Palliative Care: How Interdisciplinary Teams Make a Difference

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

Core Members Patient Family Caregiver Physician RN/NP Social Worker Chaplain Psychologist Extended Members Pharmacist PT/OT Nursing Assistant Dietician Speech Pathologist Housekeeper Who is on a Palliative Care Team?

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)

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 Team Pitfalls

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

Palliative Care: How Interdisciplinary Teams Make a Difference