Teamwork

In Australia palliative medicine physicians must complete 3 years of full-time equivalent training in either a paediatric or adult setting under the supervision of a palliative medicine physician to gain the qualification of Fellow of The Royal Australasian College of Physicians (FRACP) / Fellowship of the Australasian Chapter of Palliative Medicine (FAChPM) and be accredited to practice as a palliative care physician. [1] Palliative care specialists primarily admit and manage patients under their own care, as well as providing consultations on other colleagues’ patients, as well as provide ambulatory care services. [2] Palliative Medicine Physicians work collaboratively with a multidisciplinary team of health professionals to ‘provide end-of-life care, provide relief from pain and symptoms of illness, and optimise the quality of life for a patient’. [3] Palliative medicine specialists can also offer alternative approaches to aggressive or distressing therapies for people with life-threatening illness. [2] Their support of patients, family and staff in decision making sometimes results in withdrawal or refusal of disease-controlling or life-prolonging treatment. [2] They can ensure that appropriate referrals are made to community palliative care services or hospices, enable community-based patients to access specialised symptom-control and support services (e.g. anaesthetics, psychiatry, rehabilitation medicine) and educate hospital staff in the culture and principles of palliative care. [2]

References:

1. Australian Institute of Health and Welfare (AIHW). Palliative care services in Australia [Internet]. Canberra: AIHW; 2022 [cited 2022 Oct 24].
2. Glare PA, Auret KA, Aggarwal G, Clark KJ, Pickstock SE, Lickiss JN. The interface between palliative medicine and specialists in acute-care hospitals: boundaries, bridges and challenges. Med J Aust. 2003 Sep 15;179(S6):S29-31.
3. Australian Institute of Health and Welfare (AIHW). Palliative care services [Internet]. Canberra: AIHW; 2022 [cited 2022 Nov 22].

Registered nurses can specialise in palliative care through undertaking a postgraduate qualification. Palliative care nurses, have knowledge, skills and attitudes to enable them to undertake assessment and management of palliative care patients. [1] The role of the specialist palliative care nurse in this setting is to educate, empower and validate the generalist team through the provision of quality palliative care. [2] They also work alongside allied health professionals. [3]

While many palliative care nurses have specialist training, all will incorporate a palliative care approach to patients to improve a patient’s quality of life across all domains, rather than an emphasis on physical symptoms alone. [3] They not only care for patients but also the patient’s family members by helping them to make decisions (with, or on behalf of the patient), as well as providing comfort in the lead up to, and after the patients death. [3] To learn more visit the CareSearch Nurse's hub.

References:

1. Australian College of Nursing. Graduate Certificate in Palliative Care [internet]. Canberra: Australian College of Nursing; 2022 [cited 2022 Nov 21].
2. Gott, M, Seymour J, Ingleton C, Gardiner C, Bellamy G. 'That's part of everybody's job': the perspectives of health care staff in England and New Zealand on the meaning and remit of palliative care. Palliat Med. 2012 Apr;26:232-41. Epub 2011 Jun 15.
3. Palliative Care Nurses Australia. Our Work [Internet]. Port Pirie, SA: Palliative Care Nurses Australia. 2022 [cited 2022 Nov 21].

Nursing complement will include some senior and experienced nurses such as nurse practitioners and clinical nurse consultants, some of whom will have completed specialist qualifications related to palliative care. [1]  Designated palliative care beds require a mix of direct nursing care which will include Clinical Nurse Consultants (CNC), Clinical Nurses, and Registered Nurses (RN) over Enrolled Nurses (EN), and may include patient carers. [1]  The classification of nurses varies with the type of training that they have undertaken: Enrolled nurses complete a 2-year Diploma of Nursing, Registered nurses complete a 3-year Bachelor of Nursing Degree, and Nurse Practitioners complete a 3-year Bachelor of Nursing Degree and a Masters Degree and are endorsed by the Nursing and Midwifery Board. [2]

Enrolled nurses work under the supervision of Registered nurses, with Registered nurses having a broader scope of practice that includes: assessing patients, developing a nursing care plan, providing specialised nursing care and for some performing leadership roles such as nursing unit manager. [2]  Nurse practitioners work autonomously within advanced and extended clinical roles to diagnose, plan and provide high quality comprehensive health care. [2] Clinical Nurse Consultants work as part of the acute care consultation team and work independently to provide nursing and medical care, to coordinate, monitor and review patient’s care. [1] They also supervise Clinical Nurses. [1]

Through providing direct patient care nurses are well informed about the wishes, needs and experiences of dying patients and their families, which means that they are well-placed to advocate on behalf of patients and families during discussions with treating medical teams. [3]

