Palliative Care - An Ideal Environment for Interprofessional Education and Practice

Rokusek C* and Chandan N

College of Osteopathic Medicine, Nova Southeastern University, USA

*Corresponding author: Cecilia Rokusek, Office of Research and Innovation, College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, Florida 33328, USA

Received: May 02, 2016; Accepted: July 01, 2016; Published: July 04, 2016

Abstract

Palliative care involves an interprofessional collaborative approach in working with patients and their families and caregivers by providing patient-centered and individualized pain relief compassion, caring, and overall minimization of symptom severity. Because palliative care patients most often also have one or more chronic illnesses, the need for the interprofessional practice model is even more important. This type of collaborative care is often referred to as “comfort” care or “end-of-life” care, with the focus being on improving quality of life for both the patient, family, and both family and non-family caregivers. This paper discusses palliative care and the importance of it in the interprofessional education of students in the educational pipeline and of professionals for ongoing effective practice in addition to the interprofessional education of students placed under their supervision during practicums and clinical supervision. There has been a paucity of research specifically in the area focused on the interprofessional proponent in the palliative care setting. A thorough literature review was conducted to analyze the unique components of palliative care that make it an ideal setting for the interprofessional team-building model. Given the increased emphasis on interprofessional education over the past five years with the establishment of the Core Competencies for Interprofessional (IPE) Collaborative Practice, the incorporation of interprofessional education standards into over 60 professional health education organizations, and the need to increase the clinical training and active participation for students in interprofessional settings, palliative care should be utilized more in educational settings as a primary interprofessional education environment for learning about the interprofessional core competences through active involvement of students, practitioners, patients, family members, and caregivers. Although the literature is limited in relationship to Interprofessional education and practice in palliative care, it is clear that palliative care emphasizes a focus on both the patient and family and provides an ideal interprofessional environment including but not limited to physical, social, emotional, and spiritual care. Interprofessional care is integral in palliative care. Additionally, the high risk of burnout among professionals in palliative care further suggests the need for interprofessionalism and integration of IPE core competences in both preservice and continuing education. IPE can build resilience among professionals, family members, and caregivers. While the interprofessional proponent is critical to the outcomes of palliative care, the resilience of team members must be taken into consideration. These findings need to be further developed so that interprofessional care in palliative care settings is used more extensively to prepare students and practicing professionals in interprofessional patient-centered care. The clinical component of interprofessional education is most often lacking in student education. Palliative care environments can help in developing interprofessional leaders for the entire health care delivery system. In addition, there is a need to collect ongoing outcomes data related to the Interprofessional outcomes resulting from effective collaborative care delivery in the palliative care setting. A meta review of the literature was implemented to review the peer-reviewed literature and other professional publications of the past 20 years (1996-2016) to examine the role of palliative care in interprofessional education and practice for professionals and for students in the academic pipeline.

Keywords: Interprofessional Education; Interprofessional Practice; Models of Interprofessional Practice; Patient-Centered Collaborative Coordinated Care; Palliative Care; Patient and Practioner Outcomes in Palliative Care

Background

Since the passage of the Patient Protection and Affordability Care Act in 2010 and the Interprofessional Core Competencies for Collaborative Practice published in 2011, patient centered Interprofessional collaborative throughout the lifespan delivered within the context of the primary care medical home has become the standard of achievement for all health and social care professionals and all health care delivery systems. This focused lifespan approach to health care provided by teams of interprofessional health and health related professionals that include the patient and family member or care partners as equal team members in the planning and implementation of care is important in both “wellness and illness”. The U.S. health and social care systems are not well prepared to carry out a fully integrated interprofessional system of care. Interprofessional education that includes hands on and active involvement in interprofessional practice experiences need to be expanded for both working professionals and students in the academic pipeline. It is not enough that students or professionals be educated about interprofessional education and practice. They must be actively involved in team based care with the patient. Educational institutions and accredited professional continuing education programs need to identify and incorporate interprofessional education and practices into their programs. Although the U.S. health care system has a distance to go yet before achieving this ideal system, palliative care can be used as a model in both education and practice for the delivery of care within the interprofessional practice foundation with full involvement of the patient and their family and or caregivers. Palliative care has developed on the full involvement of interprofessionals who utilize the team-building model to provide high-quality, specialized patient-centered care in the milieu of complex, multiple chronic health conditions and multi-faceted emotional issues. Such a framework involves the collaboration of health professionals from various fields, including physicians, nurses, dietitians, occupational therapist, physical therapists, dentists, optometrists, pharmacists, psychologists, counselors, spiritual leaders, and social workers, with the purpose of working to actively achieve the goals of patients, families, caregivers, and health system decision-makers regarding services to support the end of life in both home and non-home settings [1]. Quality of this care to achieve optimal outcomes especially for the person receiving palliative care and the family is influenced by the competence of the team members, their understanding of individual roles and responsibilities, general team coordination, and communication within the interprofessional team [2], Specific concepts that underpin successful collaboration include sharing of responsibilities and decision-making, partnerships established on mutual trust, interdependency among providers to reach common goals, and shared power among team members [3]. All of these concepts of collaboration are also part of the Interprofessional core competencies: teamwork, communication, understanding of roles and responsibilities, and values/ethics [4]. The unique collaborative and ongoing team approach to care giving in palliative care provides an ideal setting to practice interprofessional core competencies and to achieve the most appropriate and individualized level of care for patients, families, caregivers, and health professionals alike. A critical point in palliative care, also important to Interprofessional care, is the well being of all involved, including the professional and family member/caregiver.

