St Georges University, London, UK, and Institute Rotary Cancer Hospital, AIIMS, New Delhi, India
Copyright: © Indian Journal of Palliative Care
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INTRODUCTION
A multidisciplinary team (MDT) is a group of healthcare professionals of varied disciplines and roles, working together towards a common goal of providing optimal care for a patient. Most areas of healthcare now work in multidisciplinary teams, but palliative care lends itself particularly well to this approach because of the multiple dimensions involved in caring for palliative patients: physical, social and psychological, and with close links to the family.[1] The palliative care I saw in the UK was one of the best functioning multi-disciplinary approaches that I have seen, and I visited India because I was interested to get a cross-cultural perspective. In this essay I reflect on my time spent with the team at IRCH, with reference to one of the cases that I followed.
CASE REPORT
Mrs D was a 36-year-old female patient diagnosed with metastatic triple negative breast cancer (stage T4b N3 M1). The patient had undergone 7 cycles of chemotherapy before being referred to and managed by the pain and palliative care team. Metastases had spread to her cervico-dorsal, lumbar and sacral vertebrae and bilateral pelvic bones. On presentation to the pain control out patients department (OPD) she had severe pain in her head and neck, and was admitted to the inpatient palliative care unit for analgesic titration and control of nausea and vomiting.
Management
The patient was already on anti-sickness medication (Ondansetron); further management of nausea and vomiting included the introduction of a proton pump inhibitor (Pantoprazole) as well as advice on diet and patterns of eating.
The management of the patient's pain was more complex, and can be framed in the context of total pain [Table 1].[2]
Table 1: Management using a ‘total pain’ approach
Physical pain control was managed as per the WHO pain ladder.[3] The patient was already on step 3 of the ladder, so her morphine dose was increased from 20 mg every 4 h to 30 mg every 4 h. Due to her head and neck pain, an MRI was done. This was discussed at a cross-disciplinary meeting with the radiologists to clarify what the progression of the disease was and what would be the most appropriate way to move forward with management. Although the progression of disease was such that treatment was no longer an option, a decision to give radiotherapy was taken as a palliative measure in order to prevent spinal cord compression and its complications, as well as to relieve pain and preserve function.[4] As an adjunct to this, the physiotherapists provided advice on movements of the head and neck, and also a neck brace.
The patient's social problems had started when she first fell ill. She had to leave her job of making clothes and therefore lost some of the family income. Her brother and husband were also missing work to bring her to the hospital and spend time with her there, resulting in a further loss of income. Housing problems arose when the family's landlord found out that the patient was in the terminal stages of illness and asked the family to vacate the property. The children went to stay with another family but the patient was left without a home to go to once she was discharged from the palliative care unit. In this situation a non-governmental charity organization was called upon, who run a hospice. The hospice provides care for patients who have nothing further to benefit from cancer treatment, providing symptomatic care for pain and other distressing cancer symptoms (nausea, restlessness, and respiratory problems).
Psychological pain was clearly evident upon speaking with the patient, and support was provided by all members of the palliative care team. I found there was an emphasis on communication and empathy above and beyond what is seen in other medical disciplines in the hospital. The patient's family (daughter, brother and husband) also spent lots of time with her in the hospital and were an ongoing source of psychological support.
I did not witness any interactions with health professionals in the hospital that were explicitly spiritual. However, the approach taken when discussing the patient's prognosis and coming to terms with things implicitly involved some level of spirituality, to a greater degree than is common in the UK. The hospice has more space for spiritual matters; spiritual counselors or leaders can come to the hospice to see the patients, with each religion given equal respect. The hospice state that the sisters themselves interact spiritually with the patient whenever needed and is possible, while maintaining that there is strictly no indoctrination.
Reflections on the role of MDT
The care of the above patient involved doctors from different specialties (anaesthetics, medical oncology, surgical oncology, radiology), as well as other health professionals (nurses, physiotherapists), health professionals working in other sectors (NGOs), and also the patient's family who play a key role in palliative care in India. I will discuss the roles and interactions of different members of the team in turn.
Doctors
Doctors from different specialties worked closely with each other, sharing discussions on ward rounds and between times, so that there was collaboration rather than disciplines working independently on what they believe to be their remit of a patient's care. There was also a smooth system in operation between the OPD management of pain, and the small (6 bed) ward that was reserved for the most urgent cases of pain control. When patients presented to the OPD, if they were suffering from pain that could not be remedied with a simple change in prescription, they were admitted to the ward for titration of analgesics or for an episode that required some other management in the hospital.
