The Multidisciplinary Team in Palliative Care PDF

The Multidisciplinary Team in Palliative Care Dr. Meryem ERCEYLAN 23.02.2024 Multidisciplinary Team A multidisciplinary team (MDT) is a group of healthcare professionals of varied disciplines and roles, working together towards a common goal of providing optimal care for a patient. The Multidiscipli...

The Multidisciplinary Team in Palliative Care Dr. Meryem ERCEYLAN 23.02.2024 Multidisciplinary Team A multidisciplinary team (MDT) is a group of healthcare professionals of varied disciplines and roles, working together towards a common goal of providing optimal care for a patient. The Multidisciplinary Team in Palliative Care Most areas of healthcare now work in multidisciplinary teams, but palliative care lends itself particularly well to this approach because of the multiple dimensions involved in caring for palliative patients: physical, social and psychological, and with close links to the family The Multidisciplinary Team in Palliative Care Palliative care is a medical specialty that health professionals receive specific training for. Palliative care team may be made up of medical, nursing and allied health professionals, who offer a range of services to assist patient, their family and carers throughout their illness. This team may include spiritual or carers and volunteers. Who is in the palliative care team? Palliative care is provided by a team of healthcare professionals with a range of skills to help patients manage your life-limiting illness. Specialist palliative care services are made up of a multidisciplinary team of doctors, nurses and allied health professionals, such as occupational therapists, physiotherapists and social workers, who are trained to look after people with complex health care issues. Who is in the palliative care team? Palliative care team works together to meet patients' physical, psychological, social, spiritual and cultural needs and also helps their family and carers. How is palliative care provided? Palliative care can be provided in a variety of ways. A whole range of people are involved in palliative care teams such as social workers, physiotherapists, chaplains, doctors, nurses and volunteers. For some people, palliative care is best provided in their own community at a nearby clinic, by their usual nurse or doctor. For other people palliative care is best provided at home. This may mean relatives, friends or volunteers providing most of the care, with visits from health care workers for support and training. Some people require more specialized palliative care services. These may be provided in a hospice, in a hospital or community setting by a specialist team. Possible members of the palliative care team General Practitioner (GP) or family Doctor ✓ Coordinates palliative care for many people. ✓ Continues to see you for day-to-day health care issues if you are being cared for at home. ✓ May be able to make home visits. ✓ Talks with your nurse or palliative care specialist to coordinate ongoing care and refer you to a palliative care specialist if you have complex needs. ✓ Organises your admission to hospital or a palliative care unit (hospice) if your circumstances change. ✓ Offers support to you, your family and carers, and gives referrals for counselling and other services. Possible members of the palliative care team nurse or nurse practitioner ✓ May be a nurse, community nurse or specialist palliative care nurse at a hospital, community nursing service, residential aged care facility or palliative care service. ✓ Helps you manage pain and other symptoms with medicines, treatments and practical strategies. ✓ Visits you if you are being cared for at home and provides after-hours telephone support. ✓ Coordinates other health professionals and works out what care you need (e.g. home nursing or personal care). ✓ Refers you to a specialist palliative care unit (hospice). Possible members of the palliative care team palliative care specialist, physician or nurse practitioner ✓ Oversees treatment for symptoms such as pain, nausea, constipation, anxiety, depression, breathlessness. ✓ Usually provides care in a palliative care unit (hospice) or hospital (both for inpatients and outpatient clinics), but may be part of a community specialist palliative care service and visit you in your home or in a residential aged care facility. ✓ Communicates with and advises the cancer specialist and your GP so your treatment is well coordinated. ✓ May refer you or your family to a counsellor, psychologist or other support person, and assist with decisions about care or treatment, including advance care directives. Possible members of the palliative care team ✓ May be a medical oncologist, surgeon, radiation oncologist or haematologist and may manage some of your palliative care. cancer specialist ✓ Oversees treatment (e.g. surgery, chemotherapy, immunotherapy, targeted therapy, radiation therapy) aimed at slowing cancer growth and/or managing symptoms of the cancer. Possible members of the palliative care team counsellor, psychologist or clinical psychologist ✓ Trained in listening