Couchiching Family Health Team (1.0 FTE Permanent with Perks) 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. 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.
- 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.
- 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. Patient, Family and Caregiver Support:
- Provide education, anticipatory guidance, counselling and support to patients, families and caregivers.
- Assess caregiver needs a

📌 Palliative Care Nurse Practitioner (Orillia)
🏢 Couchiching Family Health Team
📍 Orillia