Interprofessional Collaborative Care

Question 1

Benefits of team-based care delivery

Answer 1

• Improved quality and quantity of services
• Improved accessibility
• Improved job satisfaction for HCPs
• No one care provider can meet all needs associated with illness and bereavement
• Maximal diversity of professional expertise
• Reduced hospitalization time and costs
• Reduced unanticipated admissions
• Better accessibility

Question 2

Domains of care associated with illness and bereavement

Answer 2

1. Physical
   - Disease management (e.g. investigations and management, treatment decisions, team collaboration)
   - Pain and other symptoms
   - Function
   - Nutrition habits
   - Physical activity
   - Cognitive function
2. Social/Cultural
   - Finances
   - Relationships (e.g. estrangement)
   - Personal routines
   - Recreation
   - Vocation (e.g. loss of role)
   - Rituals
   - Legal issues
   - Family caregiver support (e.g. family stress/fatigue)
   - Practical issues
3. Psychological
   - Personality
   - Psychological symptoms
   - Emotions (e.g. fear of progression, helplessness)
   - Control and dignity (e.g. helplessness, loss of control)
   - Coping responses (e.g. feeling a victim)
   - Self image/self esteem
   - Loss and grief
4. Spiritual
   - Meaning and values (e.g. search for meaning)
   - Existential issues (e.g. helplessness)
   - Beliefs
   - Spirituality
   - Rites and icons
   - Loss and grief
   - Life transitions
   - Religions

Question 3

Domains of care: Physical

Answer 3

Physical

• Disease management (e.g. investigations and management, treatment decisions, team collaboration)
• Pain and other symptoms
• Function
• Nutrition habits
• Physical activity
• Cognitive function

Question 4

Domains of care: Emotional/Psychological

Answer 4

Psychological

• Personality
• Psychological symptoms
• Emotions (e.g. fear of progression, helplessness)
• Control and dignity (e.g. helplessness, loss of control)
• Coping responses (e.g. feeling a victim)
• Self image/self esteem
• Loss and grief

Question 5

Domains of care: Social/Cultural

Answer 5

Social/Cultural

• Finances
• Relationships (e.g. estrangement)
• Personal routines
• Recreation
• Vocation (e.g. loss of role)
• Rituals
• Legal issues
• Family caregiver support (e.g. family stress/fatigue)
• Practical issues

Question 6

Domains of Care: Spiritual

Answer 6

Spiritual

• Meaning and values (e.g. search for meaning)
• Existential issues (e.g. helplessness)
• Beliefs
• Spirituality
• Rites and icons
• Loss and grief
• Life transitions
• Religions

Question 7

Definition: Multidisciplinary/professional teams

Answer 7

• Two or more care providers from different professions or disciplines within the same profession
• Each assess the patient and work with the patient (and family) to achieve the goal
• Cooperate and coordinate with one another
• Simple difference of different professional backgrounds

Primary goal:
- Coordinate the care strategies of a profession or discipline while each stays committed to their own profession

Question 8

Definition: Interdisciplinary/professional teams

Answer 8

• Care providers from different disciplines or professions, the patient, and/or the family
• Exchange knowledge and expertise and integrate the strategies learned from one another to achieve common goals
• Common decision-making process, all team members have a defined place in the care regimen

Primary goal:
- Continual communication, shared decision making with consensus, and shared expertise

Question 9

Stages of team development

Answer 9

1. Forming
   - Team formation, insecurity and testing
2. Storming
   - Conflicts arise, self-oriented behaviour emerges, role confusion can be an issue
   - Conflict management and skills to enhance team function are important
3. Norming
   - Greater team cohesiveness as members learn to balance their processes and tasks using collaboration competencies
4. Performing
   - Innovative energy, leadership shared between team members depending on the needs of each situation
5. Adjourning
   - As team members leave and are replaced, the whole team process may revert to earlier stages

Question 10

Canadian Interprofessional Health Collaborative (CIHC) Competencies for Interprofessional Collaborative Practice

Answer 10

• Role clarification
• Team functioning
• Patient/client/community centered care
• Collaborative leadership
• Interprofessional communication
• Interprofessional conflict resolution

Question 11

CanMEDS roles relevant to teamwork

Answer 11

• Communicator

- Collaborator

Question 12

Why might teamwork be important to Palliative care?

Answer 12

• Multiple resources provide opportunities for creative solutions to complex needs
• Responsibility shared within the team (less caregiver stress and burnout)
• Greater likelihood that all patient/family needs will be identified and addressed
• Enhanced opportunity and support for ongoing communication between team members
• More seamless, consistent care delivery experiences for patients and their families
• Greater understanding of and respect for the unique skills and perspectives of various disciplines/professions
• Greater job satisfaction and improved staff retention due to feeling heard, valued, and included

Question 13

Situation awareness - defition

Answer 13

• Respect one another’s competencies, assess the needs of each health situation, and determine the complexity of the team and the demands on each member (including patient and family)

Each team member in an interdisciplinary collaborative team should demonstrate situation awareness - assess the situation, seek appropriate input from one another, and knowing when and with whom to share decision making

Question 14

How to optimize team communication and collaboration

Answer 14

• May be facilitated through technology (teleconferencing, shared access to patient charts)
• Be wary of time constraints and level of detail of information shared (may be insufficient)
• Virtual teams may have limited time, no clear leadership, and few opportunities to work together

Question 15

Evidence that an interprofessional collaborative care team is not working well together

Answer 15

• Focus moves from needs of patient and family
• Loss of common vision or goals
• Reduced quality of care (e.g. ER presentations, etc.)

