Chapter 18 Dawn M. Gross, Jane Hawgood The practice of palliative care is in its very nature multidisciplinary. It requires the expertise of multiple disciplines working together in a highly functioning team in order to accomplish the goal of providing an extra layer of support for those patients and families coping with a life-altering illness. Teams are essential to the successful implementation of both generalist palliative care, which is provided by all clinicians in the hospital, and specialist palliative care. At the heart of any high-functioning team are shared core values and mission. In this review, we will define and expand upon the core values of teamwork and then create a foundation which any healthcare professional may use to assess their current team’s level of functionality. We will also describe the contributions of different disciplines and describe how teams can leverage each discipline to work best together. So what makes a team a team? Anytime you are working with one or more people focused on achieving a specific result, you are working in the context of a team. In healthcare, generally, it is the rule for providers to be working within a team. In fact, it may even be impossible for providers to find oneself alone, except for in isolated moments of silent reflection. In many settings, teams are created without intentionality, and teamwork just “happens.” This lack of deliberate formation of a team often leads to lost opportunities for transformative collaboration. Recognition and definition of a team, its purpose, and the roles within it harness the full potential of professional, multidisciplinary collaboration. Part of recognition and definition of a team is the intentional aligning of values. We represent the core values essential to a high-functioning team with the acronym TEAM: Fundamental to building a team is the quality of trust. Everyone on a team must be able to trust and be trusted by each member. This trust is not based on a resume of documented skills, though a track record of productivity is supportive of garnering a basis for trust. What cultivates trust among team members is the consistency of communication and action that forward the agreed-upon common goal. If you are playing on a football team, the quarterback has to trust the receiver to catch the ball or he will never release it. Likewise, the receiver has to move into position and trust the quarterback to make the throw. The consequences of any team member not trusting the others to play their positions to the best of their ability will result in a failed play. In other words, trust creates the foundation of team interdependence, which is the basis of its functionality. If one team member says one thing but does another, trust will be jeopardized, and the interdependence of the team is lost. Trust is not granted in a moment but can be lost in one. It is important to constantly monitor one’s own behavior and its impact on other team members. By definition, when working in the context of a team, no singular action is isolated; everything one does will have a ripple effect on each of the team members. Having team members with a variety of areas of expertise deepens and broadens the overall perspective and insight of the team. Yet breadth of expertise is advantageous only to the extent that communication within a team facilitates equal expression by all members [1]. Respect for each member’s role as integral and unique is essential. Open communication allows the nuanced expertise of every member to help shape the efforts of the team. A high-functioning team will have the value of continually educating oneself. This is not only so that each member’s expert skill set is continually enhanced, but also so that each member understands and appreciates the cross-disciplinary expertise of the others. The expectation is that new lessons learned are shared with other team members. Each professional discipline has its own culture, set of values, and ways of framing information [2]. Cross-disciplinary communication can empower cross-disciplinary insight into each other’s approach. A high-functioning team has members who are essentially multilingual and can communicate confidently and capably in the language of each other’s disciplines. Changing sport analogies to the game of baseball, sometimes the nuanced input from another player is what allows the strength of another to flourish. When supporting a pitcher who might be struggling during a game, often the catcher will approach the mound to offer insight that the pitcher cannot see. In addition to being an expert in their individual roles, team members must also be sufficiently able to “pinch hit” for each other. How the team engages both internally and externally with patients, families, and other providers, requires flexibility and agility. Team members must be nimble, able to recognize when more action is required of them, even if it stretches beyond the boundary of their professional skill set. The interdisciplinary expertise of the team enables and empowers team members to step up for each other when needed. Team members who are empowered by and trusting in the interdependence of the team will hold themselves accountable when such circumstances arise. Thinking in terms of our sport analogies, zone defenses don’t always work and fly balls drift unexpectedly. If each player stayed in their “designated” zones, tackles would be missed and balls dropped. Areas of overlap when appreciated, trusted, and empowered become areas of strength, not redundancy. For example, a social worker, well versed in