The palliative care setting lends itself to a holistic and individualized collaborative approach to patient care and management to meet all aspects, including spiritual and creative needs, of patients [5]. End of life care involves a biomedical, emotional, and logistical complexity that requires seamless and ongoing interprofessional teamwork [6]. Individuals receiving palliative care are terminal; they cannot be cured and are facing an end-of-life situation. These dying patients have complex needs that require collaborative practice with full family and personalized care taker involvement because their physical, social, psychological, emotional, and spiritual needs are equally significant for both patient, family members, and non-family caregiver, especially if they have been involved for many years. Care must be provided for all and all persons must be involved in those decisions regarding care [7]. When faced with such multi-dimensional issues to address from many perspectives, complex interprofessional challenges, and rapidly changings situations, effective and generous teamwork is essential [8,9]. In palliative care, an Interprofessional team based approach is required at all times not just for planning.

Methodology

A meta review of the literature was conducted to examine the role of palliative care in interprofessional education and practice for health and social professionals and students. The following parameters were selected for the review of the published literature:

• Inclusionary years from 1996-2016

• Peer reviewed journals

• Professional publications and national reports

Over 200 articles, professional publications, and national reports were identified. These were reviewed and selected for inclusion into the review of the literature. The final 64 articles reviewed included two of more of the key topical areas.

Findings

Palliative care provides an ideal environment for students and professionals to observe and utilize ideal Interprofessional collaborative practice respectively. Although the literature around palliative care is extensive, little has addressed the integration of palliative care in the education of students in Interprofessional practice. In addition, few continuing professional education programs are addressing ongoing continuing education for practicing professionals in the area on how to utilize and incorporate Interprofessional education when working with students placed in the palliative care setting. The palliative care environment, whether in the home or community setting provides students with an ideal leadership focused experience in Interprofessional practice. The education field has long proposed that practice-based learning is most effective to teaching the Interprofessional core competences for collaborative practice. Standardized experiences for students from all of the disciplines involved in health care to participate in rotations in palliative care is not available. In this inclusion should be incorporation for all students domains related to health literacy, ethnicity, religion, and educational and geographic backgrounds [10]. Spiritual leaders are important for both the patient and the family and or caregiver if not a family member. These spiritual leaders should be available 24/7 which is not always possible. In this case, other team members should develop the skill set to work with the spiritual leader and serve as transdisciplinary team member to assist the spiritual leader.

A defining theme among palliative care from the literature reviewed is the use of interprofessional practice as a protective factor from the high risk of burnout among health professionals. Palliative care is particularly challenging for individual practitioners due to the “intensely emotional subject matter” [3]. A 2014 survey conducted by the American Society of Clinical Oncology found a burnout rate of over 62% among palliative care physicians, with over 50% of healthcare professionals predicted to leave the field in the next 10 years [11]. Burnout refers to a deep sense of total energy loss and emotional exhaustion; it results in a sense of incapacity to give more of oneself, depersonalization, and lack of personal and professional accomplishment due to sense of incompetence and inability to perform or sense of omnipotence [12]. Studies have shown that professionals working in palliative care teams have feelings of hopelessness and uselessness after having multiple cases pass away on them week after week. The Interprofessional core competences of team work and communication among other team members is critical. Interprofessional education and ongoing continuing education can help to build this support and resilience among professionals, patients, and family members and non-family caregivers who may have been with a patient for several years.

