Trends in Socioeconomic Inequalities in Breast Cancer Incidence Among Women in Canada.

INTRODUCTION: Breast cancer is the most common cancer among females in Canada. This study examines trends in socioeconomic inequalities in the incidence of breast cancer in Canada over time from 1992 to 2010. METHODS: A census division level dataset was constructed using the Canadian Cancer Registry, Canadian Census of the Population and National Household Survey. A summary measure of the Concentration index (C), which captures inequality across socioeconomic groups, was used to measure income and education inequalities in breast cancer incidence over the 19-year period. RESULTS: The crude breast cancer incidence increased in Canada between 1992 and 2010. Age-standardized C values indicated no income or education inequalities in breast cancer incidence in the years from 1992 to 2004. However, the incidence was significantly concentrated among females in high income and highly educated neighbourhoods almost half the time in the 6 most recent years (2005-2010). The trend analysis indicated an increase in breast cancer incidence among females living in high income and highly educated neighbourhoods. CONCLUSION: Breast cancer incidence in Canada was associated with increased socioeconomic status in some more recent years. Our study findings provide previously unavailable empirical evidence to inform discussions on socioeconomic inequalities in breast incidence.

Socioeconomic inequalities in colorectal cancer incidence in Canada: trends over two decades.

PURPOSE: Colorectal cancer is the third most commonly diagnosed cancer in Canada. This study aimed to measure and examine trends in socioeconomic inequalities in the incidence of colorectal cancer in Canada. METHODS: This study is a time trend ecological study based on Canadian Census Division level data constructed from the Canadian Cancer Registry, Canadian Census of Population, and National Household Survey. We assessed trends in income and education inequalities in colorectal cancer incidence in Canada from 1992 to 2010. The age-standardized Concentration index ([Formula: see text]), which measures inequality across all socioeconomic groups, was used to quantify socioeconomic inequalities in colorectal cancer incidence in Canada. RESULTS: The average crude colorectal cancer incidence was found to be 61.52 per 100,000 population over the study period, with males having a higher incidence rate than females (males: 66.98; females: 56.25 per 100,000 population). The crude incidence increased over time and varied by province. The age-standardized C indicated a higher concentration of colorectal cancer incidence among lower income and less-educated neighborhoods in Canada. Income and education inequalities increased over time among males. CONCLUSION: The concentration of colorectal cancer incidence in low socioeconomic neighborhoods in Canada has implications for primary prevention and screening.

Socioeconomic Gradients in Prostate Cancer Incidence Among Canadian Males: A Trend Analysis From 1992 to 2010.

INTRODUCTION: Understanding the effects of socioeconomic status on cancer incidence and their trends over time will help inform public health interventions for cancer control. This study sought to investigate trends in socioeconomic inequalities in prostate cancer incidence among Canadian males. METHODS: Using a census division level dataset (n = 280) constructed from the Canadian Cancer Registry, Canadian Census of Population (1992, 1996, 2001, 2006) and 2011 National Household Survey, we examined the effect of socioeconomic status on prostate cancer incidence among Canadian males between 1992 and 2010. The age-adjusted concentration index was used to quantify education/income-related inequalities in prostate cancer incidence. RESULTS: The crude prostate cancer incidence increased from 115 to 137 per 100 000 males in Canada from 1992 to 2010 with a peak in 2007. The rate increased significantly in all but three of four western provinces. The age-adjusted concentration index showed a higher concentration of prostate cancer diagnoses among males living in high-income neighbourhoods in Canada in particular from 1996 to 2005. In contrast, the index was higher among males living in less-educated neighbourhoods in the most recent study years (2006-2010). CONCLUSIONS: The concentration of new prostate cancer cases among high-income populations in Canada may be explained by the rise of opportunistic screening of asymptomatic males; however, this should be studied in further detail. Since we found a higher incidence rate of prostate cancer among less-educated males in Canada in recent years, risk-benefit investigation of primary prevention and opportunistic screening for less-educated males is advised.

Workforce Planning for Community-Based Palliative Care Specialist Teams Using Operations Research.