Other hospital healthcare workers
The different health professionals worked side by side. It was a hierarchical system, with doctors being in charge of patient care and nurses and physiotherapists involvement arising as instructed by the doctor, but the role of the physiotherapist and nurses was highly valued by the doctors. In outpatient clinics the different professionals were working in the same room so could work closely together.
NGO Sector
Involvement of the NGO sector was complementary to the care given at the hospital. Rather than being two separate entities, the government hospital and NGOs worked together. In the above case, the hospital suggested hospice care and the suitability of this was considered between the doctors, the hospice, the family and the patient. Hospices are far less common than in the UK, and the doctors of this hospice described themselves as acting in a way as a safety net, providing care for people who did not have the option of family care at home as per the norm for Indian society.
In other cases, I saw a further role for NGOs. There was another NGO that provided home support to patients being cared for by their families. Contact with the NGO was usually made by doctors from hospitals, and many patients were both receiving home visit care and visiting outpatient pain clinics. The home support team was able to spend more time with individual patients in their own environment, and also provide practical and emotional support to the families. For this they had a counselor in their team as well as a doctor and a nurse. Because of this emphasis there was a less hierarchical structure, with many patients requiring the counseling services over and above the medical ones, and doctors were not present on all visits. There was communication between the home team doctors and leads of the hospital pain unit, which ensured that both services were operating with the same principles and allowed discussion of difficult cases.
The home care team also collaborated with the hospice, keeping it as an option to suggest for patients or families who were not coping well at home. The role that the home care team NGO provided is somewhat analogous to the Macmillan nurses in the UK. Macmillan nurses are also funded partly by charity, although after a Macmillan nurse role has been operating for three years, the National Health Service takes over the funding. A systematic review of studies from western countries showed that home care can reduce symptom burden as well as making patients more likely to die at home (as many of them wish). The set up is very different in India to that of the western countries in the study, but it shows the potential value of such home care teams, particularly where even more focus is on families caring for dying patients in the home.[5]
The family
In palliative care worldwide the importance of the family is emphasized.[6] In India this importance is manifold, as most patients are cared for in the family home, and die at home. The family then take on a role not just as part of the patients' social and emotional life, but also as carers and therefore part of the healthcare team. The daughter of the patient discussed was doing most of the caring for the mother, cooking and cleaning in the house and helping her to get around as she needed. This requires a different kind of collaboration with families, involving education as to the patients' physical needs as well as emotional.
Linked with this central role of the family in India seemed to be a subtly different reality with respect to the four pillars of medical ethics (autonomy, beneficence, non-maleficence, justice).[7] In the UK there is a strong emphasis on autonomy, and patients' right to knowledge about their health and disease as well as decisions arising from this.[5] Indian law also emphasizes autonomy and consent, but in clinical practice there is sometimes a different reality, with patients not always aware of their diagnosis or prognosis.[8] The philosophy of the palliative care team I was working with was to be open with the patients about their disease status and prognosis and to encourage them to accept this, often addressing these issues with patients for the first time. Even within this strong culture of openness there were still some cases in OPDs where families wanted to shelter their relatives from this information and the family's wishes were upheld. The above patient had full knowledge of her condition and prognosis, and the doctors took time with the relatives when the patient was in the ward to discuss the prognosis and difficulties in uncertainties of not knowing exactly how long the patient had to live.
The role of communication
During my time at IRCH it was World Palliative Care day. Many patients and relatives of patients told their stories of being cared for under this palliative care team. The overall theme to come out of their accounts was the positive effect on both the patients and the families' experience of the end of life. An emphasis on the human aspects of the care received was made, so it is clearly not just the imposition of a structure of individuals from different disciplines working well together, but the nature of those individuals which may be a more difficult or more gradual thing to instill in a department.
CONCLUSION
My experience of the multidisciplinary team in an Indian palliative care was of a team with cohesive structure and relationships. Working between disciplines and between sectors provided a good support structure for patients. A limitation of this is that it is a single center that provides care to patients from a vast geographical area because of the absence of such services elsewhere. To extend the benefits of such teams requires greater education and advocacy of the palliative care approach in other institutions and care providers. The main contrast to the UK that I found was the more practical role of the family in providing care, and patients commonly staying at home throughout the duration of their illness.
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FAQs
What is the multidisciplinary team in palliative care a case reflection? ›
A multidisciplinary team (MDT) is a group of healthcare professionals of varied disciplines and roles, working together towards a common goal of providing optimal care for a patient.
What is multidisciplinary team involvement in palliative care? ›Multidisciplinary team meetings are a recognised component of palliative care as well as in a range of other care settings (eg, cancer). The meetings provide an opportunity to coordinate multiple clinical and social services that might be relevant for complex patient needs.
