Complexities of care of the elderly


The Communication and Cultural Competence program is based on case studies that give examples of everyday medical practice in Canada. These modules do not focus on diagnosis and treatment. Instead, they focus on communication between health professionals and patients. Please note that the modules are not intended to show the only way to deal with a situation. Instead, they are intended to provide guidance on how to approach and reflect on these different scenarios.
  • The theme of this module is the care of the elderly with multiple medical problems. This age group is one of the fastest growing segments of our population, and consumes a large proportion of health-care resources. We focus on three common issues in this case:

    • The appropriate location of care (e.g., home, long-term care facility, hospital acute care) is an important resource issue in every province and territory.
    • Collaboration and communication among team members and with patient and family are required professional skills. Patient management by health-care teams is the norm.
    • The psychosocial issues of patients nearing the end of life, and of the caregivers who support them, are often equally as important as the biomedical conditions.

    The context for this case is the patient’s home in a rural area 20 kilometres from the primary care provider’s office and 70 kilometres from the community hospital.

    As in other modules, there are commentaries and reflective exercises that can be accessed after each part of the module. They are used to stimulate thinking about what has occurred in the video.

MCC role objectives


  • Accurately elicit relevant information and perspectives from patients, families, colleagues and other professionals (2.0)
  • Accurately convey relevant information and explanations to patients, families, and communities (3.0)
  • Develop a shared plan of care with patients, their families, and other professionals (4.0)



  • Participate effectively on health-care teams (3.0)
  • Manage conflict effectively (4.0)



  • Accept responsibility for ensuring continuity of care (2.2)
  • Know, and appropriately implement, current ethical and legal aspects of the consent and capacity process (2.4)
  • Accountability to other health professionals and the health-care system (5.0)

For a complete list of the CanMEDS roles, visit

Sentinel habits

  • Incorporate the patient’s experience and context into problem identification and management
  • Demonstrate respect and/or responsibility
  • Communicate verbally and in writing in a clear and timely manner

Entrustable professional activities

  • Manage transitions of care (7)
  • Lead and work within interprofessional health-care teams (8)
  • Collaborate with patients, families and members of the interdisciplinary team (9)


Critical competencies 

  • Function effectively as an MRP and Internal Medicine consultant, integrating all of the CanMEDS roles to provide optimal, ethical, safe and patient-centred medical care (1)
  • Seek appropriate consultation from other health professionals, recognizing the limits of one’s own expertise (5)
  • Develop rapport, trust and ethical therapeutic relationships with patients and families (8)
  • Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues and other professionals (9)
  • Convey relevant information and explanations accurately to patients and families, colleagues and other professionals (10)
  • Develop a common understanding on issues, problems and plans with patients, families and other professionals to develop a shared plan of care (12)
  • Participate effectively and appropriately in an interprofessional health-care team (13)


By the end of this module participants should recognize the need to become familiar with:

  • Consent and capacity guidelines within their own jurisdiction
  • Community resources within their jurisdiction
  • The scope of practice of other health-care providers
  • The principles of conflict resolution
  • The principles of communication with the elderly and caregiver family members, including confidentiality


Next: Part 1