CONTEXT: Many countries have aging populations. Thus, the need for palliative care will increase. However, the methods to estimate optimal staffing for specialist palliative care teams are rudimentary as yet. OBJECTIVES: To develop a population-need workforce planning model for community-based palliative care specialist teams and to apply the model to forecast the staff needed to care for all patients with terminal illness, organ failure, and frailty during the next 20 years, with and without the expansion of primary palliative care. METHODS: We used operations research (linear programming) to model the problem. We used the framework of the Canadian Society of Palliative Care Physicians and the Nova Scotia palliative care strategy to apply the model. RESULTS: To meet the palliative care needs for persons dying across Nova Scotia in 2019, the model generated an estimate of 70.8 nurses, 23.6 physicians, and 11.9 social workers, a total of 106.3 staff. Thereby, the model indicated that a 64% increase in specialist palliative care staff was needed immediately, and a further 13.1% increase would be needed during the next 20 years. Trained primary palliative care providers currently meet 3.7% of need, and with their expansion are expected to meet 20.3% by 2038. CONCLUSION: Historical, current, and projected data can be used with operations research to forecast staffing levels for specialist palliative care teams under various scenarios. The forecast can be updated as new data emerge, applied to other populations, and used to test alternative delivery models.

Assessing the Quality of Care Provided to Older Persons with Frailty in Five Canadian Provinces, Using Administrative Data.

Nous avons examiné la qualité des soins fournis aux personnes âgées fragiles dans cinq provinces canadiennes à partir de données administratives sur la santé. Dans chaque province, nous avons considéré les personnes âgées fragiles en fonction de deux cohortes : les personnes décédées et les personnes vivantes. Des règles de décision ont été utilisées pour déterminer quelles personnes étaient frêles, soit celles résidant en établissement de soins de longue durée, qui étaient en phase terminale ou dont le profil correspondait à deux des sept domaines identifiés. Ces domaines étaient fondés sur des échelles de fragilité, des discussions avec des gériatres et des indicateurs d'utilisation des services de santé. Nous avons évalué la qualité des soins à l'aide des indicateurs de qualité suivants : diminution de la durée de l'hospitalisation, diminution du nombre de réadmissions à l'hôpital, diminution du nombre de visites à l'urgence, augmentation de la continuité des soins fournis par un médecin de famille, diminution de l'utilisation de la ventilation mécanique et diminution du nombre d'admissions aux soins intensifs. À l'aide d'analyses de régression, nous avons également constaté que le sexe masculin et l'âge avancé étaient associés à une moins bonne qualité de soins dans les deux cohortes. Cette étude fournit des données de base qui permettront d'évaluer les futurs efforts visant à améliorer la qualité des soins offerts aux personnes âgées fragiles.We examined the quality of care provided to older persons with frailty in five Canadian provinces, using administrative health data. In each province, we identified two cohorts of older persons with frailty: decedents and living persons. Using decision rules, we considered individuals to be frail if they were long-term care residents, terminally ill, or met at least two of seven domains, which were based on frailty scales, geriatrician discussions, and health service utilization indicators. We assessed quality of care using selected quality indicators: decrease in length of hospital stay, decrease in the number of in-patient readmissions, decrease in the number of emergency department visits, increase in the level of family physician continuity of care, decrease in the use of mechanical ventilation, and decrease in the number of admissions to intensive care. Using regression analyses, we also found male sex and older age were associated with poorer quality of care in both cohorts. This study provides baseline data for evaluating future efforts to improve the quality of care provided to older persons with frailty.

Jesus Practiced Advance Care Planning: Biblical Basis and Possible Applications.

Background: Persons from a Christian tradition may have concerns that impede advance care planning for end of life. Sharing how Jesus practiced advance care planning may provide a pivot point to help ameliorate this problem. Objective: To present a novel approach to advance care planning from a Christian tradition. Evolution of the Novel Approach: Experiential learning that resulted in the novel approach is described using Kolb's learning cycle: proceeding from concrete experience to reflective observation followed by abstract conceptualization and then active experimentation. Results: The novel approach builds on events toward the end of Jesus' life to demonstrate how he practiced advance care planning: telling those close to him that he was going to die even though they did not want to hear this, participating in a celebration of his life on Palm Sunday, sharing a Last Supper with those close to him, showing them how he wanted to be remembered, asking his friends to pray with him in the garden of Gethsemane, and saying to his mother that John would care for her. Questions related to these events are posed for use by health and spiritual care professionals to innovatively engage persons in advance care planning. Discussion: This approach might be adapted for persons of other religious traditions by exploring their sacred teachings. It is proffered for others to explore, adapt, and evaluate for its utility in initiating and facilitating advance care planning.

Population surveillance of navigation frequency and palliative care contact before death among cancer patients.

