A case study showcasing “team in action”

Tuesday 16 February 2010

At the end of this session we’d like you to: Have refreshed your knowledge on the

philosophy of palliative care Be able to discuss the “team” working in

palliative care within Northland Identify how you could fit into this team now Identify opportunities within your practice

for increased team participation for the future.

Palliative care is an approach that improves the quality of life of patients and their

families facing the problems associated with life threatening illness, through the

prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and

other problems, physical, psychological and spiritual.

World Health Organisation (2003)

GeneralistGeneralist Palliative Care palliative care is best delivered through an

integrated approach that focuses on the needs of the patient and their family and whanau.

Such an approach should recognise and define the respective roles of all players, both specialist and generalist, within a collaborative framework across a given geographical area

The MoH Palliative Care Strategy – 2001 The Northland Palliative Care Project - 2001 The Palliative Care Strategic Action Plan

2007 NDHB Annual Plan 2009/2010

Hospice practices under the Holistic

Framework or Te Whare Tapa Wha

(Mason Durie)

This model compares health to the four

walls of a house: all four are necessary to ensure strength and

balance”

Social/

Whanaungatanga

Physical/Tinana Emotional/Hinengaro

Spiritual/Wairua

Hospice Framework

North Haven Hospice – Whangarei and districts

Hospice Kaipara – Dargaville and districts

Hospice Mid-Northland – Mid North region

Far North Hospice – Far North region

A group of people with a full set of complementary skills required to complete a task, job or project.

operate with a high degree of interdependence,

share authority and responsibility for self-management,

are accountable for the collective performance and

work toward a common goal and shared reward(s).

Phil and Betsy General Practitioner – Russell and Kerikeri Cancer Society Surgical Team Urologist ACH – Oncology Department/Radiotherapy Team Hospice Mid-Northland Whangarei Oncology Centre North Haven Hospice Kerikeri District Nurses Pharmacists – Russell, Kerikeri, WBH/ACH Pain Team – Whangarei Hospital

Surgical Team

DN’s

Hospital Pain Team

Oncology DeptRadiation Oncologist

Radiotherapy Team Urologist

Cancer Society

Hospital Pharmacy

Local Pharmacy

GP

NHH

Hospice MN

Phil

PhilHospice MN

NHH

GP

Local Pharmacy

Hospital Pharmacy

Cancer Society Urologist

Radiotherapy Team

Oncology DeptRadiation Oncologist

Hospital Pain Team

DN’s

Surgical Team

A new model?

“We are most effective as a team when we compliment each other

without embarrassment and disagree without fear.”

Unknown

Common purpose Preparedness to work together (Bliss et al,

2000) Value/understand the role & contribution of

each member (Bliss et al, 2000) Interaction of the team Members cover each Careful documentation Recognition of the challenges

68 year old Kiwi Bloke! Married to Betsy for 31 years 2 children from a previous marriage-

Gary (44), Kerry (42). Engineer Resident of Tapeka Point, Russell until 2008 when

moved to Kerikeri Referred to Hospice Mid-Northland by the Cancer

Society in 2006 for Symptom Control (Pamidronate)

1997 - Diagnosed with hormonal refractory prostate cancer -> surgery Radical Prostatectomy

1998 -biochemical relapse -> orchidectomy (1998), 2000 - DXR to prostate bed 2005 - bone scan showed increased update and several areas

Treatment with localised DXR R) sacro-iliac joint ilium, sterum, R) lat & post rib, thoracic spine, R) shoulder, Lumbosacral spine

2005 – commenced on monthly IV Pamidronate infusions that -> 3/52 as disease progressed

2007 - Strontium 2008 - MRI shows widespread sclerotic metastases &

degenerative changes in cervical spine March - localised DXR to thoracic spine (T9-. T12), R) lower pelvis and hip. Bone scan shows increased areas of uptake. Further DXR to clavicle and rib July – DXR to R) ant rib, L) med clavicle, L) mid axillary rib, L) shoulder

2009 ◦ March – Suprapubic catheter◦ MRI shows more changes

April - localised DXR to T8->L3 for T9 nerve impingement and L1 SCC, R) iliac crest

July – localised DXR from skull vault to C3

◦ September – cystoscopy◦ Sept – Dec – increased bladder spasm/pain -> removal of SPC◦ Dec 2 – Intrathecal catheter inserted◦ Dec 18th – Intrathecal catheter blocked & palliative sedation

therapy commenced◦ Dec 22nd – Phil passed away at home

Social/whānaugatanga◦ Betsy and Phil very private◦ estranged from daughter, ◦ little contact with son, ◦ family overseas, ◦ kept MDT isolated to HMN.

Spiritual/wairua◦ to be at home, ◦ strong connection to the sea, ◦ no religious beliefs

Emotional/hinengaro◦ boredom, ◦ decision making difficulties, ◦ Betsy became his voice, ◦ decrease concentration, ◦ philosophical

Physical/tinana◦ Multiple pain sites- predominately skeletal and

bladder/pelvic origin◦ Escalating pain management including

methadone, ketamine, (oral and subcutaneous) pamidronate, intrathecal catheter and IV narcotics.

