Derek Doyle, OBE, MD
A multidisciplinary/team approach to assessment and treatment is mandatory. Successful palliative care requires attention to all aspects of a patient’s suffering. This requires input or assistance from a range of medical, nursing, and allied health personnel—a multidisciplinary approach.
Failure to do this often results in unrelieved pain and unrelieved psychosocial suffering. No one professional can deal with the many problems encountered in palliative care. An integrated team is essential.
Established palliative care services work as a multidisciplinary or inter-professional team:
Where palliative care services have not yet been established, it is important for the few professionals providing such care to work as a team, meeting regularly, planning, and reviewing care, and supporting each other.
The patient may be considered a 'member' of the team (although they do not participate in team meetings), as all treatment must be with their consent, understanding and in accordance with their wishes.
The members of the patient’s family can be also considered 'members', as they have an important role in the patient’s overall care and their opinions should be included when formulating a plan of management, then fully explained to them.
Volunteers play an important role in many palliative care services. They receive no pay but may be offered expenses. They work in reception, coffee rooms, library, appeals office, flower arranging, transport, charity shops but in most units do not perform 'hand-on' role with patients. They work under the direction of a Volunteer Service Manager, a salaried member of the staff.
The ideal core multidisciplinary clinical team consists of:
Very useful, but not essential, are:
There are compelling reasons for delivering palliative care in an acute-care setting and alongside other disciplines.
The hospital, and therefore its Trustees/Board and Managers, must be able to recognize a benefit for it as an institution by having defined palliative care services as well as benefit to the inpatient population. Those developing hospital PC services should encourage local administrative authorities to accept symptomatic and end-of-life care as a worthwhile investment in their communities as part of an overall plan for their region.
Good palliative care requires a high nurse/patient ratio. This applies to both in-patient care and community care. Ratios cannot be given because they are influenced by the diseases from which the patients are suffering (AML patients often having higher dependence and therefore requiring more nursing care than cancer patients, for example). The availability of other nurses working in patients' homes, workload, distances to travel in the community, whether there is a hospital palliative care team etc. all affect nurse: patient ratios. It is safer to over-estimate staffing needs when planning a service.
Palliative care, whether in hospital, hospice, or home, is always multi-professional. When attempts are made to reduce costs by excluding one professional group or another, the quality and comprehensiveness of the service deteriorates. It must be noted that the composition and roles of different professions vary greatly, depending on the type of service offered.
The physician plays a major and very prominent role in a hospital palliative care team, whereas in a day hospice the medical presence is almost subliminal. How much a doctor or a nurse does in a community palliative care service depends on the experience and roles of family doctors and community nurses, if available. Generally, professions allied to medicine (physiotherapy, occupational/ art/music/speech therapy) play an important role only in in-patient units and need not be factored into plans for community services.
Recruitment of staff may be expected to be difficult though many will apply. Personality, aptitude, and commitment are more important than professional experience.
All staff, whatever their profession, discipline, qualifications, and experience, will need comprehensive pre-service training before starting this work, much of it based in the new service and the rest in established palliative care services. No member of staff, junior or senior, should ever be expected to learn the basics of palliative care on the job!
In countries with no tradition of hospice/palliative care there be some initial difficulty in recruiting, but such is the attractiveness and professional satisfaction to be gained in palliative care that recruiting is soon not a problem. It goes without saying that staff selection, support, pre-service training, and employment legal requirements must be as strict as in any other health care unit.
A good rule is to aim for a nurse/patient ratio of not less than one nurse to 1.5 patients throughout 24 hours. At least 50% of nurses on duty at any one time should be registered (i.e. trained) nurses. The others nursing auxiliaries should undergone basic nurse training plus in palliative care nursing training.
Most experienced units do not use student nurses rotating through different specialties, able to spend only a few weeks in the palliative care unit, but have a permanent, designated palliative care staff.
How many physicians needed depends on:
A rule of thumb is that one full time physician can:
A critical issue is 'out-of-hours' cover. For the sake of patients and nurses, it should not be provided by a doctor (senior or junior) lacking experience in hospice/palliative care. This cannot be overstressed.
Extensive experience in the United Kingdom shows that units with full-time physicians have a higher admission and discharge rate of patients, and provide more education, than units served by part-time visiting physicians.
Table 4 - Palliative Care Australia recommends the following medical and nursing staffing level for specialist palliative care services per 100,000. (16)
|Position||Community-based service*||Consultative service**||Palliative care designated beds***||Comments|
|Palliative care consultant||2.0||1.5||Specialist and registrar positions have both community and hospital responsibilities|
|Registrar||←-------------------- 1.0 -------------------→|
|Resident medical officer||0.25||Resident position attached to designated palliative care beds only|
|Liason psychiatry||←-------------------- 0.25 -------------------→||It is expected that between 30-50% of the referrals will have a diagnosable mental illness|
|Clinical Nurse Consultants (CNC)||1.0
Plus 2 clinical nurses
|0.75||Community and acute care consultation teams require CNC level nurses to act independently, provide consultation to primary carers (nursing and medical), and to coordinate, monitor and review patient care. Clinical Nurses are senior palliative care nurses who work under the direction of the CNC.|
|Registred (RN) and errolled nurses (EN)||6.5 hours per patients per day||Designated palliative care beds require a mix of direct care. This care will include CNC, Clinical Nurses, RN and EN level nurses, with a predominance of RNs over ENs. Patient carers may also be part of the workforce mix|
|Discharge Liason||←-------------------- 0.25 -------------------→||This role could be included in a nursing or social work position|
|Notes* Full-time equivalent per 100,000 population, ** Full-time equivalent per 125 beds, *** Full-time equivalent per 6.7 beds (within acute hospital)|
Will this be a 'doctor only' or 'nurse only' service or a genuine team of doctor, nurse, pharmacist and social worker and pastoral care worker? Bear in mind the steadily increasing workload of all, the salary implications, the stresses involved, the range of conditions they will be asked to advise on.
