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CreatedOn: 24 Mar, 2024
LastUpdatedOn: 15 May, 2024

Multidisciplinary team(MDT)

About Multidisciplinary Team

  

A multidisciplinary team for palliative care is a collaborative group of healthcare professionals from various disciplines who work together to provide comprehensive care to patients facing serious illnesses and their families. This team approach ensures that patients receive holistic support addressing their physical, psychological, social, and spiritual needs. Here are some key members of a multidisciplinary palliative care team:
 
1. Physicians.
2. Nurses.
3. Social workers.
4. Chaplains or spiritual care providers.
5. Psychologists or counselors.
6. Pharmacists.
7. Occupational therapists.
8. Physical therapists.
9. Dietitians.
 
 
By working together as a cohesive team, these professionals collaborate to develop personalized care plans, address complex needs, optimize symptom management, support patients and families, and enhance quality of life throughout the illness journey.
Goal of Multidisciplinary Team
The primary goal of a palliative care multidisciplinary team is to provide holistic and comprehensive care to patients facing serious illnesses and their families. This includes:
 
  • Enhancing quality of life: By addressing physical symptoms, psychological distress, social concerns, and spiritual needs, the team aims to improve the overall quality of life for patients, focusing on comfort, dignity, and well-being.
  • Managing symptoms: The team collaborates to identify and manage symptoms such as pain, nausea, fatigue, and shortness of breath, using evidence-based interventions to alleviate suffering and enhance comfort.
  • Supporting decision-making: Through open and honest communication, the team assists patients and families in understanding their illness, treatment options, and prognosis, empowering them to make informed decisions that align with their values and goals of care.
  • Providing psychosocial support: The team offers emotional support, counseling, and practical assistance to help patients and families cope with the emotional, social, and existential challenges of serious illness, fostering resilience and adaptation.
  • Facilitating care coordination: By coordinating care among various healthcare providers and services, the team ensures seamless transitions, continuity of care, and optimal utilization of resources, promoting efficiency and effectiveness in care delivery.
  • Promoting advance care planning: The team facilitates discussions about advance care planning, including preferences for end-of-life care, resuscitation, and life-sustaining treatments, helping patients and families articulate their wishes and document them in advance directives.
  • Providing spiritual care: Spiritual care providers offer support, guidance, and pastoral care according to the patient’s beliefs and values, addressing existential concerns, facilitating rituals and ceremonies, and promoting peace and meaning.
  • Optimizing medication management: Pharmacists collaborate with the team to optimize medication regimens, ensuring appropriate symptom control, minimizing adverse effects, and aligning treatments with palliative goals of care.
  • Maximizing functional independence: Occupational and physical therapists work with patients to improve mobility, strength, and independence in activities of daily living, enhancing functional status and quality of life.
  • Facilitating end-of-life care: As patients approach the end of life, the team provides compassionate and dignified care, focusing on symptom management, comfort measures, and emotional support, while respecting the patient’s wishes and preferences.
 
Overall, the goal of a palliative care multidisciplinary team is to provide personalized, patient-centered care that addresses the unique needs, preferences, and goals of each individual, promoting comfort, dignity, and well-being throughout the illness journey.

 

Importance of palliative care 
Palliative care is vital for several reasons:
 
  • Enhancing Quality of Life.
  • Holistic Care.
  • Pain and Symptom Management.
  • Support for Patients and Families.
  • Collaborative Approach.
  • Advance Care Planning.
  • Improved Patient and Family Satisfaction.
  • Cost-Effective Care.
 
Overall, palliative care plays a crucial role in improving the quality of life for patients with serious illnesses, supporting their families, and promoting a compassionate and dignified approach to care throughout the illness journey.

 

 

 

Assessment

Assessment
Physician MD Palliative Care Associate Consultant/Consultant
  • To exercise the highest possible standard of patient care in the specialty of palliative care according to his/her clinical privileges and available resources.
  • Participate in the training and teaching program of the hospital/ community related to the specialty.