Cancer patient navigation in Canada began in 2002 in Nova Scotia with oncology nurses providing support to patients from diagnosis up to and including end of life. This novel study was carried out to determine navigation frequency and palliative care contact rates, and variations in these rates among adults who were diagnosed with cancer, navigated, and then died between 2011 and 2014. Among the 2,532 study subjects, 56.7% were navigated for more than one month and 30.6% had palliative care contact reported. Variations were observed by geographic area, cancer stage, time from diagnosis to death, and whether the person died of cancer. Further study of the role of navigation is advised for persons at end of life.

Rules to Identify Persons with Frailty in Administrative Health Databases.

This study sought to develop frailty "identification rules" using population-based health administrative data that can be readily applied across jurisdictions for living and deceased persons. Three frailty identification rules were developed based on accepted definitions of frailty, markers of service utilization, and expert consultation, and were limited to variables within two common population-based administrative health databases: hospital discharge abstracts and physician claims data. These rules were used to identify persons with frailty from both decedent and living populations across five Canadian provinces. Participants included persons who had died and were aged 66 years or older at the time of death (British Columbia, Alberta, Ontario, Quebec, and Nova Scotia) and living persons 65 years or older (British Columbia, Alberta, Ontario, and Quebec). Descriptive statistics were computed for persons identified using each rule. The proportion of persons identified as frail ranged from 58.2-78.1 per cent (decedents) and 5.1-14.7 per cent (living persons).

Understanding the challenges to improve transition to palliative care: An issue for the primary malignant brain tumour population.

UNLABELLED: Reports highlight the growing unmet need for palliative care as it applies to all cancers, yet the system and health care professionals (HCP) appear slow to respond. The following discussion paper highlights the current state of palliative care within the context of the primary malignant brain tumour (PMBT) population and argues for a shift in the current health care system's approach, which continues to place greater emphasis on cure over care. METHODS: An exploration of extant literature over the past 10 years. RESULTS: The current literature demonstrates that timely referrals to palliative care consult teams and access to community-based resources have been associated with fewer hospitalizations and visits to emergency departments and a decrease in the initiation of invasive, aggressive treatment at end of life. Timely referral to palliative care has also been shown to reduce distress, enhance quality of life and, in some cases, increase life expectancy. CONCLUSION: Earlier referral to palliative care has yet to become a reality for many patients diagnosed with life-limiting illnesses and, in particular, those with a PMBT. More research is needed to uncover and challenge the barriers to early transition including communication issues among professionals, patients and families around palliative care.

Preferred and Actual Location of Death: What Factors Enable a Preferred Home Death?

BACKGROUND: Fulfillment of patient preferences for location of dying is of continued end-of-life care interest. Of those voicing a preference, most prefer home. However the majority of deaths occur in an institutional setting. OBJECTIVES: The study objective was to report on the congruence between the last preferred and actual location of death among adult Nova Scotians who died from chronic disease, and to identify individual, illness-related, and environmental factors associated with achieving a preferred home death. METHODS: The study employed a population-based mortality follow-back telephone survey interview. Subjects were eligible death certificate identified informants (next-of-kin) of adults (aged 18+) (n = 1316) who died of advanced chronic diseases in the Canadian province of Nova Scotia between June 2009 and May 2011 who were knowledgeable about the decedent's care over the last month of life. Congruence was assessed as to whether or not the decedent died in their preferred death location. Among decedents preferring a home death, individual, illness-related, and environmental risk factor multivariable analyses were used to identify predictors of home death achievement. RESULTS: Among all who voiced a preference (n = 606), 52% died in their preferred location (kappa: 0.29). Factors contributing independently to achievement of a preferred home death were emotional needs being met, nursing and family physician home visits, palliative care program involvement, and being at home for the majority of the last month. CONCLUSIONS: This study identifies elements of primary and integrated care that address the gap between preferred and actual place of care.

Examining palliative care program use and place of death in rural and urban contexts: a Canadian population-based study using linked data.