the process of receiving a request for a new consult, including obtaining relevant medical details to assist with triaging cases, can empower the team to take on other responsibilities or even activities of self-care that might not otherwise be possible. Similarly, physicians can be educated in the key community support services that can be considered when exploring discharge options for complex family care scenarios. While “the more, the merrier” may not always hold true, having a variety of skills and perspectives to draw upon is highly advantageous in the complex environment of healthcare. Multiplicity of team members allows for a 360 degree view surrounding the patient and family. It also provides opportunity for the creation of interrelated support systems to meet these needs. Having multiple faces and multiple personalities with which a family may interact broadens the potential scope of communication. Multiplicity of a team also highlights the need for adequate resources. Multiplicity enables a team’s agility and interdependence, and enables team members to build trust with each other. While it is difficult to play baseball with fewer than nine players on the field, the optimum number of people on a palliative care team has many variables. Matching multiplicity to the need within a healthcare context is not just a function of numbers; it is a function of the efficacy of teamwork. In the next section, we elaborate on the specific and essential roles within a palliative care team. The specific team members can be variable, but often aim to model themselves after the Medicare-mandated hospice format comprised of the following: physician, nurse, social worker, and chaplain. This team composition is supported by many national organizations and should be leveraged at both the level of specialist palliative care and hospitalist working to provide generalist palliative care [3, 4]. Although volunteers are required to be part of a Medicare-certified hospice program, they are yet to become mainstream in most palliative care programs. Though most hospitals with 300 or more beds have formal palliative care teams, their composition is far from uniform [5, 6]. Research is still needed to determine what composition of team members in which situations offers the most effective service. What is clear is that a formal palliative care service harnesses the advantages of multiple disciplines. In hospitals where no formal palliative care team is available, we suggest leveraging the following disciplines. Captured within the Hippocratic Oath, the focus of medical training is to acquire the skills of diagnosis and treatment with the expectation of teaching this art and science as integral to its practice. For patients who would benefit from palliative care support, the first and foremost responsibility of the physician is to provide high-quality symptom management. Conversations about goals of care, advance care or discharge planning are severely constrained if a patient is experiencing any poorly controlled symptom. If trained palliative medicine practitioners are not available to aid with symptom management, consideration should be given to consultation of other subspecialists. For example, patients with intractable nausea with cancer may benefit from a consultation with a local oncologist and/or gastroenterologist. Physicians are also responsible for providing insight into disease trajectory and prognosis. Working with other physician specialists can help team members expand their own knowledge and forward implementation of care plans. A common description of the art and science of nursing is “the use of clinical judgment in the provision of care to enable people to improve, maintain or recover health, to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability, until death” [7]. Universally, nurses have the most direct patient contact and therefore offer the greatest insight into symptom triggers and intervention effectiveness [8]. Similarly, the nurse may have a unique trust relationship with the patient and an experience of family dynamics over time. In particular, nurses who introduce the concept of palliative care to patients in a skilled way, matched to the particular needs of the patient and family, may facilitate entry of other members of the team. Medical social workers are dedicated to empowering patients and families to identify their strengths in an effort to find creative solutions needed to meet their individual and communal needs along the dynamic continuum of an illness. The relationship with patient and families is the most important tool for a social worker. In addition to being able to provide frontline psychosocial needs assessment, the social worker plays a key role in facilitating communication between patients, families, and their extended support groups. Medical social workers have an expertise in understanding the unique communities and cultural dynamics that families are a part of and will return to after discharge. Collaboration with a social worker enables optimal discharge plan implementation for the patient and family as well as the healthcare system. Spiritual care focuses on helping patients to define and cultivate meaning in their lives. The chaplain explores any spiritual sources of pain, anxiety, and anticipatory grief and encourages spiritual expression as a way to access internal strength and sources of healing for the patient and family members. Chaplains also model and support self-care practices for team members, promoting team sustainability and functioning. The chaplain who works on a palliative