and offering guidance to help you manage your emotional response to diagnosis and treatment. ✓ Allows you to talk about any fears, worries or conflicting emotions and about feelings of loss or grief. ✓ Helps you and your family talk about relationships or emotions. ✓ May suggest strategies for lessening the distress, anxiety or sadness you and others are feeling or teach meditation or relaxation exercises to help ease physical or emotional pain. ✓ Gives grief care and support to your family and carers. Possible members of the palliative care team occupational therapist ✓ Helps manage physical aspects of daily activities, such as walking, bathing, getting in and out of bed and chairs. Shows carers the best way to move you or help you sit or stand. ✓ Suggests physical aids to help you move around and maintain independence, such as a toilet seat raiser, walking frame or pressure-relieving cushions. Organises equipment hire or home modifications to make it safer and more accessible (e.g. handrails, shower chair). ✓ Helps you prioritise activities to conserve energy for important tasks. ✓ Helps manage issues with memory, planning and problem solving. Possible members of the palliative care team social worker ✓ Works out what support you, your family and carers need, and identifies ways you can receive this support. ✓ May refer you to legal services, aged and disability services, and housing support or help with completing advance care directives. ✓ Helps communicate with family or health professionals (including about care goals) and supporting children or dependants. ✓ May provide counselling or suggest other ways of coping. Possible members of the palliative care team dietitian ✓ ✓ ✓ ✓ ✓ Helps with issues such as loss of appetite or weight loss. Suggests changes to diet and suitable foods to eat. May provide nutritional supplements or protein drinks. Tries to resolve digestive issues, nausea or constipation. May work with a speech pathologist for problems swallowing. Possible members of the palliative care team speech pathologist ✓ Helps you eat and drink as safely as possible if you have problems chewing food or with swallowing. ✓ Gives advice on consistency of food and helps with good mouth care (e.g. dry mouth, too much saliva). ✓ Helps with communication, such as voice problems and speaking or understanding language. ✓ Recommends communication devices and talking boards for patients who have trouble speaking. ✓ May help with memory, planning and problem solving. Possible members of the palliative care team physiotherapist ✓ Suggests physical aids to help you move safely and maintain independence, such as a walking frame or walking stick. ✓ Helps you improve or maintain your balance when moving. ✓ Offers pain relief techniques, such as positioning your body, stimulating nerves in your body and using hot or cold packs. ✓ Shows how to safely exercise to reduce pain and stiffness. ✓ Can help clear congestion from your lungs, and teach you breathing exercises to better manage breathlessness. ✓ May work with a massage therapist to relieve stiff and sore muscles or swelling, or a podiatrist for foot-related issues. Possible members of the palliative care team Pharmacist ✓ Dispenses medicine, gives advice about medicines, doses and possible side effects or interactions with other drugs. ✓ Can organise a medicine pack (e.g. Webster-pak) that sets out all the doses that need to be taken throughout the week. ✓ Communicates with the prescribing doctor if needed. ✓ Can help you keep track of medicines, including costs on the Pharmaceutical Benefits Scheme (PBS). Possible members of the palliative care team spiritual or pastoral care practitioner ✓ May be called a spiritual adviser, pastoral carer, priest, deacon, rabbi, mufti or reverend. ✓ Supports you and your family to talk about spiritual matters. Helps you reflect on your life and, if you want, on your search for meaning. ✓ May help you to feel hopeful and develop ways to enjoy your life despite the cancer. ✓ Can organise prayer services and religious rituals for you and connect you with other members of your faith. ✓ May discuss emotional issues (many are also counsellors). Possible members of the palliative care team cultural adviser or patient care navigator ✓ Cultural advisers, help to make sure you feel supported, safe and respected while using health services and help the people looking after you to provide care that is respectful to culture. ✓ Patient care navigators work with you, your family and community to help you navigate the health system and avoid any barriers to receiving timely care. Some may organise care plans for you. Some cancer centres may have a patient care navigator who can also help you organise palliative care or book appointments. ✓ Residential aged care facility outreach support services can help residents or people having high level support in the home to get care. Possible members of the palliative care team volunteer ✓ Offers friendship, support and companionship – their role will vary, depending on the organisation they volunteer with. ✓ May provide practical assistance, such