Couchiching Family Health Team
Position: Palliative Care Nurse Practitioner (NP)
(1.0 FTE Permanent with Benefits)
Reports To: Manager Specialized Care & Programs
Position Summary:
The CFHT Palliative Care Nurse Practitioner (NP) provides specialized, person-centred,
community-based palliative care to individuals living with serious, progressive and life-
limiting illness. Working within the interdisciplinary model of the Couchiching Family Health
Team, the NP provides comprehensive assessment, diagnosis, treatment, symptom
management, advance care planning, care coordination and end-of-life care, with an
emphasis on supporting patients in the setting that best reflects their goals and preferences.
The NP works collaboratively with patients, families and caregivers, primary care providers
and community and regional partners to promote timely, coordinated and continuous
palliative care. The role includes direct clinical care for patients with palliative care needs,
including eligible individuals who do not have a primary care provider.
In addition to direct clinical care, the NP serves as a palliative care clinical resource to CFHT
and community primary care providers through consultation, education, mentorship and
capacity building. The NP also contributes to the ongoing development, evaluation and
growth of CFHT's palliative care program, with a focus on improving access, quality and
continuity of care across the Couchiching community.
Why Join Us:
The Couchiching Family Health Team offers an opportunity to practise in a collaborative,
innovative and community-focused primary care environment. This position provides an
opportunity to make a meaningful impact through direct care to patients and families while
helping strengthen palliative care capacity across the broader primary care and community
healthcare system.
The Palliative Care Nurse Practitioner will combine advanced clinical practice, meaningful
patient relationships, education, collaboration and program development in a role focused
on improving the experience of patients and families living with serious illness.
Roles and Responsibilities:
Clinical Palliative Care:
- Provide comprehensive in-home assessment, follow-up and ongoing clinical
management for patients with serious, complex, progressive and life-limiting illness.
October 2026
- Assess, diagnose and manage complex physical, psychological, social and spiritual
symptoms associated with advanced illness, including pain, dyspnea, nausea, anxiety,
fatigue, delirium, depression and constipation.
- Prescribe, initiate, adjust and deprescribe medications and other treatments within the
NP's scope of practice and in accordance with applicable legislation and professional
standards.
- Develop, implement, monitor and evaluate individualized care plans that reflect each
patient's goals, values, preferences, cultural needs and stage of illness.
- Provide timely assessment and management of changing or urgent palliative care needs
and symptom crises to support patients in their preferred place of care and, where
clinically appropriate, reduce avoidable emergency department visits and
hospitalizations.
- Provide ongoing clinical follow-up and continuity as patient needs evolve throughout
the illness trajectory, including deterioration and transition to end-of-life care.
- Collaborate with the patient’s primary care provider (PCP), where one is established, to
support coordinated, person-centred palliative care and continuity of care
- Provide NP-led palliative care to eligible unattached patients within the defined scope
of the CFHT palliative care program, collaborating with other providers and community
services to support continuity of care.
Goals of Care, Advance Care Planning and End-of-Life Care:
- Lead and participate in compassionate, timely and person-centred goals-of-care
discussions.
- Support advance care planning and shared decision-making with patients, families and
substitute decision-makers.
- Help patients and families understand illness, expected disease trajectory, treatment
options, prognosis and available supports.
- Facilitate discussions regarding preferred place of care,
treatment limitations,
resuscitation and end-of-life wishes.
- Ensure goals of care, substitute decision-maker information, advance care planning and
patient preferences are accurately documented and communicated across care
settings.
Care Coordination and System Navigation:
- Coordinate care with physicians, nurse practitioners, nurses, social workers,
pharmacists, rehabilitation professionals, spiritual care providers and other members of
the interdisciplinary team.
- Collaborate with Ontario Health atHome, hospice programs, hospitals, retirement
residences, pharmacies, community agencies and other healthcare partners.
- Facilitate transitions between hospital, home, hospice, primary care, and other care
settings.
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- Support timely access to medications, equipment, home care, respite, financial
assistance, transportation and other community resources.
- Participate in case conferences, interdisciplinary rounds and care planning meetings.
- Identify gaps and barriers in patient care and work collaboratively with partners to
develop practical solutions.
Patient, Family and Caregiver Support:
- Provide education, anticipatory guidance, counselling and support to patients, families
and caregivers.
- Assess caregiver needs and burden and facilitate access to appropriate respite,
bereavement and community supports.
- Prepare patients, families and caregivers for anticipated changes in condition and the
end-of-life process.
- Support families and caregivers through disease progression, end-of-life care and
transition to bereavement.
Consultation, Education and Capacity Building:
- Act as a palliative care clinical resource to CFHT physicians, nurse practitioners, nurses,
allied health professionals and other team members.
- Provide consultation and clinical support to community primary care providers caring
for patients with palliative and end-of-life care needs.