Question 16

Concept of total pain

Answer 16

• Encompasses difficulties in all four domains of issues associated with palliative care
• Physical
• Emotional/psychological
• Social/cultural
• Spiritual

Question 17

Three philosophies of teamwork

Answer 17

1. Directive philosophy
   - Assumption of hierarchy within the team
   - One person takes lead by virtue of status/power and directs others
2. Integrative philosophy
   - Assumes each professional’s contribuation has equal value
   - All team members are team players
   - Communication within the team are vital
3. Elective philosophy
   - Clear and distinct team roles to operate autonomously
   - Relate briefly to other team members when seen as a need

Question 18

Members of the palliative care team

Answer 18

Core team

• Physician (with admin support)
• Specialist nurse

Extended team

• Psychology
• Social work
• Chaplain
• PT
• OT
• Dietician
• Specialist pain management
• Patient
• Family members

Question 19

Miller’s Pyramid (Model of assessment)

Answer 19

1. Knows
   - Multiple Choice questions
2. Knows how
   - Extended matching questions
   - Portfolio
3. Shows how
   - OSCE
   - Stimulated patient assessment
4. Does
   - Multisource feedback
   - Direct observation of procedural skills
   - Mini CEX

Question 20

Benefits of certification in hospice/PC nursing

Answer 20

Individual nurse has:

• Proven and tested competency across a spectrum of palliative care and hospice nursing care
• Access to a national network of experienced/knowledgeable palliative care and hospice nurses
• Demonstrated commitment to his/her specialty practice
• Dedication to professional development
• Asset to employer given focus upon quality in healthcare

Question 21

Benefits of palliative care nursing

Answer 21

• Improved care (lower symptom distress, better function, better patient outcomes)
• Improved patient QOL
• Cost-effective

Question 22

What does ‘occupation’ refer to in the context of OT?

Answer 22

1. Self/personal care
   - ADLs, IADLs
2. Productivity
   - Work related and domestic roles
3. Leisure
   - Sports, hobbies, general interests

Question 23

Core skills of Occupational Therapy

Answer 23

1. Collaboration with the patient to promote engagement with the therapeutic process and autonomy
2. Assessment (functional potential, limitations, ability, and needs)
3. Enablement (enabling patients to engage in their ADLs)
4. Problem-solving (identifying and solving problems in day to day life)
5. Activity as therapeutic tool (activities to promote health, well-being, and function)
6. Group week (planning, organizing, and leading activity groups)
7. Environmental adaptation (optimizing environments to increase function and social participation)

Question 24

Equipment and Aids: Bed transfers

Answer 24

• Back rest to support patient in a sitting position
• Mattress variator to assist lying to sitting
• Leg lifter to enable patient to lift legs into bed
• Blocks to raise bed height
• Sliding sheets for positioning/moving
• Hospital bed (especially if nursing care is required)
• Hoists and slings

Question 25

Equipment and Aids: Toilet transfers

Answer 25

- Toilet seats of varying height/design - Toilet frames - Grab rails - Commode - Urinals

Question 26

Equipment and Aids: Bath/Shower transfers

Answer 26

- Bathboards - Bath seats with hydraulics for lifting - Grab rails - Shower seats

Question 27

Equipment and Aids: Chair transfers

Answer 27

- Blocks to raise chairs - High back, orthopedic chairs with firm armrests - Riser recliners to elevate legs, +/- option to assist sit to stand

Question 28

Equipment and Aids: Car transfers

Answer 28

Sliding boards

Question 29

Equipment and Aids: Mobility

Answer 29

- Collaboration with PT to ensure safety - Wheelchairs with detachable sides to assist with transfers - Correctly fitted wheelchair - Walkers

Question 30

Equipment and Aids: Stairs

Answer 30

- Handrails or banisters - Stairlifts - Through floor lifts

Question 31

Equipment and Aids: Meal preparation

Answer 31

- Jar openers - Non-slip mats - Specialised cutlery - Adapted equipment

Question 32

Equipment and Aids: Personal care

Answer 32

- Shoehorns - Long handled spontes - Button hooks - Elastic shoe laces - Velcro fasteners

Question 33

Equipment and Aids: Manual handling

Answer 33

- Hoists for safe transfers | - Transfer boards or sliding sheets

Question 34

Equipment and Aids: Fall

Answer 34

Falls risks assessment of patient and environment

Question 35

OT: Management of cognitive/perceptual impairments

Answer 35

- Observation during functional activities (washing, dressing, meal preps) - Assessment for deficits and implications for safety/independence

