Transcript Details This is a transcript of an educational program accessible on the ReachMD network. Details about the program and additional media formats for the program are accessible by visiting: https://reachmd.com/programs/dying-in-america-series/interdisciplinary-teamwork-palliative-caresuccesses-challenges/7854/ ReachMD www.reachmd.com info@reachmd.com (866) 423-7849 Interdisciplinary Teamwork in Palliative Care: Successes and Challenges Narrator: Welcome to ReachMD. This episode is one of four specific topics from Dying in America, a report by the Institute of Medicine (IOM), a division of the National Academies of Sciences, Engineering, and Medicine. The following program is intended for U.S. health care professionals only. Welcome to ReachMD. I m your host, Dr. John Russell. Joining me today is Dr. Jean Kutner, with the University of Colorado School of Medicine and University of Colorado Hospital at Aurora. In this episode, we are going to discuss interdisciplinary teamwork who support end-of-life decisions and processes. Dr. Kutner, welcome to the program. Thank you. Happy to be here. So, doctor, could you tell us a little bit about your participation on this committee and what made you 2018 ReachMD Page 1 of 7
want to be part of this particular topic and why you want to share it with us? Well, the committee itself reflected the interdisciplinary nature of palliative care, and I d like to note that by palliative care I mean a spectrum of approaches to delivering care for serious advanced illness that focuses on pain and other symptoms and supports quality of life. Palliative care includes but is not limited to hospice, and the committee members themselves were experts in geriatrics, pediatrics, palliative care, nursing, ethics, social work, oncology, spirituality, diversity, health economics and policy, as well as other areas so a truly interdisciplinary group. And then, as a geriatrician and palliative medicine physician myself who experiences the benefits of working in an interdisciplinary team really on a daily basis, the opportunity to collaborate with colleagues from multiple disciplines in developing these recommendations assured that the recommendations would truly focus on the spectrum of needs of people with serious illness and their families. So, the deliberations of the committee very much reflected these diverse views all coming together to review the evidence and make recommendations about enhancing care for people near the end of life. So achieving the recommendations as set forth in t h e Dying in America report will require an interdisciplinary approach so that there s really truly something for everybody in these recommendations. What do you think is the primary reason to have this interdisciplinary team to support our end-of-life decisions and processes? Well, it s really about the needs of people who have serious illness and their families, and these needs cut across the expertise of multiple disciplines including addressing the physical, the emotional, the spiritual, and the social support needs of these patients and their families. And while we may have some common skill sets such as being expert in communication, each discipline uniquely contributes to supporting the needs of these patients and their families. And the interdisciplinary team approach contributes to the development and implementation of comprehensive plans of care, helps ensure coordination of care, enhances the ability to anticipate and solve problems that arise during transitions and crises, and facilitates quality improvement contributing to good pain management as well. And the high-performing interdisciplinary team is really now widely recognized as an essential tool for constructing a more patient-centered, coordinated, and effective health care delivery system. So, for example, if we re talking say, about advance care planning, and the new Medicare code that provides reimbursement for advance care planning discussion, well, the physician may need to ultimately have 2018 ReachMD Page 2 of 7
the discussion with the patient and clearly needs to know the patient s goals and values. Other members of the interdisciplinary team such as social workers may actually be better suited to initiate the conversation, provide information, and help patients clarify their goals and values, before they go and speak with the physician. So, by engaging all members of the interdisciplinary team, it s more likely that the care will meet the Institute of Medicine report recommendations that care consider the evolving physical, emotional, social, and spiritual needs of individuals approaching the end of life and their family caregivers. So, for best practices, who do you think should typically make up this interdisciplinary team? Well, the interdisciplinary palliative care team typically compromises physicians, advanced practice providers such as nurse practitioners and physician assistants, social workers and chaplains, and these team components are required, in fact, to achieve Joint Commission advanced certification in palliative care. In addition, these interdisciplinary palliative care teams may include nurses, pharmacists, dieticians, physical and occupational therapists, psychologists, child life specialists, volunteers, and creative art therapists. So, communication is always our big issue in medicine, so how do these team members best communicate and interact with one another? Well, the interdisciplinary approach really should begin with the initial patient assessment. For example, say a nurse may perform the initial assessment which then leads to the involvement of other members of the interdisciplinary team as indicated by that patient s actual situation. And we have to keep in mind, though, that both the content and the functioning of the team may depend upon local resources in terms of both personnel and other resources. The most effective teams will meet together regularly to review the patient and provide discipline-specific input into the plan of care. So, for example, here at the University of Colorado Hospital where I was just on clinical service, we have full-team huddles twice a day where we, as the full interdisciplinary team, review the patients, offer suggestions from our discipline s perspective, and also decide whom from the team is seeing which patient when. And these team huddles have really greatly enhanced both the efficiency and the outcomes of patients for whom we re providing care. 2018 ReachMD Page 3 of 7