- Promote a palliative approach to care through mentorship, case consultation,
education and knowledge sharing.
- Support the development of palliative care knowledge and competencies across CFHT
and with community partners.
- Contribute to educational sessions, clinical rounds and other professional development
initiatives.
Clinical Leadership, Program Development and Quality Improvement:
- Contribute to the development, implementation, evaluation and growth of CFHT's
palliative care program.
- Identify opportunities to improve access, patient experience, quality and continuity of
palliative care services, including for unattached, rural, vulnerable, marginalized and
underserved populations.
- Support early identification of patients who may benefit from a palliative approach and
facilitate timely assessment and referral.
- Participate in the development and implementation of clinical pathways, protocols,
policies, procedures and evidence-informed practices.
- Support the collection, monitoring and reporting of program outcomes and quality
indicators, and participate in quality improvement initiatives using data and patient
feedback to inform service improvements.
- Identify emerging community needs and contribute to innovative approaches to
palliative care delivery.
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- Build and maintain strong relationships with internal and external partners to improve
awareness, access and coordination of palliative care across the community.
Professional Practice:
- Maintain timely, accurate and comprehensive clinical documentation in the electronic
medical record.
- Practice in accordance with the standards and requirements of the College of Nurses of
Ontario, applicable legislation, professional guidelines and CFHT policies and
procedures.
- Maintain current knowledge and clinical competence through continuing education,
professional development and evidence-informed practice.
- Participate in relevant committees, working groups, team meetings and organizational
initiatives.
- Demonstrate professional accountability, sound clinical judgment and a commitment to
patient- and family-centred care.
Medical Assistance in Dying (MAID) (Under review, not confirmed)
- Participate in MAID assessments and provision, where appropriate, in accordance with
applicable legislation, professional standards, CFHT policies, and the NP's individual
scope of practice and competencies.
Qualifications:
Required Qualifications:
- Current registration with the College of Nurses of Ontario (CNO) as a Nurse Practitioner,
in good standing and authorized to practice in Ontario.
- Mandatory Declaration of Professional Liability Protection upon hire, and annually
thereafter
- Basic Cardiac Life Support (BCLS) Certification required
- Successful completion of an approved Nurse Practitioner education program.
- Minimum of three (3) years of relevant clinical experience in palliative care, primary care,
home and community care, oncology, geriatrics or a related clinical setting.
- Demonstrated knowledge and clinical expertise in palliative symptom management,
serious illness communication, advance care planning and end-of-life care.
- Demonstrated ability to work independently while functioning effectively within an
interdisciplinary team.
- Strong clinical assessment, diagnostic reasoning, communication and care coordination
skills.
- Able to work flexible hours including evenings and Saturdays when required
- Valid Ontario driver's licence and access to a reliable vehicle for community-based visits.
- Police Record/Vulnerable Record Check
- It is a condition of employment that you receive the necessary vaccinations to protect
against infection of COVID-19, or any similar infectious diseases, which may be
recommended by governmental and public health authorities from time to time
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Preferred Qualifications/Assets:
- LEAP (Learning Essential Approaches to Palliative Care) certification or equivalent
recognized palliative care education.
- Experience providing home-based or community palliative care.
- Experience working in a Family Health Team, Ontario Health Team, Community Health
Centre, hospice, home care or other interprofessional healthcare environment.
- Experience providing care to unattached patients and/or individuals with complex
medical and social needs.
- Experience with quality improvement, program development, education or clinical
leadership.
Core Competencies:
- Advanced clinical assessment, diagnostic reasoning and decision-making
- Palliative care and complex symptom management
- Serious illness communication and goals-of-care conversations
- Patient- and family-centred care
- Interprofessional collaboration
- Care coordination and system navigation
- Clinical leadership, mentorship and education
- Program development and quality improvement
- Robust communication and relationship-building
- Cultural humility and trauma-informed practice
- Advocacy and health equity
- Ability to work effectively in both independent and team-based environments
Working Environment:
This is a community-based position that includes in-home patient visits and collaboration
across multiple healthcare and community settings. The NP must be comfortable working
independently in the community while maintaining strong communication and collaboration
with the CFHT interdisciplinary team and external partners.
Please submit cover letter and resume including position title in subject line to:
[email protected]
The Couchiching Family Health Team supports diversity, equity and a workplace free from harassment
and discrimination. The CFHT is committed to an inclusive, barrier-free recruitment and selection process
and workplace. If you are contacted to participate in our recruitment process, please advise the interview
coordinator of any accommodations. The CFHT has an Accommodation Policy and Procedure to ensure
you have access to a fair and equitable process. While we thank all applicants, only those contacted for
an interview will be acknowledged.
October 2026
📌 Palliative Care Nurse Practitioner (Orillia)
🏢 Couchiching Family Health Team (CFHT)
📍 Orillia