American College of Physicians: Internal Medicine — Doctors for Adults ®

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How team care can help during end-of-life care

From the May 2001 ACP-ASIM Observer, copyright © 2001 by the American College of Physicians-American Society of Internal Medicine.

By William Hoffman

Atlanta—A team-oriented approach to end-of-life care can not only provide significant benefits for patients, but also help relieve physicians from having to solely bear the burden of caring for the dying.

That was the assessment of a three-person panel at the session, “Role of the Health Care Team in End-of-Life Care.” The panel consisted of a physician, an advanced practice nurse and a licensed clinical social worker.

“Role overlap and blurring is sometimes inevitable in team-building,” said Susan E. Blacker, a social worker from the department of oncology social work at the Johns Hopkins Oncology Center in Baltimore. To minimize confusion and conflicts among providers, she said, care teams need to identify team members’ skills, as well as who is most likely to be called on for different kinds of help.

Providing relief

Janet L. Abrahm, FACP, director of palliative care programs at Boston’s Dana Farber Cancer Institute, said that one of physicians’ most important roles in end-of-life care is playing a decisive role in providing pain relief.

“We have so many choices right now” among types of pain relief and delivery methods, she explained. For example, physicians can substitute liquid opioids for pills when patients have problems swallowing, and they can use fentanyl patches to dispense time-released medication.

Ms. Blacker explains that social workers can help patients’ families cope with terminal illness and the dying process.

Dr. Abrahm urged physicians to recognize the different types of pain in the terminally ill—and to not flinch from treatment. For example, bone pain sometimes requires ASA, NSAIDs, acetaminophen, corticosteroids or osteoclast inhibitors. Neuropathic pain may also call for corticosteroids, but anticonvulsants such as gabapentin may be indicated. Some physicians prescribe tricyclic antidepressants, though Dr. Abrahm said she avoids giving these to dying patients because of the side effects.

Because some patients present no symptoms of pain, Dr. Abrahm suggested that physicians ask individuals to rate their pain. Beware, however, because “delirium at the end of life looks like pain” and should be treated separately, she said. “Thorazine works wonders.”

Doctors also have a duty to inform terminally ill patients when death is imminent, Dr. Abrahm noted. Many shrink from the task, she explained, because they worry about hurting patients’ morale. But patients usually know the worst, she said, and they need affirmation from their doctor so they have time to communicate their wishes to loved ones.

Sharing burdens

Terri Maxwell, an advanced practice nurse who is executive director at the Center for Palliative Care in the department of family medicine at Philadelphia’s Thomas Jefferson University, explained that nurses specialize in treating the human response to illness. With terminally ill patients, nurses must not only treat symptoms but also monitor how patients adapt—or fail to adapt—to those symptoms. “We see patients through a different lens,” she explained.

Nurses on an end-of-life team serve as patients’ care manager for pain and symptoms throughout the dying process. Nurses must educate patients and their families about medication scheduling, side effects and safety, Ms. Maxwell said, and ensure that patients take prescribed medications.

Ms. Maxwell also pointed out that the nurse member of an end-of-life team can help physicians by sharing the burden of responsibility, frustration and grief. She recalled working with a physician who temporarily traded his post with a palliative care nurse. She said he felt great relief when he learned that he was not the sole source of hope for dying patients and their families.

Lending perspective

Ms. Blacker said that while many patients misunderstand social workers’ role in end-of-life care, she and her colleagues can lend valuable perspective as a family copes with diagnosis, treatment, remissions, recurrences, palliation, death and bereavement.

Ms. Blacker said she often serves as the principal contact between the family and the dying patient’s physicians and nurses. She also explained that social workers can often help unlock mysteries that might otherwise baffle caregivers.

For example, one dying patient’s family met periodically with the physician. While the family always listened carefully to treatment options, they rarely responded, except to confirm future appointments. When Ms. Blacker learned that the family always consulted clergy before making major medical decisions, it eased the way for clearer communication among all parties.

Ms. Blacker said social workers can also help patients and their families with other issues, such as the financial strain of terminal illnesses. She noted that 80% of families caring for a terminally ill relative exhaust their savings and go into debt by the end of the process. Social workers can often help the families of patients find solutions to these problems.

William Hoffman is a freelance writer in Fairfax, Va.

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