 

Physician MD Palliative Care Assistant Consultant
  • To exercise the highest possible standard of patient care in the specialty of palliative care according to his/her clinical privileges and available resources.
  • Participate in the training and teaching program of the hospital/ community related to the specialty.

 

Advanced Nurse Practitioner/Nurse Practitioner/ Physician Assistant
  • Practices at an advanced level, providing autonomous and collaborative

  • Expert palliative care nursing for patients with a life limiting illness.

  • The NP role includes assessment and management of clients using nursing knowledge and skills and may include but is not limited to:

    • the direct referral of patients to other health care professionals,

    • prescribing medications and ordering diagnostic investigations.

  • To exercise the highest possible standard of patient care in the specialty of palliative care according to his/her clinical privileges and available resources.

  • Participate in the training and teaching program of the hospital/ community related to the specialty.

 

Palliative Care Nurse Coordinator
  • Assesses patients’ physical, psychological, social, and spiritual needs of patients with incurable diseases

  • Responsible for Patient Care Coordination.

  • Facilitates development, implementation, coordination and evaluation of a patient's interdisciplinary care plan.

  • Collaborates with inter and multidisciplinary teams to ensure best quality care delivery and provides specialized care required

  • Provides specialized care for patients with advanced, incurable diseases, on a direct or consultative basis, assessing their needs, and support needs of their families, makes recommendations for their management using a holistic approach through utilizing an interdisciplinary team.

 

Registered Nurse Acute Setting
  • Provides care for patients with advanced, incurable diseases, on a direct or consultative basis, assessing their needs, and support needs of their families in acute care setting

 

 Home Health Care Nurse
  • Provides care for patients with advanced, incurable diseases, on a direct or consultative basis, assessing their needs, and supporting the needs of their families in home healthcare settings.

 

Social Worker
  • Provides critical psycho-social support to palliative care patients through the palliative care services consult team.

  • Uses their professional background and skills to assist the team and facilitate patient family meetings and assists team, attending physicians, staff, and patient and family in the clarification of the goals of care and the plan of care.

  • Coordinates team efforts with appropriate hospital support departments to ensure smooth discharge planning and clear follow-up post discharge; may assist in the development of creative community or system care options for patients.

  • Serves as a liaison with the hospital hospice and other community hospices, home health, and nursing homes to ensure care coordination and appropriate assignments and resource allocation to meet patient needs throughout the continuum of care.

 

Clinical Pharmacist
  • To exercise the highest possible standard of patient care in the specialty of palliative care according to his/her clinical privileges and available resources.

  • Participates in the training and teaching program of the hospital/ community related to the specialty.

  • To ensure the safe, appropriate and cost effective provision of medicines and professional advice in line with current legislation and local and national policies.

  • Manages and improve the medication-use process in patient care settings

  • Demonstrates excellence in the provision of medication counseling to patients, caregivers, and families

  • Ensures safe and legal disposal of medication and medication supply chain management.

 

Medical Spiritual Advisor/provider/Counselor
  • Provides emotional and spiritual counseling to palliative and hospice patients, families, and bereaved.

  • Provides spiritual care of the dying and their families and facilitates available contacts within the local religious community, if requested by patients and/or families,

  • Provides and supports bereavement services

 

Dietician
  • Is responsible for medical nutrition therapy of patients.

  • Performs clinical nutrition care functions of screening, assessment, nutrition intervention, patient education and documentation of care in accordance with physician’s order and in collaboration with food services department and nursing unit.

 

Physiotherapist
  • Provides an expert and skilled therapy service to palliative care patients.

  • Contributes to the multidisciplinary team

  • Screens rehabilitation referrals and undertake holistic, specialist assessments of patients and develop dynamic treatment plans.

