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