Hospital
Dr Stephen CHAN Associate Consultant (Paediatrics & Adolescent Medicine), Caritas Medical
Centre
Dr Sharon CHERK Deputy Consultant (Paediatrics), Kwong Wah Hospital (up to 31 March 2017)
Prof C K LI Cluster Coordinator (Paediatrics), New Territories East Cluster / Professor

(Paediatrics), Prince of Wales Hospital
Dr C H LI Consultant (Paediatrics & Adolescent Medicine), Tuen Mun Hospital
Representatives of Nursing Grade
Ms Y F WONG Advanced Practice Nurse (Paediatrics), Queen Elizabeth Hospital
Ms Vivian CHAN Chief Nursing Officer (Commissioning), Hong Kong Children’s Hospital
Representatives of Allied Health Grade
Ms Anice GUM Dietitian, Queen Mary Hospital & Hong Kong Children’s Hospital
Dr Susan FUNG Clinical Psychologist in-charge (Clinical Psychology) & Clinical Psychologist
(Paediatrics), Queen Elizabeth Hospital
Head Office Executives
148
Appendix 5: Subgroup on Cluster Service

Organisation
Terms of Reference
• To advise the Working Group on Palliative Care Service Model on the Cluster-based palliative care
service arrangement
• To suggest future service model(s) and system infrastructure, and to propose priority areas and
strategies for addressing the existing and anticipated gaps in HA palliative care services over the
next five to ten years

Co-chairs
Members
– Representative of Hong Kong East Cluster

Representative of Hong Kong East Cluster
Dr K K YUEN Consultant (Clinical Oncology), Queen Mary Hospital – Representative of Hong

Kong West Cluster
Dr Theresa LAI Nurse Consultant (Palliative Medicine), Grantham Hospital – Representative of

Hong Kong West Cluster
Dr Y H CHONG Cluster Coordinator (Chinese Medicine), Kowloon Central Cluster / Hospital

Chief Executive, Hong Kong Buddhist Hospital / Tung Wah Group of Hospitals
Wong Tai Sin Hospital – Representative of Kowloon Central Cluster
Ms Eva LIU Cluster General Manager (Nursing), Kowloon Central Cluster / General
Manager (Nursing), Queen Elizabeth Hospital – Representative of Kowloon
Central Cluster
149
Members
Hospital – Representative of Kowloon East Cluster
Dr P T LAM Consultant (Medicine & Geriatrics), United Christian Hospital – Representative

of Kowloon East Cluster
Dr K Y WONG Consultant (Oncology), Princess Margaret Hospital – Representative of

Dr Annie KWOK Consultant (Medicine & Geriatrics), Caritas Medical Centre – Representative of
Dr C Y MAN Clinical Stream Coordinator (Medical Stream), New Territories East Cluster
/ Hospital Chief Executive, Alice Ho Miu Ling Nethersole Hospital & Tai Po
Hospital – Representative of New Territories East Cluster
Dr Raymond LO Cluster Coordinator (Hospice & Palliative Care), New Territories East Cluster
/ Consultant (Geriatrics & Palliative Medicine), Shatin Hospital & Bradbury
Hospice / Chief of Service (Hospice & Palliative Care), Bradbury Hospice –
Representative of New Territories East Cluster
Dr S H LO Consultant (Clinical Oncology), Tuen Mun Hospital – Representative of New

Territories West Cluster
Dr Benjamin CHENG Associate Consultant (Medicine & Geriatrics), Tuen Mun Hospital –
Representative of New Territories West Cluster
150
Appendix 6: HA Central Committee on

Palliative Care
Terms of Reference
• To coordinate the efforts of various hospitals providing palliative care
• To advise on the future development of palliative care services and identify service targets and priorities
• To advise on the resources requirement in developing palliative care services
• To identify training needs and determine priorities in training programmes
• To advise on the development and implementation of professional guidelines, clinical targets

and quality assurance system in the palliative care services
• To advise on the monitoring and evaluation of the palliative care services

