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Multidisciplinary Team Approach for Palliative Care

1. Multidisciplinary team is required for the palliative care patient which is based on comprehensive care after returning back to home. Multidisciplinary team is an important unit which works on the principle of the team approach, one to one communication, access to the therapeutic assortments, national standards and patient’s involvement (Cancer Australia, 2022). Multidisciplinary Team involves providing comprehensive care plan that is based on the clinical practice guidelines and; also contains psychosocial support and access to information. MDC can be described as a team approach practice which is considered for the treatment planning and care for the patients those who have life- limiting illness. MDC is an approach of healthcare which is integrated and; works together with medical and allied health care professionals including various options for treatment as well as developing patient- centred treatment and care plans for each individual patient (Cancer Australia, 2022). Multidisciplinary team approach coordinates and works along with all health professionals such as General Physician, Oncologist, Physiotherapist, Palliative care nurse and other healthcare staffs; and discussing various treatment options as well as decision- making altogether for the treatment and supportive care planning with attention to the preferences for the patient. MDC must coordinate and support the patient with clear and good communication; and proper collaboration between the team members regarding the patient treatment and its outcomes. MDC focuses on certain aspects of care, i.e., clinical, mental and psychosocial support for the patients. Palliative care along with a team of healthcare professionals work together to achieve the physical, social, psychological, cultural and spiritual needs, taking care of the family and the carers. MDC comprises of Comprehensive Care Plan which is a dynamic document planning describing the goals for patient care, outlining medical planning, nursing and allied health services for the patient. An important element in the multidisciplinary care approach is the Advanced Care Plan (ACP), which is required to achieve quality palliative care (Rietjens et al., 2021). Advanced Care Plan encourages patients for decision- making by their own for healthcare preferences that can be documented in Advance Care Directives (ADP). There are certain goals of ACP that includes- autonomy of the patient, improving quality of care, strengthening of relationships, preparing end-of-life decisions and reduction of overtreatment.

Hence, ACP can be considered as an intervention that targets to promote autonomy for the end-of-life decision-making of the patient (Rietjens et al., 2021). For example- In the provided case study, patient is in metastatic bowel cancer stage and he wishes to return to his home as well as he does not want that his wife get burdened. An effective approach of the multidisciplinary team to ensure home care for the patient and continuation of the care plan helps to improve the understanding towards the patient and his wife or family, regarding the disease progression; symptoms managing plan; supportive assistance for physical, social, psychosocial, mental and spiritual along with the outcome is an important aspect and assist with the cancer patients journey of life. Therefore, multidisciplinary team care approach is considered best for attaining the optimal palliative care with a common goal for better treatment outcomes of the patient.

Comprehensive Care Plan and Advanced Care Plan

2. Strategies to support palliative care patient and the family or carers during end of life care are quite critical for overall health and mental well- being. Strategies for end of life care provide emotional, social, psychosocial, mental, spiritual and practical support to the families and the care givers. Palliative care along with the end of life care helps to improve the quality of life for the person with chronic illness or to the family members and carers who are about to lose their loved ones (Smithard et al., 2019). Such strategies include- offering services, assistance services; and access to information, referral and support. It provides emotional support to the carers, the family members and the closed ones of the patient by listening patiently to them and being present with them when needed. The physical presence and holding hands of the patient, carers and the family members helps to make them feel supportive, soothing and comfortable. Nurses must provide support to the patient, the family members and the closed ones by building rapport with them, encouraging them to speak up, expressing emotional feelings. Focusing on active listening skills and providing a non-judgemental situation is important from end of life care aspect. Assistance to family members or closed and loved ones with increased interpersonal contacts, promoting sense of positivity and offering optimistic reappraisal are the considerable strategies of end of life care.

Two essential strategies include:

1. Practical support

Under practical support it includes Respite care which gives break from providing care; helping out with the concerns or emotions of the family members and the patient; advocating the family members or the carers regarding “how to provide care”, including giving medications. Nurses must guide family members with the required equipment for the palliative patient for the comfort (Fernando & Hughes, 2019). Physical support also includes- assistance with activities of daily life and other such activities; assisting with management of symptoms and medications; assisting with financial insecurity; caring responsibilities; assistance with relocating; transporting assistance; assistance with private healthcare and other healthcare funds.

2. Emotional/ mental support

From the view of emotional/ mental support, nurse can start having a conversation, listening to the patient and understand the personal values and emotions in order to provide emotional and psychosocial support (Schroeder & Lorenz, 2018). There are certain emotional needs required regarding anxiety; tolerance level; agitation; restlessness; feelings of guilt, fear and grief; worthlessness; anger; frustration; depression and stigma. Ways of communication and appropriate use of language is an important concern to keep in mind while communicating with the patient and the family members or carers along with the multidisciplinary team. Emotional support also comprises of autonomy, competence and relatedness.

Therefore, Palliative Care strategies are an important part while providing end of life care in order to support patient; carers or caregivers; family members and closed ones by making them comfortable with physical support along with mental, emotional and psychosocial support for maintaining healthy life and achieving better quality of life and well-being.