Out/Day patient

Home visits Telephone calls

2006 7

2007 11 13

2008 15 7 44

2009 6 95 159

0

5

10

15

20

25

30

Phone Calls - Day Phone calls - AH Visits - Day Visits - AH

Oct

Nov

Dec

PalCare Referrals Phones calls MDT meetings Visits to IPU at NHH,

hospital liaison team etc

Cared for Phil for only 2 yrs vs more time Role recognition within the team Good communication with specialists and

HMN Support & training with IV Pamidronate – access

Shared decision making Ongoing care of Betsy

““Phil’s care exemplifies good Phil’s care exemplifies good teamwork”teamwork”

Clinic vs Home Visits Relationship developed over time Good communication Liaison with Continence Nurse (Helen

Brown) Cost implications of products

Minimal stock held due to cost Advance ordering of drugs Updates – felt a bit on the “outer”

4 IPU admissions over a period of 10 months – 20 days total

Betsy stayed with him alwaysPositives

◦ Ketamine did offer some benefit◦ Better than being admitted to hospital ◦ Relationship building with staff◦ North Haven Hospice Staff – increased skills for

mgt of IT infusion. ◦ “should have done this some time ago” - on top

of world & walked to front door.

Negatives◦ Away from usual environment/support system◦ Didn’t like being away from home◦ Stayed in room a lot of the time (sometimes with

door shut!)◦ 3rd visit had different family dynamics of another

IPU patient.

IT was new to WBH Consumables Delay

◦Bags mixed on site by anaesthetist Competency & confidence of ward staff

managing infusion Planned infusion time delayed due to

other high category patients. No theatre space and no bed -> ICU bed

found

IT infusion started – NO PAIN Next day independently mobilising – NIL

PAIN MRI done – IT stopped -> extreme pain Trans -> North Haven Hospice On-call 24/7 for hospice staff

Changeover mid way through◦ Change of relationship – ending one and building

another ◦ Change of prescription and methods of working

IV pamidronate Intra-thecal management Staffing Location Long term patient Team networking-????

Things don’t always go smoothly Trust within and of the team is important There is a difference for access for

Northland Engaging the team long term – how to keep

this up Leadership – who and when Nothing ventured nothing gained It bought time for Betsy & Phil to work

through the transition from life to death

A procedure/flowchart to ensure preparation avenues are exhausted for future changes

Expand the team (prn) & work within it – documentation of a “team plan/MoU”

Question long term management of cases such as this - ? Whether different options are offered

Interprofessional Education (Bliss et al, 2000) Policy development to facilitate closer

collaboration. (Bliss et al, 2000)

Teamwork is the ability to work together toward a common vision. The ability to direct

individual accomplishments toward organizational objectives.

It is the fuel that allows common people to attain uncommon results.

Andrew Carnegie

”Coming together is a beginning.Keeping together is progress.Working together is success.”

- Henry Ford

He aha te mea nui o te ao?Maku a ki atu.

He tangata.He tangata.He tangata.

Bliss, J., Cowley, S. & While, A. (2000). Interprofessional working in palliative care in the community: a review of the literature. Journal of Interprofessional Care. 14 (3). Retrieved 6 January 2010 from www.sagepub.com

Crawford, G. & Price, S. (2003). Team working: palliative care as a model of interdisciplinary practice. MJA Vol 179. Retrieved 6 January 2010 from www.sagepub.com

Head, B. (2002). The blessings and burdens of Interdisciplinary teamwork. Home Health Care Nurse 20(5). Retrieved 6 January 2010 from www.sagepub.com

Lemieux-Charles, L. & McGuire, W (2006). What do you know about health care team effectiveness? A review of the literature. Med Care Res Rev 2006. Retrieved 6 January 2010 from www.sagepub.com

Ministry of Health and New Zealand Cancer Control Trust. (2003). The New Zealand cancer control strategy. Wellington: Author.

Ministry of Health. (2001a). The New Zealand palliative care strategy. Wellington: Author. Northland District Health Board. (n.d.) District annual plan 2009-2010. Whangarei: Author. Northland District Health Board. (2006). Northland Palliative Care Strategic Action Plan 2006-2011.

Whangarei: Author O’Connor, M., Fisher, C., & Guilfoyle, A. (2006). Interdisciplinary teams in palliative care: a critical

reflection. International Journal of Palliative Care. 12(3). Retrieved 6 January 2010 from www.sagepub.com

Palliative Care Expert Working Group to the Cancer Control Steering Group. (2003). Palliative care report. Retrieved February 25, 2007 from the Google database.

Palliative Care Service Specifications Review Group. (2006). Consultation draft: Specialist palliative care tier two service specifications. 03.12.2006. Wellington: Author