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Specialized rural models of palliative care are greatly needed to address the challenges rural communities face in providing palliative care services and to ensure that their unique strengths and needs are considered. In late 2005, a Rural Palliative Care Program was developed to support primary care providers in delivering palliative care to patients in rural communities outside of Calgary, Alberta, Canada. The program was grounded in the needs of individual communities, incorporated integral roles for local champions, and adopted pre-existing, accepted rural structures and processes. Needs and gaps in rural palliative care service delivery were identified and prioritized. The following actions were taken to address the top six priorities: 1) more accessible palliative care education opportunities with a rural focus were provided to health care professionals; 2) linkages with rural and urban resources were strengthened and access to specialists and procedures was improved; 3) strategies were implemented to improve psychosocial support for patients and families; 4) resources were developed to facilitate rural home deaths; 5) opportunities were expanded for education and utilization of volunteers; and 6) a mobile specialist consultation team was developed to support rural health care professionals and their patients in their rural communities. In its first four years, the team consulted on 640 patients, nearly three-quarters of whom died in their rural communities. Rather than imposing an urban outreach strategy, the development of a rural-based program through respectful engagement of local providers has proven to be crucial to the success of this rural palliative care program.

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Objectives: 1) To determine clinical characteristics and end-of-life experiences for patients receiving continuous inotrope therapy referred to hospice care; 2) to determine hospice clinician attitudes and clinical experiences providing care for these inotrope-dependent AHF patients. Methods: We retrospectively reviewed hospitalized AHF patients receiving PC consultation who were discharged with hospice services on continuous inotropes. All hospices received inotrope-weaning guidelines to use as indicated. Data collected included patient AHF disease characteristics, symptomatology, inotrope therapy course, and inotrope plan at discharge. We also surveyed hospice clinicians regarding inotrope therapy in hospice plan-of-care. Descriptive statistics were used to analyze data. Results: Between March 2015 and March 2016, 10 AHF patients (median age 62 years, 70% non-ischemic cardiomyopathy, 80% with implantable cardioverter-defibrillators) were discharged to hospice at 4 different agencies. Patients received care in both inpatient (n¼5) and outpatient (n¼5) settings with either milrinone (n¼8) or milrinone plus dobutamine (n¼2). All received hospice care ¼72 hours, and 5 received for >14 days. Four patients were weaned from inotropes and survived > 48 hours from time of inotrope discontinuation. Three clinicians used the inotrope weaning guidelines and found them helpful. Three patients had inotropes discontinued without weaning and survived for at least 24 hours after discontinuation. Three patients continued inotrope therapy until death. All hospice providers said they would accept other patients on continuous inotropes. Conclusion: Inotropes can be safely weaned or discontinued for patients with AHF receiving hospice care. Predicting survivability and symptomatology after inotrope discontinuation requires further investigation.