3. Integrated disease management for chronic illness must be effective in managing using a model of shared care that involves chronic disease patient as well as service providers (Reynolds et al., 2018). Integrated chronic disease management comprises of the vision which is a responsive delivery, patient- centred, effective system for care that can improve outcomes of the health and quality life for the person living with chronic diseases. This primarily aims to slow down the disease progression rate and in turn improving the health and well-being. This also improves the quality access integrated with multidisciplinary care; facilitating empowerment for the patient and the carer through self- management programs and approaches; engaging general practitioners in the multidisciplinary team and reducing demands in acute healthcare system. Integrated disease management involves in identification of early needs of the patient that leads to timely referrals; is evidence- based care; use of team- based approaches across several organisations; supporting for self- management; review on regular basis and following up (Reynolds et al., 2018). Apart from that, fostering between primary healthcare services and other organisations; supporting practice for better communication; and, planning for care and referrals. Developing partnerships and articulating various roles and responsibilities as well as developing certain care pathways.

Strategies for End-of-Life Care

Integrative palliative care includes Multidisciplinary team approach, i.e., the group of healthcare professionals varying from different disciplines or roles; that provide a common goal for achieving optimal care of the patient, while working altogether in a team (Raco et al., 2019). It is an important aspect of considering an opportunity for coordinating many clinical and social services that may be critical for the patient and the family members. Coordinated and integrated palliative care approach along with multidisciplinary team conduct meetings and discussions regarding the components of palliative care and other ranges of healthcare settings (Fulton et al., 2019). For example- In case of advanced bowel cancer patient, in the given case study, multidisciplinary team includes- Oncologist, Chemotherapist, General Physician, Physiotherapist, Psychologists, Social workers, Counsellors and Palliative care nurse are working together in a team for the better outcome of the patient. The integrated team works by organising together and coordinating the healthcare services that helps to achieve the required needs of the palliative patient and his wife or family with other required needs and support. Different professional’s expertise for planning strategies in regards of treatment options and managing care is required for joint decision- making. Palliative care approach provides services in an integrative and coordinative way for treating pain and other related symptoms. Palliative nurse discuss regarding the treatment options and manages the symptoms during home care settings; coordinate care services along with the healthcare providers (Fernando & Hughes, 2019).

“Pain Management” is being considered as a way to provide coordinated and integrated palliative care in a critically ill person. Pain relieving is an important factor in order to improvise the quality of life of the patient (Altilio et al., 2019). Pain management involves management of unpleasant sensations, unusual experiences and fear of pain. This includes nursing strategies such as- medicines for pain; physical therapies like hot or cold packs, massages, exercises, yoga and hydrotherapy. In addition to this, it also includes- psychological therapies; relaxation techniques; meditation; acupuncture and community support groups. Hence, main goal of the pain management is to reinstate the patient’s sense during chronic pain and improve the health and well-being.

References

Altilio, T., Otis?Green, S., Hedlund, S., & Fineberg, I. C. (2019). Pain management and palliative care. Handbook of health social work, 535-568. https://doi.org/10.1002/9781119420743.ch22


Cancer Australia. (2022). Multidisciplinary care. Cancer Australia. Retrieved 21 April 2022, from

https://www.canceraustralia.gov.au/clinicians-hub/multidisciplinary-care.


Fernando, G. V. M. C., & Hughes, S. (2019). Team approaches in palliative care: a review of the literature. International journal of palliative nursing, 25(9), 444-451. https://doi.org/10.12968/ijpn.2019.25.9.444


Fulton, J. J., LeBlanc, T. W., Cutson, T. M., Porter Starr, K. N., Kamal, A., Ramos, K., ... & Williams, J. W. (2019). Integrated outpatient palliative care for patients with advanced cancer: a systematic review and meta-analysis. Palliative medicine, 33(2), 123-134. https://doi.org/10.1177%2F0269216318812633


Raco, M., Burdett, T., & Heaslip, V. (2019). Exploring an integrated palliative care model for older people: an integrative review. Journal of Integrated Care. https://doi.org/10.1108/JICA-10-2018-0065


Reynolds, R., Dennis, S., Hasan, I., Slewa, J., Chen, W., Tian, D., ... & Zwar, N. (2018). A systematic review of chronic disease management interventions in primary care. BMC family practice, 19(1), 1-13.

https://bmcprimcare.biomedcentral.com/articles/10.1186/s12875-017-0692-3


Rietjens, J., Korfage, I., & Taubert, M. (2021). Advance care planning: the future. BMJ supportive & palliative care, 11(1), 89-91. https://dx.doi.org/10.1136/bmjspcare-2020-002304


Schroeder, K., & Lorenz, K. (2018). Nursing and the future of palliative care. Asia-Pacific journal of oncology nursing, 5(1), 4. https://dx.doi.org/10.4103%2Fapjon.apjon_43_17


Smithard, D., Mitchell, L., & Patel, F. (2019). Ethical considerations of care towards the end of life. Nursing And Residential Care, 21(3), 146-150. https://doi.org/10.12968/nrec.2019.21.3.146

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