Nurse Navigators contribute to the patients integrated care, through coordinating patient care through fostering interdisciplinary collaboration and providing education and points-of-contact for health care professionals across health care settings. [4]

References:

1. Palliative Care Australia (PCA). Palliative care service development guidelines (340kb pdf). Canberra: PCA; 2018.
2. Australian Institute of Health and Welfare (AIHW). Palliative care services in Australia [Internet]. Canberra: AIHW; 2022 [cited 2022 Oct 24].
3. Shepherd J, Waller A, Sanson-Fisher R, Clark K. Nurses' perceptions, experiences and involvement in the provision of end-of-life care in acute hospitals: A mapping review of research output, quality and effectiveness. Int J Nurs Stud. 2021 Oct;122:104007.
4. Hannan-Jones C, Young C, Mitchell G, Mutch A. Exploring nurse navigators’ contribution to integrated care: A qualitative study.  Aust J Prim Health. 2019 Oct;25(4):339-345.

Allied health professionals actively provide care across the acute, subacute and primary care sectors, however in the acute setting it is preferrable for allied health staff to be specifically designated as part of the palliative care team rather than on rotation. [1] Allied health professionals play an essential role in meeting the palliative care needs of people living with a life-limiting illness, their families and carers. [2] Allied Health Professionals:

• Provide support to manage physical symptoms including support related to medication, nutrition, communication and mobility;
• Assist people to maintain function and independence;
• Provide psychological support, social support, pastoral care and bereavement support;
• Provide therapies to improve the quality of life and support people, families and carers to achieve their goals; and
• Provide information about disease progression and provide education for people living with a life limiting illness, their families and carers. [2]

Within this setting of care, they also provide assistance with discharge planning and the education of health care providers within the hospital. [3] Depending on their specific role they also provide psychological, social work, bereavement support, and pastoral care. [2]

There are a number of distinct allied health roles that actively provide palliative care within the acute care setting:

• Speech pathologist – Assess and treat swallowing dysfunction, and support communications skills, particularly for people with worsening physical disability.
• Dietician – Enhance quality of life by planning enjoyable and attractive food within the constraints imposed by the patient’s condition.
• Physiotherapy therapists –Help to keep patients mobile and safe, as well as providing short-term symptom relief for people with lung congestion, lymphoedema etc.
• Occupational therapists - Work with both patients and carers to promote the patient’s function, safety and independence in the home and hospital environment.  Will also work closely with Physio therapists to provide lymphoedema symptom relief. [2]
• Social worker – work to enhance social and emotional functioning through targeted interventions and the mobilisation of services and supports. [4]
• Counsellors – Help patients deal with the emotions related to losing their independence, the prospect of dying, quality of life, and other issues relating to their circumstances.

To learn more about the role of allied health in palliative care visit the CareSearch Allied Health hub.

References:

1. Gravier S, Erny-Albrecht, K. Allied health in Australia and its role in palliative care (935kb pdf). Adelaide, SA: CareSearch; 2020 Jan.
2. Palliative Care Australia (PCA). Palliative care service development guidelines (340kb pdf). Canberra: PCA; 2018.
3. Palliative Care Australia (PCA). Service provision in Australia: A planning guide (632kb pdf). Canberra: PCA; 2003.
4. Cordoba S. Scope of social work practice: Hospitals. Melbourne, Australia. Australian Association of Social Workers. 2020.

• Discharge Planner or Continuing Care Coordinator – is actively involved in the discharge planning process through providing education and support to other hospital staff with the development and implementation of discharge plans.
• Aged Care Assessment Team – use patient information to analyse whether the patient requires support or if they are already support whether they require a higher level of care. They provide the starting point to accessing Government subsidised aged care services.
• Aboriginal Liaison Officers – increase access to culturally safe care and help to address inequalities through improving communication between patients and health professionals, strengthen continuity of care and help to reduce patient discharge against medical advice. 
• Cancer Care Coordinators (261 kb pdf) - improve the coordination of care through their role as the facilitator responsible for the implementation of care coordination interventions in the context of the multidisciplinary team.

Volunteers play a role in improving the patient journey and contribute to the experience of the patient, their carer and family.  Volunteers perform different roles depending on local need, these roles may include biography, bereavement support, community visiting, complementary therapies, inpatient support, memorial services and paediatric (children) support. Learn more about the specific roles they perform.

The patients voice needs to be acknowledged so that people affected by life-limiting illnesses are included in all aspects of planning for their care, including identifying and addressing barriers to access and choice.  Involving individuals and their families and carers in the conversation, including in the design and monitoring of services, will improve the ability of services to provide the care that is best for the individual, their carer and family. [1]

References:

1. Department of Health. National Palliative Care Strategy 2018 (6.01MB pdf). Canberra: Australian Government; 2018.