If you re just tuning in, you re listening to a medical industry feature focusing on 1 of 4 specific topics on Dying in America. I m your host, Dr. John Russell, and I m joined today by Dr. Jean Kutner, and we re discussing interdisciplinary teamwork to support end-of-life decisions and processes as addressed in the Dying in America report from the IOM. So doctor, what training is involved for those who are part of these teams in order to best provide support services to our patients and their families? Well, since the publication of the prior report in 1997, the Approaching Death Institute of Medicine report, hospice and palliative medicine has become a defined physician specialty with board certification, and palliative care has also become a certified specialty in nursing, social work, and chaplaincy. Each of these certifications has its own requirements in terms of training, examination, and continuing education. So for example, physicians complete a one-year fellowship training program, and the certified hospice and palliative care nurse examination requires that nurses have 500 hours of hospice and palliative nursing practice in the most recent 12 months. Social work certification requires documentation of at least 2 years of supervised social work experience in hospice and palliative care. And the chaplaincy certification requires completion and documentation of a minimum of 3 years of clinical experience in hospice and palliative care. So, I imagine there are some hurdles to developing this type of interdisciplinary team that you have at your hospital. What do you think are these hurdles and how does the report say we can surmount those hurdles? Well, the establishment of specialty practice in hospice and palliative medicine is a major improvement in the education of health professionals, but there are some problems that remain. First of all, while there has been great improvement, there remains insufficient attention to palliative care in medical and nursing school curricula. There are also educational silos that impede the development of interdisciplinary teams; if we re each only taught within our discipline, we don t learn to work with each other. And third, there are deficits in equipping clinicians with these high-level communication skills that are needed. So, among other recommendations related to health care provider education, the Dying in America Institute of Medicine report recommends that all clinicians, I ll repeat that again, all 2018 ReachMD Page 4 of 7
clinicians across disciplines and specialties who care for people with advanced serious illness should be competent in basic palliative care so, communication skills, interprofessional collaboration, and symptom management. And that educational institutions and professional societies should provide this training in the palliative care domains throughout a professional s career. So, you talked about really having every physician in every specialty, because I think we ll all at some point probably have to deal with some death and dying issues. How do you educate physicians across the wide spectrum of medicine? Well, it really is important that all clinicians who care for patients with serious illness have these communication skills and basic symptom management will be referred to as primary palliative care and there are a number of ways that the Institute of Medicine report recommends this being achieved. One is through educational institutions and professional societies providing training in these important palliative care domains throughout their professional career, thinking about at the earlier training end of things for the Accreditation Council for Graduate Medical Education requiring palliative care educational and clinical experience in training programs for those specialties that are responsible for managing advanced serious illness, including primary care. And thinking about then further along in a professional s career, having certifying bodies, such as our specialty boards, requiring knowledge, skills, and competency in palliative care. So, there are a number of places along the educational continuum where there are opportunities to, I guess, insert this knowledge. So, Dr. Kutner, it sounds like you have a wonderful team in place, but for a hospital or a health system that s just starting out, what would be some tips for some first steps to putting together this great interdisciplinary team? Well, the Institute of Medicine report actually includes a table that s in the summary section around core components of quality end-of-life care that includes the components that somebody, or a hospital, that is just starting out might want to consider as they re getting things going, and it includes things 2018 ReachMD Page 5 of 7
such as the frequent assessment of the patient s physical, emotional, social, and spiritual well-being. So thinking, Okay, how would I meet that as a hospital? And it includes offering referral to expert level palliative care and it talks about different ways to address that, that it doesn t actually have to be at that hospital, but having access, so seeking out expertise in the area, for example. So, I guess I would actually refer people back to the report to look at what those components are, and then to see what is available in my area so that I can leverage off of existing resources. If a hospital does not have a fully functioning system, what can they do? Well, this is one of those things that we actually address in the Institute of Medicine report and recognizing that not all hospitals may have access to the full set of resources, that we provided a recommendation that access to the interdisciplinary team may be either onsite or by virtual consultation such as maybe through telehealth or by transfer to a setting that has those resources and expertise. So, what do you want to make sure that your colleagues take away from this discussion to share with their own patients? I d say a few things. First of all, all people with serious advanced illness should have access to skilled palliative care in all settings where they receive care, and that interdisciplinary teams are necessary to effectively address the evolving physical, emotional, social, and spiritual needs of these individuals, as well as their families. And each member of the team contributes to a achieving the highest quality of care for people with serious illness and their families. Dr. Kutner, thank you for sharing the details of this report on interdisciplinary teamwork with our ReachMD listeners. Thank you. Narrator: You have been listening to ReachMD. This program was sponsored by the National Academy of 2018 ReachMD Page 6 of 7
Medicine and focuses on a report by the Institute of Medicine. To listen to this discussion and download the podcast, visit www.reachmd.com/dying in America. That s www.reachmd.com/dying in America. Thank you for listening. 2018 ReachMD Page 7 of 7