as taking you shopping or to appointments, giving your carer a break, minding children, or doing basic jobs around the house. ✓ You may find a volunteer through a palliative care service (volunteers are screened, trained and supervised) or through a state or territory palliative care organisation. ✓ May be a friend, family member or neighbour. You may not like asking for help, but people usually want to help you. Pat’s story I was first diagnosed with bowel cancer 2 years ago. I had a year of intensive treatment and thought I was in remission, but then a PET scan revealed advanced cancer. The oncologist recommended another 7 months of chemotherapy treatment. The treatment is palliative – it is trying to stop the cancer spreading further. Pat’s story My main worry was transport: “How will I get to hospital for all these appointments?” My husband is 89 and can drive only in the local area. Our children are all working and I wanted to lessen the impact on them. The local community care service put me in touch with a volunteer palliative care group. The volunteers are marvellous. They drive me to all my appointments, but also offer mentoring, comfort and friendship. I also got some help with house cleaning, which has taken such a burden off me and my husband. Pat’s story I’ve used many of the hospital services as well. My oncologist arranged a meeting with the counsellor. The social worker gave me practical advice, and the occupational therapist modified our home to suit my illness. My spiritual needs are met by the chaplain, and I know the palliative care coordinator will be there to help me. With all these palliative care services, I feel like I have a window of time to get my house in order. I want my transition to be easy for my family. Pat’s story I’ve taught my children how to live, and now I’m teaching them how to die. Strangely, it’s an experience I wouldn’t have missed – it’s brought so many beautiful people into my life and renewed my faith that kindness and love are at the core of all humanity. I’d like people with advanced cancer to know that there are a myriad of services. You only have to ask; you are not alone. CASE REPORT D was a 36-year-old female patient diagnosed with metastatic triple negative breast cancer. The patient had undergone 7 cycles of chemotherapy before being referred to and managed by the pain and palliative care team. Metastases had spread to her cervico-dorsal, lumbar and sacral vertebrae and bilateral pelvic bones. On presentation to the pain control out patients department (OPD) she had severe pain in her head and neck, and was admitted to the inpatient palliative care unit for analgesic titration and control of nausea and vomiting. The multidisciplinary team in palliative care: A case reflection Management The patient was already on anti-sickness medication (Ondansetron); further management of nausea and vomiting included the introduction of a proton pump inhibitor (Pantoprazole) as well as advice on diet and patterns of eating. The multidisciplinary team in palliative care: A case reflection The management of the patient’s pain was more complex, and can be framed in the context of total pain The multidisciplinary team in palliative care: A case reflection Physical pain control was managed as per the WHO pain ladder. The patient was already on step 3 of the ladder, so her morphine dose was increased from 20 mg every 4 h to 30 mg every 4 h. Due to her head and neck pain, an MRI was done. This was discussed at a cross-disciplinary meeting with the radiologists to clarify what the progression of the disease was and what would be the most appropriate way to move forward with management. The multidisciplinary team in palliative care: A case reflection Physical pain control Although the progression of disease was such that treatment was no longer an option, a decision to give radiotherapy was taken as a palliative measure in order to prevent spinal cord compression and its complications, as well as to relieve pain and preserve function. As an adjunct to this, the physiotherapists provided advice on movements of the head and neck, and also a neck brace. The multidisciplinary team in palliative care: A case reflection The patient’s social problems had started when she first fell ill. She had to leave her job of making clothes and therefore lost some of the family income. Her brother and husband were also missing work to bring her to the hospital and spend time with her there, resulting in a further loss of income. Housing problems arose when the family’s landlord found out that the patient was in the terminal stages of illness and asked the family to vacate the property. The multidisciplinary team in palliative care: A case reflection The patient’s social problems The children went to stay with another family, but the patient was left without a home to go to once she was discharged from the palliative care unit. In this situation a non-governmental charity organization was called upon, who run a hospice. The hospice provides care for patients who have nothing further to benefit from cancer treatment, providing symptomatic care for