INTRODUCTION: Palliative care has been both more available and more heavily researched in urban than in rural areas. This research studies factors associated with palliative care program (PCP) enrollment and place of death across the urban/rural continuum. Importantly, rather than simply comparing urban and rural areas, this article examines how the effects of demographic, geographic, and socioeconomic factors differ across service delivery settings within the Canadian province of Nova Scotia. METHODS: This study linked PCP patient enrollment files from three districts to Nova Scotia vital statistics death certificate data. Postal codes of the decedents were mapped to 2006 Canadian dissemination area census data. The study examined 23 860 adult residents of three district health authorities, who died from 2003 to 2009 with a terminal illness, organ failure, or frailty and who were not nursing home residents. Demographic, geographic, and socioeconomic predictors of PCP enrollment and place of death were investigated using logistic regression across the entire study area, and stratified by district of residence. Univariate and multivariate (adjusted) odds ratios (OR) and their 95% confidence intervals (CI) are reported. RESULTS: Overall, 40.3% of the study subjects were enrolled in a PCP, and 73.4% died in hospital. Odds of PCP enrollment were highest for females (OR: 1.30; 95%CI: 1.22, 1.39), persons aged 50-64 years (OR: 1.50; 95%CI: 1.35, 1.67), and persons with a terminal disease such as cancer. While in overall multivariate analysis residents of census metropolitan areas and agglomerations had higher odds of enrollment (OR: 1.51; 95%CI: 1.29, 1.77), and those at greater distance from a PCP had lower odds (OR: 0.33; 95%CI: 0.27, 0.40), stratified analysis revealed a more nuanced picture. Within each district, travel time to PCP remained a significant predictor of enrollment but the magnitude of its effect differed markedly. There was no consistent relationship with urban/rural residence, social deprivation, or economic deprivation. Enrollment in a PCP was associated with lower adjusted odds of dying in hospital (OR: 0.78; 95%CI: 0.72, 0.84), and those living at greater distance from a PCP had higher odds of hospitalization (OR: 1.52; 95%CI: 1.28, 1.81), but there was no consistent relationship for urban/rural residence or across districts. CONCLUSIONS: Geographic patterns of PCP enrollment and place of death differed by district, as did the impact of economic and social deprivation. Analysis and reporting of population-based indicators of access should be grounded in an understanding of the characteristics of geographic areas and local context of health services. Although more research is needed, these findings show promise that disparities in access between urban and rural settings are not unavoidable, and positive aspects of rural and remote communities may be leveraged to improve care at end of life.

Palliative care costs in Canada: A descriptive comparison of studies of urban and rural patients near end of life.

BACKGROUND: Significant gaps in the evidence base on costs in rural communities in Canada and elsewhere are reported in the literature, particularly regarding costs to families. However, it remains unclear whether the costs related to all resources used by palliative care patients in rural areas differ to those resources used in urban areas. AIM: The study aimed to compare both the costs that occurred over 6 months of participation in a palliative care program and the sharing of these costs in rural areas compared with those in urban areas. DESIGN: Data were drawn from two prior studies performed in Canada, employing a longitudinal, prospective design with repeated measures. SETTING/PARTICIPANTS: The urban sample consisted of 125 patients and 127 informal caregivers. The rural sample consisted of 80 patients and 84 informal caregivers. Most patients in both samples had advanced cancer. RESULTS: The mean total cost per patient was CAD 26,652 in urban areas, while it was CAD 31,018 in rural areas. The family assumed 20.8% and 21.9% of costs in the rural and urban areas, respectively. The rural families faced more costs related to prescription medication, out-of-pocket costs, and transportation while the urban families faced more costs related to formal home care. CONCLUSION: Despite the fact that rural and urban families assumed a similar portion of costs, the distribution of these costs was somewhat different. Future studies would be needed to gain a better understanding of the dynamics of costs incurred by families taking care of a loved one at the end of life and the determinants of these costs in urban versus rural areas.

Patterns of health care utilization preceding a colorectal cancer diagnosis are strong predictors of dying quickly following diagnosis.

BACKGROUND: Understanding the predictors of a quick death following diagnosis may improve timely access to palliative care. The objective of this study was to explore whether factors in the 24 months prior to a colorectal cancer (CRC) diagnosis predict a quick death post-diagnosis. METHODS: Data were from a longitudinal study of all adult persons diagnosed with CRC in Nova Scotia, Canada, from 01Jan2001-31Dec2005. This study included all persons who died of any cause by 31Dec2010, except those who died within 30 days of CRC surgery (n = 1885 decedents). Classification and regression tree models were used to explore predictors of time from diagnosis to death for the following time intervals: 2, 4, 6, 8, 12, and 26 weeks from diagnosis to death. All models were performed with and without stage at diagnosis as a predictor variable. Clinico-demographic and health service utilization data in the 24 months pre-diagnosis were provided via linked administrative databases. RESULTS: The strongest, most consistent predictors of dying within 2, 4, 6, and 8 weeks of CRC diagnosis were related to health services utilization in the 24 months prior to diagnosis: i.e., number of specialist visits, number of days spent in hospital, and number of family physician visits. Stage at diagnosis was the strongest predictor of dying within 12 and 26 weeks of diagnosis. CONCLUSIONS: Identifying potential predictors of a short timeframe between cancer diagnosis and death may aid in the development of strategies to facilitate timely and appropriate referral to palliative care upon a cancer diagnosis.