Does palliative care use a multidisciplinary approach? ›Moreover, the central tenets of palliative care include both multidisciplinary and interdisciplinary approaches to whole-person care. To reiterate, providing care in multiple settings may allow for a deeper understanding of patient and family needs.
What is the role of the multidisciplinary team? ›Multidisciplinary teams (MDTs) are the mechanism for organising and coordinating health and care services to meet the needs of individuals with complex care needs. The teams bring together the expertise and skills of different professionals to assess, plan and manage care jointly.
Why is a multidisciplinary approach important in palliative care? ›For patients:
increased survival for patients managed by a MDC team. shorter timeframes from diagnosis to treatment. greater likelihood of receiving care in accord with clinical practice guidelines, including psychosocial support. increased access to information.
Multi-Disciplinary Meetings (MDM) in which medical and allied health care professionals consider relevant options and collaboratively arrive at a decision regarding diagnosis, prog- nosis or treatment for a patient have been found to lead to better decisions than those made by sole physicians (Lamb et al., 2011a; ...
What is the purpose of multidisciplinary team in healthcare? ›A multidisciplinary team (MDT) is a group of health and care staff who are members of different organisations and professions (e.g. GPs, social workers, nurses), that work together to make decisions regarding the treatment of individual patients and service users. MDTs are used in both health and care settings.
What are the key factors for successful multidisciplinary team working? ›MDTs should proactively consider how to involve individuals and families to ensure that their views and interests are kept at the centre of decision making. Successful MDT working requires facilitative leadership, equality between members, encouragement of constructive challenge, and common access to information.
Do multidisciplinary teams improve patient outcomes? ›Improved patient outcomes
Working with a multidisciplinary team allows you to treat the entire patient and provide comprehensive care. With each physician focused on a different aspect of the patient's health, providers are more likely to identify areas of need, and subsequently manage those needs in an effective way.
Examples could include: Shadowing or interviewing colleagues and partners outside of one's discipline such as marketing majors meeting with engineers and information technology specialists or political science majors meeting with social justice advocates, entrepreneurs, and family scientists.
What is a multidisciplinary plan of care? ›
Multidisciplinary care occurs when professionals from a range of disciplines work together to deliver comprehensive care that addresses as many of the patient's health and other needs as possible.
What are the multidisciplinary approach? ›An approach to curriculum integration which focuses primarily on the different disciplines and the diverse perspectives they bring to illustrate a topic, theme or issue. A multidisciplinary curriculum is one in which the same topic is studied from the viewpoint of more than one discipline.
What part of the multidisciplinary team is the most important? ›It's the requirement to keep the focus on the most important member of the multidisciplinary team: the patient. To listen to their priorities and concerns and use those to guide the team's decision-making and inform the care you provide.
What are the benefits of multidisciplinary team working? ›Evidence suggests that MDT working can lead to improved job satisfaction for professionals and practitioners as a result of greater autonomy, skill enhancement and knowledge sharing. In addition, shared projects, a focus on the patient/ service user and being able to celebrate together can all help to improve morale.
What are the benefits of multidisciplinary team? ›- Shared knowledge. The obvious benefit to working within an MDT is the opportunity for collaboration and shared expertise. ...
- Multiple perspectives. ...
- Continuity of care. ...
- Additional support.
Nurses manage most of your ongoing care and treatment while you receive palliative care in a hospital and they can also provide palliative care nursing services to you at home. They assess, plan and administer your daily treatment and manage your symptoms.
Why is it important to be multidisciplinary? ›Through a multidisciplinary approach, a student gains an arsenal of skills—problem-solving, critical thinking, time-management, self-management, communication and writing, analysis and research methodologies, team work, and much more—that are easily transferable across work environments.
What are three 3 characteristics of an effective multidisciplinary team? ›Some of the key attributes of an effective and efficient multidisciplinary team include: Collaborative practice. Clear communication. Clear definition of tasks and responsibilities.
What is an example of a multidisciplinary team? ›A multidisciplinary team (MDT) should consist of psychiatrists, clinical nurse specialists/community mental health nurses, psychologists, social workers, occupational therapists, medical secretaries, and sometimes other disciplines such as counsellors, drama therapists, art therapists, advocacy workers, care workers ...
How would you work with multidisciplinary team? ›- Understand who does what and why. Members of a multidisciplinary team will have different qualifications, training, and methods of working. ...
- Learn from each other. ...
- Respect other points of view. ...
- Prevent power struggles. ...
- Cut the confusing jargon. ...
- Build a community within the workplace. ...
- Use the right communication tools.