pain and other distressing cancer symptoms (nausea, restlessness, and respiratory problems). The multidisciplinary team in palliative care: A case reflection Psychological pain was clearly evident upon speaking with the patient, and support was provided by all members of the palliative care team. I found there was an emphasis on communication and empathy above and beyond what is seen in other medical disciplines in the hospital. The patient’s family (daughter, brother and husband) also spent lots of time with her in the hospital and were an ongoing source of psychological support. The multidisciplinary team in palliative care: A case reflection She did not witness any interactions with health professionals in the hospital that were explicitly spiritual. The hospice has more space for spiritual matters; spiritual counselors or leaders can come to the hospice to see the patients, with each religion given equal respect. Reflections on the role of MDT The care of the patient involved doctors from different specialties (anaesthetics, medical oncology, surgical oncology, radiology), as well as other health professionals (nurses, physiotherapists), health professionals working in other sectors (NGOs), and also the patient’s family who play a key role in palliative care. Reflections on the role of MDT Doctors Doctors from different specialties worked closely with each other, sharing discussions on ward rounds and between times, so that there was collaboration rather than disciplines working independently on what they believe to be their remit of a patient’s care. When patients presented to the OPD, if they were suffering from pain that could not be remedied with a simple change in prescription, they were admitted to the ward for titration of analgesics in the hospital. Reflections on the role of MDT Other hospital healthcare workers The different health professionals worked side by side. It was a hierarchical system, with doctors being in charge of patient care and nurses and physiotherapists involvement arising as instructed by the doctor, but the role of the physiotherapist and nurses was highly valued by the doctors. In outpatient clinics the different professionals were working in the same room so could work closely together. Reflections on the role of MDT NGO Sector Involvement of the NGO sector was complementary to the care given at the hospital. Rather than being two separate entities, the government hospital and NGOs worked together. In the case, the hospital suggested hospice care and the suitability of this was considered between the doctors, the hospice, the family and the patient. Contact with the NGO was usually made by doctors from hospitals, and many patients were both receiving home visit care and visiting outpatient pain clinics. The home support team was able to spend more time with individual patients in their own environment, and also provide practical and emotional support to the families. For this they had a counselor in their team as well as a doctor and a nurse. Reflections on the role of MDT The Family The family take on a role not just as part of the patients’ social and emotional life, but also as carers and therefore part of the healthcare team. The daughter of the patient discussed was doing most of the caring for the mother, cooking and cleaning in the house and helping her to get around as she needed. This requires a different kind of collaboration with families, involving education as to the patients’ physical needs as well as emotional. Reflections on the role of MDT The role of communication Many patients and relatives of patients told their stories of being cared for under this palliative care team. This was the positive effect on both the patients and the families’ experience of the end of life. An emphasis on the human aspects of the care received was made, so it is clearly a structure of individuals from different disciplines working well together. Reflections on the role of MDT Conclusion Working between disciplines and between sectors provided a good support structure for patients. To extend the benefits of such teams requires greater education and advocacy of the palliative care approach in other institutions and care providers. Meetings provided a space where patients, families and professionals could be cared for through regular discussions of service provision. While the many practical, clinical and social support elements that inform decision-making are formally recorded, the meetings also enable staff members to share and negotiate the negative affective dimensions of their work. REFERENCES https://pcc4u.org.au/learning/topics/topic1/t1_section2/t1_activity5/ https://spcare.bmj.com/content/bmjspcare/early/2021/09/29/bmjspcare2021-003267.full.pdf file:///C:/Users/lenovo/Desktop/Understanding-Palliative-Care-2023.pdf https://www.cancercouncil.com.au/cancer-information/advancedcancer/palliative-care/key-questions/team/ https://www.betterhealth.vic.gov.au/health/servicesandsupport/whoswho-in-a-palliative-care-team#bhc-content https://www.mariecurie.org.uk/help/support/diagnosed/practicalemotional-support/people-involved