Comprehensive Care Plan for Palliative Care Patients
Topic: Role of the multidisciplinary team using a Palliative approach.
Explanation: Comprehensive care is required by the multidisciplinary team for the palliative care patients after returning back to home, based on Advanced Care Planning (ACP).
Evidence: Comprehensive Care Plan is a dynamic documenting planning which describes of agreeing goals for care, medical planning outline, nursing as well as allied health activities for the patient. Multidisciplinary team work on the principle of a team approach, communication, accessing to the therapeutic ranges, nationally agreed standards and involvement of the patients (Cancer Australia, 2022). Multidisciplinary team care (MDC) is managed for the increased survival of the patients. MDC team includes providing of comprehensive care plan based on clinical practice guidelines which also comprises of psychosocial support, access to information. MDC is a team approach practice considered for the treatment planning and care for the patients. MDC is an integrated approach of healthcare, works together with medical and allied health care professionals with various treatment options as well as developing individualized treatment and care plan for every individual patient (Cancer Australia, 2022). This team approach involves all health professionals and discussing different options and making decisions jointly for treatment and supportive care planning with consideration of the preferences for the patient. Clinicians involved in the management of the cancer patients with recommended guidelines and the treatment plan for the patients according to the circumstances or wishes of the patients. Maintaining standards of practice is supported to promote better professional development. Supportive care is also involved in the multidisciplinary care as an integral part which supports the patient to have access for appropriate services. MDC must support the patient with good communication and collaboration between the team members regarding the patient treatment and its outcomes. MDC focuses from both the aspects of care, i.e., clinical and psychosocial support for the patients. General practitioner is also involved in several various roles to assess disease process that includes diagnosis, referral, treatment plan, coordination, and care plan along with information provision and support for the patient and their family.
Advanced Care Plan (ACP) is an important element in the multidisciplinary care approach to achieve quality palliative care (Rietjens, Korfage & Taubert, 2021). In this plan approach, patients are encouraged for decision- making by their own regarding their healthcare preferences which can be documented in advance care directives. Underlying goals of ACP includes respecting patients autonomy, improvising quality of care, strengthen of relationships, preparation for the end of the life decisions and diminishing overtreatment. ACP is an intervention that is targeted to promote autonomy for the end-of-life decision-making of the patient (Rietjens, Korfage & Taubert, 2021). For example- In the given case study, patient is in advanced bowel cancer stage and he wished to return to his home as well as he does not wish that his wife get burdened. An effective approach of team to ensure care for the patient and continuation of the care plan helps to improve the understanding towards the patient, regarding the disease, diagnosis and treatment plan along with the outcome is important and assist with the cancer patients journey of life. Therefore, multidisciplinary team care approach is best for achieving the optimum palliative care.
Importance of Multidisciplinary Team Care Approach
Link: Thus, Advance Care Plan is very important for palliative care patient along with comprehensive care; with multidisciplinary care team.
Topic: Strategies to support palliative care patient and the family during end of life care.
Explanation: Different strategies are important to support families or care givers while providing end of life care.
Evidence: End of life care strategies provides emotional, psychosocial, mental and practical support to the families, friends and the care givers. End of life care along with palliative care helps to improvise the quality of life for the person with advanced illness or just before dying (Smithard, Mitchell & Patel, 2019). These strategies may include- offering services, assistances, information, referral and support. Providing emotional support to the family members and the closed ones of the patient by listening to them and being present with them is much needed. Being physically present and holding hands of the patient and family members can make them feel supportive and soothing. Nurse can provide support to the patient or the family members and the closed ones by building rapport with them, encouraging them to speak or share feelings, speaking openly or honestly, expressing emotional and mental feelings. Utilizing listening skills actively and providing a non- judgemental atmosphere. They can assist family members or closed and loved ones with increased interpersonal contacts, promoting sense of positivity and offering optimistic reappraisal. Nurses must encourage family members in identifying the needs of support and care.