  • Implements and delivers excellent treatment to the patients focusing on maximizing function and engagement with their lives

 

Occupational Therapist
  • Provides an expert and skilled therapy service to palliative care patients

  • Contributes to the multidisciplinary team

  • Improves quality of life as defined by each patient and optimizing his or her functional abilities are integral to the philosophy and practice of occupational therapy.

  • Identifies current and potential abilities, and determines barriers to engaging in occupations including activities of daily living, instrumental ADLs, rest and sleep, leisure, and social participation.

 

Counselor
  • Uses counseling methods to help people manage and overcome mental and emotional issues.

  • Listens to patients, developing treatment plans, and creating coping strategies

 

Volunteer
  • Responsible and willing to serve others in a volunteer capacity and able to work within an interdisciplinary team the hospice concept
  • Supports sensitive to the social, emotional, spiritual and medical complexities of the dying patient.
  • Able to relate to people from varying races, cultures, religions and backgrounds without bias or prejudice

Management

General management 
 
A multidisciplinary team for palliative care enhace the management of palliative care patients by:
 
  • Physicians: Palliative care physicians, often known as palliative care specialists or palliative medicine physicians, lead the team and provide medical expertise in managing complex symptoms, coordinating care, and facilitating discussions about goals of care and treatment options.
  • Nurses: Palliative care nurses play a central role in assessing and managing symptoms, providing skilled nursing care, coordinating care transitions, educating patients and families, and offering emotional support throughout the illness journey.
  • Social workers: Palliative care social workers assist patients and families in navigating the healthcare system, accessing community resources and support services, addressing financial and practical concerns, and providing counseling and psychosocial support.
  • Chaplains or spiritual care providers: Chaplains or spiritual care providers offer spiritual support, guidance, and pastoral care according to the patient’s beliefs and values, addressing existential concerns, providing emotional support, and facilitating rituals and ceremonies as needed.
  • Psychologists or counselors: Psychologists or counselors provide psychological assessment and therapy to address emotional distress, anxiety, depression, grief, and existential concerns, offering coping strategies and support to patients and families.
  • Pharmacists: Palliative care pharmacists contribute expertise in medication management, including optimizing pain control, managing complex drug regimens, minimizing adverse effects, and ensuring compatibility with palliative goals of care.
  • Occupational therapists: Occupational therapists assess patients’ functional abilities and provide interventions to improve independence in activities of daily living, mobility, and self-care, as well as recommending assistive devices and environmental modifications.
  • Physical therapists: Physical therapists focus on improving patients’ mobility, strength, balance, and endurance through exercises, manual therapy, and assistive devices, enhancing quality of life and optimizing functional status.
  • Dietitians: Dietitians assess patients’ nutritional status, provide dietary counseling, and develop personalized nutrition plans to address malnutrition, cachexia, dysphagia, and other nutritional concerns, optimizing nutritional support and comfort.
  • Hospice and palliative care aides: Aides provide direct personal care assistance to patients, including bathing, dressing, grooming, and toileting, as well as providing companionship and emotional support, enhancing comfort and quality of life.

Specific Management 
 
For oncology palliative patients, management focuses on addressing symptoms related to cancer and its treatment, as well as providing psychosocial and spiritual support. Here are some specific aspects of management:
 