Question 36

OT: Skills required for ADLs

Answer 36

1. Motor skills 2. Sensory skills (identification/interpretation of external and internal sensory cues) 3. Cognitive skills 4. Intrapersonal skills (self image, identity) 5. Interpersonal skills (relationships - parenting, working, etc.) 6. Self-maintenance (toileting, washing and dressing, feeding, sleeping) 7. Productivity (shopping, cooking, paid employment) 8. Leisure occupations

Question 37

Aims of music therapy

Answer 37

1. Supportive validation - Validation of feeling, thoughts, self-worth - May facilitate contemplation 2. Increased self-awareness to aid coping - Self-discovery - Identification with lyrics associated with feelings 3. Symptom relief and relaxation - May help with pain, tension, dyspnea, nausea, insomnia - Use of music to evoke pleasant memories - Individually 'preferred' music most associated with symptom relief 4. Connectedness - Interactions with family members, friends, other patients, staff - Can provide this for those with cognitive impairment or communication barriers 5. Aesthetic and spiritual experience - Diversion, pleasure, creative expression 6. Support expression of grief and bereavement

Question 38

Nutritional Strategies: Altered taste and smell

Answer 38

Results in food aversions | - Dietary counselling and identification of food aversions/preferences

Question 39

Nutritional Strategies: Oral thrush/ulceration

Answer 39

Results in blunting of taste - Treatment of thrush - Increase use of nutrient-dense cold fluids - Optimize oral hygiene

Question 40

Nutritional Strategies: Reduced flow and altered consistency of saliva

Answer 40

Results in gagging and nausea - Artificial saliva and hydrating oral gel - Chew gum or suck on hard candy - Optimize oral hygiene

Question 41

Nutritional Strategies: Nausea and vomiting

Answer 41

May be due to physical obstruction, drugs, or radio/chemo - Pharm treatment - Small frequent meals - Avoidance of food aversions - Fluids after, not with meals

Question 42

Nutritional Strategies: Dysphagia

Answer 42

May be due to physical obstruction or compression - Use pureed foods - Nutrient dense supplements - Consider a PEG tube

Question 43

Nutritional Strategies: Respiratory distress

Answer 43

May result in patient focussing on breathing rather than eating - Pre-medicate prior to meals - Loose clothing - Relaxation exercises - Small meals, foods that do not require chewing

Question 44

Nutritional Strategies: Early satiety

Answer 44

- Maximize availability of food - Small, frequent meals - Encourage PO consumption when patient feels at their best

Question 45

Nutritional Strategies: Altered bowel function

Answer 45

Constipation or diarrhea - can result in bloating, abdominal discomfort, and food avoidance due to fear of symptoms Constipation - Appropriate laxatives - Encourage PO intake - Encourage consumption of fibre - Optimize mobility Diarrhea - Appropriate meds (anti-diarrheals, pancreatic enzymes) - Avoid dairy products temporarily - Increase soluble fibre intake (bananas, oranges, oatmeal)

Question 46

Nutritional Strategies: Fatigue/lethargy

Answer 46

- Maximize intake when patient feels their best | - Avoid foods that require a lot of chewing

Question 47

Common communication issues in Palliative Care:

Answer 47

Dysphasia/aphasia - Difficulty understanding or using spoken or written language Dysarthria - Impaired speech due to muscle weakness Dyspraxia of speech - Difficulty forming speech sounds/words due to impaired motor function Dysphonia - Vocal impairment (weak or hoarse)

Question 48

SLP interventions for difficulties with communication

Answer 48

- Augmentative or alternative communication - May be low tech (paper based word or picture charts, alphabet) or high tech (computerized apps, typing with auditory output, etc.)

Question 49

Outcomes of art therapy

Answer 49

- Development of creative attitude by the patient towards their circumstance - Increased sense of control - Communication of mental/emotional state - Wider range of expressive capabilities - Increased insight into patient behaviour - Body image issues - Cathartic release of emotions - Increased self-esteem and self-efficacy - Increased ability to confront existential questions and relieve spiritual distress - Development of positive coping strategies/increase in coping resources - Reduction in experience/report of physical pain - Improved QOL

Question 50

Role of the pharmacist in palliative care

Answer 50

1. Appropriateness of med orders and timely provision of meds for symptom control "Right patient, right drug, right time" 2. Counselling/education hospice team around meds 3. Ensuring patients and caregivers understand and follow directions with meds 4. Efficient mechanism to provide compounding of non-standard dosage forms 5. Consider financial concerns 6. Ensuring safe/legal drug disposal after death 7. Effective communication with regulatory and licensing agencies

Question 51

Palliative Rehabilitation Services

Answer 51

- Short, targeted rehab - Goals may vary - may have little expectation of functional gains, but more focussed upon caregiver training to ensure safety and maximal independence for patient at home Includes: - Exercise regimes - Education around positioning - Maintenance of skin integrity - Pain control - Continence/safe elimination

Question 52

Best timing for referral to palliative rehab services

Answer 52

- New or significant difficulty with BADLs/IADLs - New or significant decrease in household or community mobility - Frail, ill, or disabled caregiver - Recent hospitalization or significant change in medical status (period of bed rest, pathologic fracture, etc.) - Symptoms interfering with function (e.g. pain, dyspnea)