Transcript The Role of the Palliative Care Team

Palliative Care: How
Interdisciplinary Teams Make
a Difference
Robyn Anderson, RN, MSN
Susan Cohen, MD
Judith L. Howe, PhD
Bronx-NY Harbor GRECC
GRECC National Audioconference
March 29, 2007
Overview and Objectives
Overview of principles of palliative care
Overview of interdisciplinary health care
teamwork
Promoting successful teamwork and
avoiding team pitfalls
Cases for discussion
Goals of Palliative Care Programs
Aim to reduce suffering and improve quality
of life for patients with advanced illness
Use a variety of hospital resources and
personnel to care across a range of settings
Care 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 care
Attention to physical, psychological,
cultural, social, ethical and spiritual
needs
Interdisciplinary team approach
Education and support of patient and
family
Principles (con’t)
Extends across illnesses and settings
Bereavement Support
May balance comfort measures and
curative treatments
Appropriate at any stage of the disease
Does not require a prognosis of less
than six months
Palliative Care is
Interdisciplinary in Nature
Traditional medical model
Disease focused
Often misses non physical assessment
Care is episodic and may be uncoordinated and
fragmented
Interdisciplinary model
Patient and family focused
Coordinate care paramount
Interdisciplinary 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 practice
Hospital Inpatient
Unit based
Consultation Team
Home care
Nursing Home
Hospice
Who is on a Palliative Care Team?
Core Members
Patient
Family
Caregiver
Physician
RN/NP
Social Worker
Chaplain
Psychologist
Extended Members
Pharmacist
PT/OT
Nursing Assistant
Dietician
Speech Pathologist
Housekeeper
VHA and Palliative Care Teams
2003 Directive requires palliative care
consultation teams at all facilities
Must include a physician, nurse, social
worker and chaplain
Many 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 making
Opportunity for personal & professional growth
Defined goals and measures which allow for flexibility
when appropriate
Action and momentum
Periodic review to allow for improvements
Team routines and rituals
Strong leader(s)
Team Pitfalls
External/Organizational
Inconsistent service delivery
Erratic, sloppy
communications
Not handling transitions well
Shared accountability may =
NO accountability
Internal/Team
Conflicts
Lack of trust
Lack of commitment
Power inequalities
among members
Conflicting 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 studies
Multiple assessment instruments employed
Positive effects on physical symptoms
demonstrated
Psychosocial symptoms more refractory
Decreased hospital cost/resource utilization
A. Franke, 2000
Cases Illustrating the Process
of Teamwork in Palliative Care
Case #1
Mr. 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 Points
Chaplain on pall care team has known patient
for years, therefore becomes team leader
Chaplain 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 Points
She overstepped her role – another provider
was the leader for THIS patient
She 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 Points
Involved ID Social Worker
Used 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 care
Result: need for team self-care
Take Home Points
Interdisciplinary teamwork is central to
palliative care
Successful teams require nurturing and
effort
Demands of end-of-life care are unique
and require the benefits of teamwork