  • Pain Management: Effective pain relief is paramount. This often involves a combination of medications such as opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), adjuvant analgesics, and nerve blocks. Pain should be regularly assessed and managed to ensure optimal comfort.
  • Symptom Management: Addressing other common symptoms like nausea, vomiting, fatigue, shortness of breath, constipation, and loss of appetite is essential. Medications, lifestyle modifications, and complementary therapies may be used to manage these symptoms.
  • Emotional Support: Many oncology palliative patients experience anxiety, depression, grief, and existential distress. Counseling, support groups, and interventions such as cognitive-behavioral therapy (CBT) can help address these emotional concerns.
  • Advance Care Planning: Discussions about goals of care, preferences for end-of-life care, and completion of advance directives are crucial. Patients should have the opportunity to express their wishes and have them documented to guide future care decisions.
  • Communication and Decision-Making: Open and honest communication about the patient’s prognosis, treatment options, and goals of care is essential. Shared decision-making between patients, families, and healthcare providers ensures that care aligns with the patient’s values and preferences.
  • Nutritional Support: Maintaining adequate nutrition is important for quality of life. Dietary modifications, oral nutritional supplements, and, in some cases, enteral or parenteral nutrition may be necessary to prevent malnutrition and support energy levels.
  • Spiritual Care: Addressing spiritual needs and providing opportunities for reflection, prayer, or ritual can help patients find meaning and peace amid their illness. Chaplains or spiritual care providers can offer support tailored to the patient’s beliefs and values.
  • Caregiver Support: Supporting caregivers is vital as they play a significant role in the patient’s care. Education, respite care, and assistance with practical tasks can help alleviate caregiver burden and promote their well-being.
  • End-of-Life Care: As the patient approaches the end of life, focus shifts to providing comfort and dignity. Symptom management, emotional support, and facilitating meaningful connections with loved ones become priorities.
  • Bereavement Support: Providing support to family members and caregivers during the bereavement period is essential. Grief counseling, support groups, and resources can help them navigate the grieving process.
 
Overall, the management of oncology palliative patients involves a holistic approach that addresses physical, emotional, social, and spiritual needs, with the goal of improving quality of life and promoting comfort and dignity throughout the illness journey.

Request

Requests by multidisciplinary team 

Certainly, here's how a multidisciplinary team might approach investigations and requests for palliative patients:

  1. *Pain and Symptom Management*: The team may request investigations such as imaging studies (e.g., X-rays, CT scans) or laboratory tests (e.g., blood tests, tumor markers) to identify the underlying causes of symptoms and guide treatment decisions for effective pain and symptom management.
  2. *Psychosocial Assessment*: The team may request psychosocial assessments by social workers or psychologists to evaluate the patient's emotional well-being, coping mechanisms, support network, and psychosocial needs, informing interventions to address anxiety, depression, grief, and existential distress.
  3. *Nutritional Assessment*: Dietitians may conduct nutritional assessments to evaluate the patient's dietary intake, nutritional status, and metabolic needs, guiding interventions to prevent malnutrition, support energy levels, and improve quality of life.
  4. *Functional Assessment*: Occupational therapists and physical therapists may perform functional assessments to evaluate the patient's mobility, strength, balance, and activities of daily living, guiding interventions to maximize independence, minimize functional decline, and enhance quality of life.
  5. *Advance Care Planning*: The team may facilitate discussions about advance care planning, preferences for end-of-life care, and completion of advance directives, ensuring that the patient's wishes are documented and respected in future care decisions.
  6. *Medication Review*: Pharmacists may conduct medication reviews to assess the appropriateness, safety, and effectiveness of the patient's medication regimen, optimizing drug therapy, managing polypharmacy, and minimizing adverse effects.
  7. *Family Support and Education*: The team may provide education and support to family members and caregivers, helping them understand the patient's condition, providing guidance on caregiving tasks, and offering emotional support to cope with the challenges of caregiving and grief.
  8. *Spiritual Care and Counseling*: Chaplains or spiritual care providers may offer spiritual support, counseling, and pastoral care according to the patient's beliefs and values, addressing spiritual needs, providing comfort, and facilitating discussions about meaning and purpose.
  9. *Care Coordination*: The team may coordinate care among various healthcare providers and services to ensure seamless transitions, continuity of care, and optimal utilization of resources, promoting efficiency and effectiveness in care delivery.
  10. *End-of-Life Care Planning*: The team may assist in developing personalized end-of-life care plans, including discussions about preferences for location of care, symptom management goals, and arrangements for hospice or palliative care services as needed.

These investigations and requests reflect the multidimensional nature of palliative care and the importance of addressing physical, emotional, social, and spiritual needs in a coordinated and holistic manner to optimize quality of life and promote comfort and well-being for palliative patients and their families.

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