Professionals face several burnout risk factors working in palliative care, including lack of confidence in communication skills, difficulties in delivering bad news, work overload, and conflicts [13]. Ethical decisions, which are central to palliative care practices, are perhaps the largest contributor to burnout rates among health professionals and family members alike. The major difference is that family members most often experience this stress related to loss only once or twice. Those professionals in palliative care can experience it daily. The need to make such decisions aligns with the general nature of palliative care in providing treatment to improve quality of life as opposed to treating the disease directly. Choices that must be made include disclosure of information to the patient and family members, implementing new treatment, increasing existing treatment, or even withholding/withdrawing treatment due to patient discomfort or the treatment no longer being beneficial. Health professionals most often perceive such decision making to be “stressful and difficult.” A 2014 study provides evidence that such decisions are associated with higher levels of burnout and moral distress, along with other work related problems among healthcare professionals [14]. However, despite the increased need to make ethical decisions in palliative care, burnout levels do not seem to be significantly higher in palliative care when compared to other professional fields when the interprofessional decision-making process is used. Such a process acts as a protective factor by promoting a sense of team-based empowerment. When ethical deliberation occurs using an interprofessional team approach, health professionals feel involved in the decision and individual doubts are alleviated through discussion and shared decision-making. Moreover, the building of relationships and mutual trust among members of the interprofessional team enables practitioners to seek emotional support from one another [3]. The Interprofessional team based collaborative approach prepares health professionals with coping strategies to counteract the effects that the continual confrontation with death and dying may have.

Palliative care can be further taxing on health professionals due to the large focus on both the patient and family as a single unit, as opposed to isolating care to just the patient. While health services are still directed towards symptom management, an equally great component of palliative care involves helping the patient and family cope with the eventual death of a loved one [3]. In such situations, it’s not just about the palliative patient, but also about the family or long time non-family caregiver who will be left behind to grieve and cope; just as the patient requires attention in dealing with spiritual, emotional, and social symptoms, so does the family. The person centered philosophy of palliative care makes interprofessional teamwork and close involvement of patients, families, and caregivers of great value [8]. Simultaneously caring for the patient’s needs and managing the families’ stresses show the realities that palliative care must deal with. Aside from worrying about their loved one, family members or long time sole surviving care givers face additional stressors. They are responsible for making decisions for the patient if he/she is unable to do so, with the knowledge that no decision will cure the patient but will only comfort and ease the patient in the process. These individuals must also deal with personal coping and grieving as they come to terms with the fact that their loved one will soon be gone and begin to prepare for life after their passing.Thus, the delivery of psychological, emotional, and medical care is as much for the family as it is for the patient, if not more, as they are the ones left behind. Only through interprofessional collaboration is it possible to meet these differing needs of the patient and family. One of the most overlooked areas for families and caregivers is individual health. Often times the family members and caregivers sacrifice their own health for the stresses and the situation of the individual in palliative care.

Gaps in the Literature

With the increasing focus on interprofessional education and practice throughout the health and social care systems, with professional accreditation agencies requiring interprofessional practice, with health care outcomes and funding tied to interprofessional coordinated care and patient involvement, and with higher education accreditation requirements for interprofessional education, there is very little attention given to the leadership role that palliative care can play in the education of practioners and students related to interprofessional education and practice. There is also a paucity of data related to the involvement of the patient, the family and or care partners on the team and the impact to the overall outcomes for the individual receiving care. Overall, there is little focused research on the team’s role in patient outcomes, patient and family satisfaction and overall health, and resilience for both the professional and the care partner involved in palliative care.

Recommendations for the Future

With the ongoing changes in U.S. healthcare system and with the need to educate both students and professionals in the interprofessional core competencies, the environment provided for in palliative care should be used to provide students and practitioners with the ideal setting for practice-based education and practice. Continuing education needs to be focused on Interprofessional practice in the palliative care environment. More attention should be paid to utilizing a more standardized experience for Interprofessional learning in the varied palliative care settings. Overall, more outcomes research needs to be conducted related to the use of the interprofessional team model and patient and family/caregiver satisfaction and overall health outcomes, realizing the individual targeted outcomes. For the family and or caregiver, an outcome may be improved health and prevention of personal deterioration. Finally, more research needs to focus on the professional resilience factor in palliative care when the interprofessional decision-making process is used.

Conclusion

Palliative care is becoming increasingly dependent on the use of an interprofessional team-building model to provide high-quality, specialized patient-centered care in the context of complex, chronic health conditions. The unique approach to caregiving in palliative care provides an ideal setting to practice the interprofessional teambuilding model to better achieve the next level of care for patients, families, and health professionals alike. It is critical that this model is incorporated into the educational pipeline in order to instill the values of teamwork and shared responsibility in future health professionals. Additionally, such a model will act as a protective factor for health professionals and caregivers and reduce burnout risks and rates among palliative care team members. The above findings may be used to further develop interprofessional care in palliative care settings, with the intentions of improving delivery of care and better meeting the needs of the patients, families, and health professionals. Interprofessional experiences in palliative care environments should be integrated into all health and social professions education programs. Concurrently, Continuing Medical Education Programs (CME’s) and other health and social professions Continuing Education Programs (CE’s) should include palliative care and interprofessional practice into their programming. Family members and other care partners need to be educated about their active role in being a member of the interprofessional team within the palliative care environment. As the health and social care systems strive to impact positive patient outcomes and improve overall population health, increased research on the outcomes of interprofessional practice in the palliative care environment should be ongoing.