care team takes primary responsibility for assessing and addressing the emotional, relational, spiritual, and existential needs and concerns of patients and families. Typical assessment domains include hopes and fears, meaning and purpose, guilt and forgiveness, beliefs about death and dying, life review and life completion tasks, and suffering, as any of these can challenge a sense of peace, worth, and wholeness. Chaplains also identify and explore spiritual and religious beliefs that can affect decision making or treatment plans. Sources of strength and coping resources are affirmed; sources of distress are identified and addressed. Support for those in caregiving roles is also provided, as well as bereavement support as needed. Chaplains also provide culturally sensitive rituals, blessing prayers, and memorials as requested. Background training in nursing provides the case manager with core knowledge to understand the complexities of disease trajectory and medical care coordination including treatment needs, medication use, and durable medical equipment requirements. This places them in a unique position to collaborate with team members in their effort to access community resources and discover the best fit for patient and family needs, both acutely and over time. Primary care providers as well as outpatient clinicians with ongoing longitudinal relationships (e.g., oncologist, pulmonologist, cardiologist, etc.) provide continuity of care and understanding of patient values over time. Their input can be invaluable if the patient should be unable to speak for themselves. In particular, these providers can be helpful when multiple members of the family have differing perspectives of the patient’s wishes. These providers give professional insight into a patient’s functional status and ability to perform both activities of daily living and executive functions. Involving them in palliative care assessment and planning facilitates a patient-centered plan of care. For example, a physical therapist who understands that the goal of care for a patient is to improve mobility at home while receiving hospice care would be able to participate in constructing a more comprehensive home-based plan for the patient, as opposed to recommending a short-term nursing facility stay for strengthening. Similarly, mental health professionals can provide expertise in coping with serious illness and the anxiety and depression that can accompany such life-altering diagnoses. Although not typically thought of as part of the hospital-based team, insurance providers can be allies in crafting continuity of care in home-care settings. In particular, hospital-based providers may be able, with the aid of local insurers, to create systems or programs that help transition hospitalized patients with complex needs to their preferred setting of choice, such as home, by carving out particular benefits that allow for optimal care outside the acute care setting. How does a team leader facilitate team functioning among these various professionals? In this section, we will elaborate on methods for establishing and cultivating the four qualities of a high-functioning team. These strategies may be particularly useful for clinicians interested in forming and growing new palliative care teams: Inherent in any team setting is the likelihood of conflict and dysfunction. For any team to continue to develop and remain high functioning, ongoing effort to identify, refine, and overcome challenges is necessary. In his book, The Five Dysfunctions of a Team, Peter Lencioni offers insight into team dynamics and concretely identifies the most common stumbling blocks (Table 18.1) [11]. Whereas the manuscript was initially written for the business sector, the concepts are directly applicable to both formal and informal healthcare teams. These dysfunctions often build upon one another; therefore, a careful assessment is necessary to identify the best place to start improvement work. The author suggests mechanisms for assessment and interventions to address each area of improvement. For example, teams struggling with a lack of trust often benefit from the addition of 360 degree feedback or personality preference profiles. These exercises can help to break down barriers and allow team members to better empathize with each other. Despite the necessity for the entire team to work on these as a whole, the importance of having strong leadership to guide the team through the challenges cannot be understated. It should be noted that the hierarchical medical model with the physician at the lead may not be the best fit for the delivery of palliative care [12]. Table 18.1 Five Dysfunctions of a Team
Interdisciplinary Team Care of Seriously Ill Hospitalized Patients
18.1 DEFINITION OF A TEAM
18.2 CORE VALUES
18.2.1 Trust
18.2.2 Expertise
18.2.3 Agility
18.2.4 Multiplicity
18.3 KEY TEAM MEMBERS FOR PALLIATIVE CARE
18.3.1 Physician
18.3.2 Nurse
18.3.3 Social Worker
18.3.4 Chaplain
18.4 ADDITIONAL AD HOC TEAM MEMBERS
18.4.1 Case Managers/Discharge Planner
18.4.2 Outpatient Providers
18.4.3 Allied Health Professionals
18.4.4 Insurers
18.5 BECOMING A HIGH-FUNCTIONING TEAM
18.6 CONFLICT RESOLUTION
Related posts:
Assessing Goals of Care: A Case-Based Discussion
Dyspnea: Management in Seriously Ill Hospitalized Patients
Hospital Care for Seriously Ill Patients and Their Families
Last Days of Life: Care for the Patient and Family
Self-Care and Resilience for Hospital Clinicians
Delirium: Identification and Management in Seriously Ill Hospitalized Patients
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