Chairman

Medicine & Palliative Care), Ruttonjee & Tang Shiu Kin Hospitals
Service Manager
Members
Representatives of PC Teams
Dr K Y CHAN Consultant in-charge (Palliative Medicine), Grantham Hospital
Dr K K YUEN Consultant (Clinical Oncology), Queen Mary Hospital
Dr Stanley TAM Consultant (Medical), Hong Kong Buddhist Hospital
Dr K H WONG Consultant (Clinical Oncology), Queen Elizabeth Hospital
Hospital
Dr W M LAM Deputy Chief of Service (Medicine), Haven of Hope Hospital
Dr P T LAM Consultant (Medicine & Geriatrics), United Christian Hospital
151
Members
Representatives of PC Teams
Kowloon West Cluster / Hospital Chief Executive, Caritas Medical Centre
Dr Annie KWOK Consultant (Medicine & Geriatrics), Caritas Medical Centre
Dr K Y WONG Consultant (Oncology), Princess Margaret Hospital
Dr Macy TONG Consultant (Clinical Oncology), Prince of Wales Hospital
Dr Yvonne YAU Consultant (Clinical Oncology), Prince of Wales Hospital
Dr Raymond LO Cluster Coordinator (Hospice & Palliative Care), New Territories East Cluster
/ Consultant (Geriatrics & Palliative Medicine), Shatin Hospital & Bradbury
Hospice / Chief of Service (Hospice & Palliative Care), Bradbury Hospice
Dr S H LO Consultant (Clinical Oncology), Tuen Mun Hospital
Other Specialists
Prof Godfrey CHAN Chief of Service (Paediatrics & Adolescent Medicine), Queen Mary Hospital
/ Commissioning Service Coordinator (Paediatric Oncology), Hong Kong
Children's Hospital
Dr P W YAU Associate Consultant (Paediatrics), Queen Elizabeth Hospital
Representatives of Nursing Grade
Ms Ellen YEUNG Nurse Consultant (Palliative Care), Hong Kong East Cluster
Ms L N CHAN Executive Partner (Nursing), HA Head Office / Department Operations Manager

(Pulmonary & Palliative Care Services), Haven of Hope Hospital
Ms C H CHAN Nurse Consultant (Palliative Care), New Territories West Cluster
Representatives of Allied Health Grade
Dr Damaris HUNG Clinical Psychologist in-charge (Clinical Psychology), Grantham Hospital /

Clinical Psychologist & Communication Ambassador, Queen Mary Hospital
Ms Eva MA Senior Occupational Therapist, Queen Elizabeth Hospital
Ms Ellie TANG Department Manager (Physiotherapy), Tung Wah Group of Hospitals Wong Tai
Sin Hospital
Ms Lorraine CHAN Medical Social Worker in-charge, Haven of Hope Hospital
Coordinator), Caritas Medical Centre
Dr Kitty WU Project Manager (Allied Health), HA Head Office / Cluster Coordinator (Clinical
Psychology), Kowloon West Cluster / Senior Clinical Psychologist Head (Clinical
Psychology) / Division II, Kwai Chung Hospital
152

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2

Prof John C Y LEONG

Dr Libby LEE Dr W L CHEUNG

All patients facing life-threatening and life-limiting conditions and their

1. Enhance governance by developing Cluster-based services with the collaboration of

4. Strengthen performance monitoring for continuous quality improvement

1. Enhance Governance by Developing Cluster-based Services

Opportunities for Improvement

• Strengthening collaboration between medical and oncology palliative care specialists to

Opportunities for Improvement

• Strengthening specialist palliative consultative service in non-palliative care settings

3. Enhance Palliative Care in the Ambulatory and Community Settings

Opportunities for Improvement

• Enhancing medical-social collaboration with community partners such as

Opportunities for Improvement

• Enhancing data collection with standardisation of data capture and alignment of

Figure 1. Future Service Model of Adult Palliative Care in HA

Framework Strategies for Paediatric Palliative Care

Opportunities for Improvement

1. Establish Territory-wide Paediatric Palliative Care Services in HA

Figure 2. Future Service Model of Paediatric Palliative Care in HA

Manpower and Training

A Cluster-based perspective of workforce planning and deployment is needed to support

Information Technology (IT) Support

Implementation and Monitoring

Figure 1. Concept of Hospice Care

Figure 2. Concept of Integrated Palliative Care

Curative and disease modifying

End-of life care Bereavement

Currently, HA is providing a spectrum of palliative care services ranging from inpatient,

Overall, healthcare service development is skewed towards technology advancement and

Vision of HA Palliative Care Services

Scope of the Strategic Service Framework for

Advance Directives (AD)b

Do-Not-Attempt Cardiopulmonary Resuscitation (DNACPR)c

Issued by HA Clinical Ethics Committee:

Escalating Demand for Palliative Care Due to

Figure 3. Hong Kong Population (2016 – 2046)

Figure 4. Top Ten Causes of Deaths in Hong Kong (2014)

HA’s Unique Position in the Delivery of Palliative Care

High Hospital Service Utilisation in Last Phase of Life

Growing Evidence Supporting the Development of

Recognition of Palliative Care Needs in Paediatrics

Figure 6. Project Governance Structure

Overview of Adult Palliative

Oncology PC Team Medical PC Team

Kowloon East Cluster - United Christian Hospital (UCH)

New Territories West Tuen Mun Hospital (TMH)

* Re-delineated from KWC to KCC with effect from 1 December 2016

Key Members in Service Delivery

Inpatient and Consultative

As at 31 December 2016, there were over

Since many terminally ill patients in need

Ambulatory Palliative Care Service

Ambulatory palliative care service includes

Specialist outpatient care is one of the important

Patients facing terminal illness and living in the

Other Supportive Services

Governance and Organisation of Service