Two important strategies to support families and carers while providing end of life care are: Practical support and emotional or mental support. Practical support includes- Respite care to give break from providing the care; helping with the concerns and emotions of the family members and the patient; advising or instructing the family members or the carers regarding “how to provide care”, including giving medications. Nurses guide family members with the required equipment for the palliative patient for the comfort (Fernando & Hughes, 2019). Nurses help to talk regarding the care and support for the palliative patient and their wishes. From the perspectives of emotional and mental support, nurse can start a conversation, listen to the patient and must understand the personal values in order to provide emotional or psychosocial support. Language and way of communication is a must concerns to keep in mind while communicating with the patient and the family members along with the interdisciplinary team and advocating patient’s wishes. Apart from that, environment must be surrounded with the positive healing vibes; encouraging physical activities for healthy mind and soul; providing information and psychological support; spiritual support; focusing on family- centred care; advocating to practice yoga and meditation. Emotional support comprises of autonomy, competence and relatedness. Autonomy describes as the desires for the behaviour of self- organising and experiences; Competence describes of having a valued outcomes based on the impacts and attainment; Relatedness can be explained as the feeling of connection with others and to provide love and care being attached to them.
Link: Thus, Palliative Care strategies is very critical in order to support patient, family members and closed ones by comforting them with practical or physical presence support along with mental or emotional and psychosocial support for the healthy life and maintaining or achieving better quality of life.
Multidisciplinary Team Work Principles
Topic: Ways to provide coordinated and integrated palliative care of the patient and the family members.
Explanation: Involvement of multidisciplinary team members in the home care for the palliative patient based on “Pain management strategy”.
Evidence: Multidisciplinary team approach involves grouped healthcare professionals from different disciplines and roles; in order to provide a common goal for achieving optimum care of the patient, while working together in a group or team. Multidisciplinary team approach is important from the aspects of providing an opportunity for coordinating several clinical as well as social services which might be critical for the patient and the family members. Multidisciplinary teams conduct meetings and discusses regarding the components of palliative care and other range of healthcare settings. For example- In case of metastatic bowel cancer patient provided in the given case study, multidisciplinary team includes- Oncologist, Chemotherapist, General Physician, Physiotherapist, Psychologists, Social workers, Counsellors, Occupational therapists and Palliative care nurse working together in a group or team for the better outcome of the patient. Multidisciplinary team works together by organising as well as coordinating the healthcare services in order to achieve the required needs of the palliative patient and his family with other needs and support. Different professionals varies based on their expertise and skills they possesses that helps the team for better diagnosis procedure, assessment of the illness, planning strategies for treatment options and managing care as per joint decision- making. Taking into account for the patient’s wish and his family members, Counsellors and Psychologists plays an important role in managing mental health, emotional and psychological support in order to achieve better outcomes of the health and better quality life. Mental and emotional health is very important as it can affects or deteriorates the physical health of a patient and hence quality of life becomes low. Palliative care nurse is quite important while taking care of the critically ill patient in home care in order to provide comfort and needs required by the patient and the family members. Palliative care also includes Advance Care Planning (ACP) for documenting decision- making processes for the patient during or before emergency situation and preparing according to the situations as well as taking note of patient’s wishes. Palliative care team also provide services for treatment of pain and other related symptoms. Palliative nurse discuss regarding the treatment options and management of the symptoms while in home care settings; coordinating care services along with all the healthcare providers (Fernando & Hughes, 2019).
An integrative part of the palliative care includes “Pain Management” (Morrison & Morrison, 2006). Relieving pain is an important factor in order to improve that quality of life of the patient. Pain management includes managing unpleasant sensations, any unusual experiences and fear of pain. Nursing strategies for pain management includes- pain medicines; physical therapies such as hot or cold packs, massage, exercise, yoga and hydrotherapy; psychological therapies such as cognitive behavioural therapy, relaxation techniques as well as meditation; body techniques such as acupuncture and community support groups. Therefore, main goal of the pain management is to restore the patient’s sense of order during chronic pain and improvise the quality of life.
Link: Thus, Multidisciplinary team approach is an important aspect in order to assess illness of a patient along with palliative care plan in order to provide comfort and mental or emotional support to the patient and the family. Apart from that, pain management is an important component of managing chronic pain in critically ill patient to maintain quality of life.
References
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
Morrison, L. J., & Morrison, R. S. (2006). Palliative care and pain management. Medical Clinics, 90(5), 983-1004. https://doi.org/10.1016/j.mcna.2006.05.016
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
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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