Identifying persons with diabetes who could benefit from a palliative approach to care.

OBJECTIVE: To determine the need for diabetes mellitus palliative care, we identified persons with a diagnosis of diabetes who accessed palliative care programs and those who may have benefited from a palliative approach to care. METHODS: This retrospective, descriptive research used 6 linked databases comprising 66 634 Nova Scotians from 3 health districts who died between 1995 and 2009, each with access to a palliative care program and diabetes centres. RESULTS: The percentage of persons with diabetes enrolled in palliative care increased from 3.2% in 1995 to 34.3% in 2009; 31.5% were enrolled within their last 2 weeks of life. Most did not have their diabetes recorded in palliative data. Among the 5353 persons with a diagnosis of diabetes who died between 2005 and 2009, 61.0% were in the Diabetes Care Program of Nova Scotia registry. An additional 19.6% were identified in the Cardiovascular Health Nova Scotia registry, and a further 3.7% in palliative data. Applying the criteria of Rosenwax et al to the 5353, 65.8% to 97.9% may have benefitted from a palliative approach. CONCLUSIONS: Rates of palliative enrollment for persons with diabetes are increasing. Diabetes care providers need to prepare patients and their families for changes in diabetes management that will be beneficial as end of life approaches. Collaboration among chronic disease programs, palliative care and primary care is advised to identify persons at end of life who have diabetes and to develop and implement care guidelines for this population.

What is the data-defined length for short time from diagnosis to death that is associated with a low rate of palliative care enrolment for persons with colorectal cancer?

OBJECTIVE: Prior research has demonstrated that people who die shortly after receiving a cancer diagnosis are at increased risk for not being referred to palliative care. No previous studies have empirically derived the length of time between diagnosis and death associated with increased risk. The objective of this study was to identify the length of time between diagnosis and death associated with increased risk for non-enrolment in a palliative care programme. METHODS: Binary recursive partitioning was employed to derive the cut-point for the number of days from colorectal cancer diagnosis to death predictive of a high risk for non-enrolment in a palliative care programme in two health districts in Nova Scotia, Canada. The study included all adults (≥20 years) who were diagnosed with colorectal cancer in the two districts between 1 January 2001 and 31 December 2005 and who died between 1 January 2001 and 31 December 2008 (n=894). RESULTS: Individuals who died within 18.5 days following diagnosis were at highest risk for non-enrolment in palliative care. Of the 60 adults who died in <18.5 days, 16.7% were enrolled in a palliative care programme; of the 835 adults who died ≥18.5 days after diagnosis, 65.9% were enrolled. CONCLUSIONS: This data-driven approach may be used to define the short diagnosis-to-death time frame at which individuals are at increased risk for non-enrolment in palliative care programmes. This approach allows researchers to further investigate and compare empirically-derived cut-points that identify those who die quickly and are at risk of not receiving palliative care.

Distribution and sharing of palliative care costs in rural areas of Canada.

Few data are available on the costs occurring during the palliative phase of care and on the sharing of these costs in rural areas. This study aimed to evaluate the costs related to all resources used by rural palliative care patients and to examine how these costs were shared between the public healthcare system (PHCS), patients' families, and not-for-profit organizations (NFPOs). A prospective longitudinal study was undertaken of 82 palliative care patients and their main informal caregivers in rural areas of four Canadian provinces. Telephone interviews were completed at two-week intervals. The mean total cost per patient for a six-month participation in a palliative care program was CA$31,678 +/- 1,160. A large part of this cost was attributable to inpatient hospital stays and was assumed by the PHCS. The patient's family contributed less than a quarter of the mean total cost per patient, and this was mainly attributable to caregiving time.

Bereaved family member perceptions of patient-focused family-centred care during the last 30 days of life using a mortality follow-back survey: does location matter?