What are the benefits of multidisciplinary approach in healthcare? ›
Multidisciplinary teams are effective for any people with complex care needs and long-term conditions, including the elderly, children and those with mental health problems. This is because the care given manages every aspect of the person's demands, be that physical, emotional or social.
How do you build relationships with a multidisciplinary team? ›- Give Your Time and Presence. These days, time is one of the most precious commodities. ...
- Listen to Your Team. ...
- Appreciate Your Differences. ...
- Hone Your Communication Skills. ...
- Rein in Distractions. ...
- Open Up, Take a Risk, and Trust. ...
- Give and Accept Feedback. ...
- Practice Empathy and Understanding.
Multidisciplinary Health Teamwork in Practice
respect and trust among team members. best use of the skill mix within the team. agreed-upon clinical governance structures.
Maintaining a productive and friendly team can become difficult. Issues such as uncertainty of the team's position in the overall service, caseload, poor coordination between team members, and uneven work distribution may cause disruption.
What do you think is the main focus of a multidisciplinary approach? ›A multidisciplinary approach in education is a way of learning which gives a major focus on diverse perspectives and different disciplines of learning to illustrate a theme, concept, or any issue. It is the one in which the same concept is learned through multiple viewpoints of more than one discipline.
What is multidisciplinary problem? ›The multidisciplinary approach signifies that knowledge of several disciplines is used for a given problem and complements each other in such a way that it is possible to draw clear conclusions without being characterized as isolated or partial.
What is an example sentence for multidisciplinary? ›Our work is based on strong multidisciplinary team work. Instead, our approach to the past must be multidisciplinary and multimedia. His credits list him as a multidisciplinary artist, musician, video artist, choreographer and performer. To some extent he is the victim of his own multidisciplinary approach.
How do you communicate with a multidisciplinary team? ›Give your team multiple channels to communicate to express themselves how they see fit: These can include meetings, emails, one-on-one interactions, phone calls, and more, according to Fleep.
How do you write a case reflection? ›- Step 1: Create a Main Theme. ...
- Step 2: Brainstorm Ideas and Experiences You've Had Related to Your Topic. ...
- Step 3: Analyze How and Why These Ideas and Experiences Have Affected Your Interpretation of Your Theme.
Improved patient outcomes
Working with a multidisciplinary team allows you to treat the entire patient and provide comprehensive care. With each physician focused on a different aspect of the patient's health, providers are more likely to identify areas of need, and subsequently manage those needs in an effective way.
What members of the interprofessional healthcare team provide palliative care and what roles do they play? ›
What members of the interprofessional health care team provide palliative/hospice care, and what roles do they play? Nursing staff, medical care providers, social service specialists and spiritual support personnel.
Who is the most important member of a multidisciplinary healthcare team? ›It's the requirement to keep the focus on the most important member of the multidisciplinary team: the patient. To listen to their priorities and concerns and use those to guide the team's decision-making and inform the care you provide.
What is reflection journal example? ›Reflective journals are most often used to record detailed descriptions of certain aspects of an event or thought. For example, who was there, what was the purpose of the event, what do you think about it, how does it make you feel, etc.
What is the best sentence to start a reflection? ›Reflection on self • At the time I felt that … Initially I did not question … Subsequently I realised … Linking theory to experience • This (concept) helps to explain what happened with …
What is a reflection statement example? ›Common reflective statement stems:
“So you feel...” “It sounds like you...” “You're wondering if...” “For you it's like…” The listener can repeat or substitute synonyms or phrases and stay close to what the speaker has said.
Through a multidisciplinary approach, a student gains an arsenal of skills—problem-solving, critical thinking, time-management, self-management, communication and writing, analysis and research methodologies, team work, and much more—that are easily transferable across work environments.
How does interdisciplinary team work improve patient outcomes? ›When everyone works together, communicating efficiently and sharing information in real-time, the interdisciplinary team can create a comprehensive treatment plan based on a holistic view of the patient. This leads to better quality care and improved outcomes.
What is the role of the interprofessional healthcare team in palliative hospice care? ›Collectively, they provide physical, emotional and spiritual support to the patient—monitoring pain, managing symptoms, addressing nutritional needs, watching for emotional issues, and offering support. Team members also teach the family caregiver how to provide the best personal care to the patient.
Who are the most important members of a patient's palliative care team? ›Someone from the team, most often the nurse, will communicate with you frequently to make sure your needs are being met. You and your loved ones are the most important members of the team. Team members providing care are not limited to doctors and nurses and the care you receive is not limited to medications.
Why is interprofessional working important in palliative care? ›Interprofessional collaboration in palliative care is an opportune context for the team working together to “learn from, with, and about” each other for optimal patient care (CAIPE 2002) and well-planned, committed work for patients.