It is possible, and sometimes necessary, to have a nurse-only service but most undesirable. The nurse will be isolated, lonely, must persuade/convince and stand up to opinionated doctors not accustomed to taking advice from a nurse. Such a service is exceedingly stressful and to be avoided if possible.
Physician(s): How many, as explained elsewhere in 'Getting Started', depends on whether there will be an associated PCU, a Community Palliative Care Service, a Day Palliative Care Unit, educational and research components, and whether the doctor works in another specialty such as oncology. Advanced training in Palliative Medicine is not optional but essential.
Nurse(s): Registered nurses with extensive training (and preferably a diploma/degree) in palliative care nursing.
Social Worker: If, as should be the case, many of the social needs of the patient are already familiar to the unit’s social worker here is less need for a fulltime social worker on the HPCT. Access to one with palliative care experience is extremely useful.
Psychologists: They can be accessed from their department in the hospital, or they can be part of the team. Access to one with palliative care experience is extremely useful.
Pastoral Care Worker: Again, invaluable but hopefully can be accessed in the hospital department.
Table 5 – Allied workforce levels for specialist palliative care services for allied health services (from Palliative Care Australia) (16)
|Position||Community-based service*||Consultative service**||Palliative care designated beds***||Comments|
|Pastoral care||0.25||0.25||0.25||Pastoral carers offer spiritual support that is quite distinct from the psychological and social support offered by other professionals|
|Speech pathology||0.2||0.2||0.2||Speech pathologists assess and treat swallowing dysfunction, and support communication skills, particularly for people with worsening physical disability|
|Dietician||←-------------------- 0.2 --------------------→||Dieticians with a particular skill and interest in palliative care can enhance quality of life by planning enjoyable and attractive food within the constraints imposed by the patient’s condition|
|Physiotherapy||0.4||0.2||0.2||PT and OT are valued by patients for providing practical help and positive intervention. Ideally the two will work closely together help to keep patients mobile and safe, as well as providing short-term symptom relief for people with lung congestion, etc.
OTs work with both patients and carers to promote the patient’s function, safety and independence in the home and hospital environment
Lymphoedema symptom relief is shared between PT and OT.
|Pharmacist||0.25||0.1||Both of these positions would have a role in supporting the community-based team. An extensive network of community pharmacists provides valuable primary healthcare for palliative patients in the community by assisting with advice, documentation of medication histories, dosage compliance, and the disposal of medications no longer required.|
|Notes: * Full-time equivalent per 100,000 population** Full-time equivalent per 125 beds *** Full-time equivalent per 6.7 beds (within acute hospital)|
It is essential that every comprehensive palliative care service (which may include in-patient unit, community care, day care and even hospital palliative care team) has an experienced social worker on staff. It is, however, recognised that in many countries there are few, if any, social workers and even fewer with training/experience in palliative care. Their work will usually focus as much on staff as on patients and relatives, and be concerned with coping strategies, loss, and personality problems.
The 'simpler' tasks of a social worker, such as facilitating discharge, arranging help in the home, obtaining financial assistance, making special holiday arrangements etc. can usually be dealt with by someone appropriately trained, though not necessarily accredited/paid as much as a social worker.
Any in-patient unit with more than 15 beds, regardless of other services it provides, will need a physiotherapist on staff. Units with 30+ beds need a full-time one. Good palliative care involves rehabilitation, not simply the aim of getting patients back to their homes and loved ones. For this a physiotherapist and, if possible, an occupational therapist are essential.
Especially useful but not strictly essential are clinical pharmacists, clinical psychologists, dentists, and podiatrists. Often, they offer their voluntary services for new hours a week.
Someone trained in pastoral care should be on staff or be readily available. Larger units (of > 25 beds) may need a full-time pastoral care worker. Others may use local clergy, according to the local needs/traditions. It must be remembered that this 'chaplain' will also support staff and volunteers, contribute to and organize educational courses, and conduct many funerals. In multi-faith societies it is necessary to have access to diverse religious/spiritual communities.
The success of a palliative team depends on its members. They must be advocates, persuaders and highly trained, skilled clinicians. Above all else they must be consummate communicators. Other colleagues may oppose your plan to start a HPCT because of perceived threats to their autonomous care of their patient or their ability to care for palliative patients.
The characteristics that will win over sceptics include:
The stress experienced by those working in a palliative care is no greater than in any other palliative care service except in one respect – they are working in a unit within a hospital where there may be little if any understanding of what palliative care is. They will find that what they do is often misunderstood, seen as sentimental and unscientific, but at the same time other nurses and junior doctors in the hospital may envy their job satisfaction.