palliative care: how interdisciplinary teams make a difference robyn anderson, rn, msn susan cohen,...
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Palliative Care: How Interdisciplinary Teams
Make a DifferenceRobyn Anderson, RN, MSN
Susan Cohen, MDJudith L. Howe, PhD
Bronx-NY Harbor GRECC
GRECC National AudioconferenceMarch 29, 2007
Overview and Objectives
Overview of principles of palliative care Overview of interdisciplinary health care teamworkPromoting successful teamwork and avoiding team pitfallsCases for discussion
Goals of Palliative Care Programs
Aim to reduce suffering and improve quality of life for patients with advanced illnessUse a variety of hospital resources and personnel to care across a range of settingsCare is provided by an interdisciplinary team and offered in conjunction with all other appropriate forms of health care treatment.
General Principles of Palliative Care
Patient and family as unit of careAttention to physical, psychological, cultural, social, ethical and spiritual needsInterdisciplinary team approachEducation and support of patient and family
Principles (con’t)
Extends across illnesses and settingsBereavement SupportMay balance comfort measures and curative treatmentsAppropriate at any stage of the diseaseDoes not require a prognosis of less than six months
Palliative Care is Interdisciplinary in Nature
Traditional medical model Disease focusedOften misses non physical assessmentCare is episodic and may be uncoordinated and fragmented
Interdisciplinary modelPatient and family focusedCoordinate care paramountInterdisciplinary team is a cornerstone
Interdisciplinary Health Care Team Definition“A group of people from different
disciplines who assess and plan care in a collaborative manner. A common goal is established and each discipline works to achieve that goal.”
(www.gitt.org)
Settings for Palliative Care Teams
Outpatient practiceHospital Inpatient
Unit basedConsultation Team
Home careNursing HomeHospice
Who is on a Palliative Care Team?
Core MembersPatientFamilyCaregiver PhysicianRN/NPSocial WorkerChaplain
Psychologist
Extended MembersPharmacistPT/OTNursing AssistantDieticianSpeech PathologistHousekeeper
VHA and Palliative Care Teams
2003 Directive requires palliative care consultation teams at all facilitiesMust include a physician, nurse, social worker and chaplainMany national and local training activities to support palliative care in VHA (e.g., AACT, HVP, Fellowships)
What Makes a Successful Team?
Team identity…”I work on a palliative care team”Shared decision makingOpportunity for personal & professional growthDefined goals and measures which allow for flexibility when appropriateAction and momentumPeriodic review to allow for improvementsTeam routines and ritualsStrong leader(s)
Team Pitfalls
External/Organizational
Inconsistent service deliveryErratic, sloppy communicationsNot handling transitions wellShared accountability may = NO accountability
Internal/Team
ConflictsLack of trustLack of commitmentPower inequalities among membersConflicting loyalties
The Dysfunctional Palliative Care Team: How Teamwork can Contribute to Stress
•Lack of clearly defined roles caused problems for collaboration
•Perceived lack of competence of some team members caused tensions
•Nurses criticized focus on need for technical skills, felt communication aspects were being neglected
•Increased workload and working overtime = “burnout”
•Lack of care for team itself ~”care for the caregivers”
(Anne Loes van Staa et. al., 2000)
Is there evidence that palliative care teams make a difference?
Evaluative studies on the impact of hospital based palliative care teams (US, UK, Canada, Belgium)
Mostly uncontrolled studiesMultiple assessment instruments employedPositive effects on physical symptoms demonstratedPsychosocial symptoms more refractoryDecreased hospital cost/resource utilization
A. Franke, 2000
Cases Illustrating the Process of Teamwork in
Palliative Care
Case #1Mr. C is a 78 year old man, former artist, who had ESRD on dialysis, chronic back pain, recent complicated ICU admission for ARDS, now with refractory severe infectious colitis. His goals of care have always been aggressive. Now, he is asking to talk to someone about heaven.
Team PointsChaplain on pall care team has known patient for years, therefore becomes team leaderChaplain was able to give team a longitudinal view of the “person” (not the patient) All disciplines were needed to control physical and existential pain and support patient and family
Case #2 On team rounds, which included
members of palliative care team and oncology, a part time member of the palliative care team questioned the patient about his spiritual beliefs and coping style. The patient visibly withdrew and cut the discussion short.
Case #2 continued The rest of the team felt that this
was inappropriate given that her role and connection with the patient was more peripheral. The team was angry and insulted.
Team PointsShe overstepped her role – another provider was the leader for THIS patientShe didn’t confirm whether this had already been discussed – communication/coordination Team lost trust in her Patient may lose trust in team if they don’t seem to have communicated prior to rounding
Case #3 Mr. H. is a 59 year old man, former
substance abuser, with severe character pathology, now with end-stage AIDS. Due to numerous behavioral issues, there are very few disposition options. Nursing and medical staff are frustrated by his behavior and his pain and emotional distress are not adequately managed.
Team PointsInvolved ID Social WorkerUsed a variety of team members in order to address “splitting” and disruptive behavior Team members acknowledged various personality styles and strengths and incorporated this into plan of careResult: need for team self-care
Take Home PointsInterdisciplinary teamwork is central to palliative careSuccessful teams require nurturing and effortDemands of end-of-life care are unique and require the benefits of teamwork
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