BACKGROUND: Improving end-of-life care is an important international issue. Recently Nova Scotia researchers conducted a mortality follow-back survey to provide a population-based description of care provided to adults during their last 30 days of life as perceived by knowledgeable bereaved family members. Here we describe the relationship between the location where the decedent received the majority of care during their last 30 days and the informant's perception of the extent of unmet need, as defined by multiple domains of patient-focused, family-centred care. METHOD: Death certificate identified informants (next-of-kin) of eligible adults who died between June 2009 and May 2011, in Nova Scotia, Canada were invited to participate in a telephone interview based on the After-Death Bereaved Family Member Interview. Whether or not the informant expressed unmet need or concerns for six patient-focused, family-centred care domains were assessed in relation to the location where the majority of care occurred during the decedent's last 30 days. RESULTS: 1358 informants took part (25% response rate). Results of 1316 eligible interviews indicated home (39%) was the most common location of care, followed by long-term care (29%), hospital (23%) and hospital-based palliative-care units (9%). Unmet need ranged from 5.6% for dyspnea help to 66% for the emotional and spiritual needs of the family. Although the mean score for overall satisfaction was high (mean = 8.7 in 1-10 scale; SD 1.8), 57% were not completely satisfied. Compared to home, adjusted results indicated greater dissatisfaction with overall care and greater communication concerns in the hospital. Greater unmet need occurred at home for dyspnea. Less overall dissatisfaction and unmet need were expressed about care provided in long-term care facilities and hospital-based palliative-care units. CONCLUSION: Bereaved informants were generally highly satisfied with the decedent's care during their last 30 days but variations were evident. Overall, no one location stood out as exceptionally different in terms of perceived unmet need within each of the patient-focused, family-centred care domains. Communication in various forms and family emotional and spiritual support were consistently viewed as lacking in all locations and identified as targeted areas for impacting quality care at end of life.

Co-morbidities of persons dying of Parkinson's disease.

INTRODUCTION: Disease interactions can alter functional decline near the end of life (EOL). Parkinson's disease (PD) is characterized by frequent occurrences of co-morbidities but data challenges have limited studies investigating co-morbidities across a broad range of diseases. The goal of this study was to describe disease associations with PD. METHODS: We conducted an analysis of death certificate data from 1998 to 2005 in Nova Scotia. All death causes were utilized to select individuals dying of PD and compare with the general population and an age-sex-matched sample without PD. We calculated the mean number of death causes and frequency of disease co-occurrence. To account for the chance occurrence of co-morbidities and measure the strength of association, observed to expected ratios were calculated. RESULTS: PD decedents had a higher mean number of death causes (3.37) than the general population (2.77) and age-sex-matched sample (2.88). Cancer was the most common cause in the population and matched sample but fifth for those with PD. Cancer was one of nine diseases that occurred less often than what would be expected by chance while four were not correlated with PD. Dementia and pneumonia occurred with PD 2.53 ([CI] 2.21-2.85) and 1.83 (CI 1.58-2.08) times more often than expected. The strength of association for both is reduced but remains statistically significant when controlling for age and sex. DISCUSSION: Those with PD have a higher number of co-morbidities even after controlling for age and sex. Individuals dying with PD are more likely to have dementia and pneumonia, which has implications for the provision of care at EOL.

Cultural understanding in the provision of supportive and palliative care: perspectives in relation to an indigenous population.

OBJECTIVES: The provision of supportive and palliative care for an indigenous people in Nova Scotia, Canada, was examined to further our understanding and thereby improve cultural competency. Most of Nova Scotia's indigenous people are Mi'kmaq. The Mi'kmaq Nation lives in Atlantic Canada as well as New England in the eastern USA. METHODS: Themes were identified in the literature and through discussion with seven experts who have Mi'kmaq health and cultural research expertise. This paper has been reviewed and approved by two Mi'kmaq consultants who frequently speak on behalf of the Mi'kmaq people in relation to health and cultural understanding. Recommendations for non-indigenous care providers are presented. RESULTS: The themes identified focused on jurisdictional issues and cultural understanding. They are interconnected and grounded in the historic Mi'kmaq context of colonialism. Jurisdictional issues experienced by the Mi'kmaq affect access, continuity and appropriateness of care. Cultural concepts were associated with worldview, spirituality, the role of family and community relationships and communication norms, and thereby with the alignment of values and language in the provision of care. Three Mi'kmaq concepts are noted: apiksiktatulti, nemu'ltus and salite. CONCLUSION: Through reflection on the situation of Nova Scotia's Mi'kmaq, non-indigenous healthcare providers can assess how they might increase their cultural understanding in the provision of supportive and palliative care. Recommendations relate to the health system, relationships with individual persons and direction for research.