Role of multidisciplinary teams using palliative approaches and strategies to support palliative care patients and their families in end-of-life care

Comprehensive Care Plan For Palliative Care Patients

Topic: Role of the multidisciplinary team using a Palliative approach.

Explanation: Comprehensive care is required by the multidisciplinary team for the palliative care patients after returning back to home, based on Advanced Care Planning (ACP).

Evidence: A comprehensive care plan is a dynamic documented plan that describes agreed care goals, draft medical plans, care, and relevant health activities for patients. Interdisciplinary teamwork based on principles of team approach, communication, access to therapeutic areas, nationally agreed standards and patient engagement (Cancer Australia, 2022). Multidisciplinary team care (MDC) is implemented to increase the patient’s chances of survival. The MDC team provides comprehensive care plans based on clinical practice guidelines, including access to psychosocial support and information. MDC is the practice of a team approach being explored for treatment planning and patient care. MDC is an integrative approach to medicine, working with physicians and related health professionals to offer a range of treatment options and develop individualized treatment and care plans for each individual patient (Cancer Australia, 2022). This team approach involves all health care professionals, discussing options and jointly determining treatment and supportive care plans that take into account patient preferences. Physicians who care for cancer patients will present recommended guidelines and treatment plans to the patient, depending on the situation and the patient’s wishes. Maintaining standards of practice is supported to promote better professional development. Supportive care is also an integral part of multidisciplinary care, helping patients access appropriate services. MDCs should support patients through good communication and cooperation among team members regarding patient care and outcomes. MDC focuses on both aspects of care. H. Concerning clinical and psychosocial care of patients. General practitioners also play a variety of roles in evaluating the disease process, including diagnosis, referral, treatment planning, coordination, and care planning, providing information and support to patients and their families.

The Advanced Care Plan (ACP) is a key element in a multidisciplinary nursing approach to achieving quality palliative care (Rietjens, Korfage & Taubert, 2021). This planning approach encourages patients to make their own decisions about their medical preferences, which can be documented in their living will. Fundamental goals of ACP include respecting patient autonomy, improving quality of care, strengthening relationships, preparing for end-of-life decisions, and reducing overtreatment. ACP is an intervention aimed at promoting patient autonomy in end-of-life decision-making (Rietjens, Korfage & Taubert, 2021). Example: In the given case study, the patient is in advanced stages of colon cancer and wants to return home and does not want to burden his wife. An effective team approach to ensuring continuity of patient care and care planning can improve patient understanding of disease, diagnosis, treatment planning and outcomes, and support cancer patients on their life journey. Helpful. Therefore, a multidisciplinary team nursing approach is optimal for achieving optimal palliative care.

Importance Of Multidisciplinary Team Care Approach

Links: Therefore, advanced care plans are very important in addition to comprehensive care for palliative care patients. with a multidisciplinary care team.

Topic: Strategies to support palliative care patients and their relatives in end-of-life care.

Rationale: Various strategies are important to support families and caregivers in end-of-life care.

Evidence: End-of-life strategies provide emotional, psychosocial, spiritual, and practical support to family, friends, and caregivers. End-of-life care, together with palliative care, can help improve quality of life for those with advanced disease or dying (Smithard, Mitchell, & Patel, 2019). These strategies may include providing services, help, information, recommendations and support. There is an urgent need to provide emotional support to the patient’s family and loved ones by listening and empathizing with them. When patients and family members are physically present and holding hands, they feel supportive and secure. Nurses build relationships with patients, families, and loved ones, encourage them to talk and share their feelings, speak openly or honestly, and express emotional and spiritual feelings. By doing so, we can support patients, families and loved ones. Actively use your listening skills to create a non-judgmental atmosphere. They help expand interpersonal relationships with family and close loved ones, encourage positive feelings, and enable optimistic reassessment. Caregivers must help families recognize their need for support and care.

Her two key strategies for supporting families and caregivers in end-of-life care are hands-on support and emotional or spiritual support. Actual support includes: Respite care to allow breaks in care. Help families and patients with their concerns and feelings. Advising or instructing family members or caregivers about “care” such as medication. Nurses provide families with the facilities they need to keep palliative care patients comfortable (Fernando & Hughes, 2019). Nurses can help talk about the care and support of palliative care patients and their wishes. From an emotional and psychiatric support perspective, caregivers need to initiate conversations, listen to patients, and understand personal values ​​in order to provide emotional or psychosocial support. Language and type of communication should be considered when communicating with patients, their families, and multidisciplinary teams and representing their wishes. Additionally, the environment must be surrounded by positive healing vibrations. Promote physical activity for a healthy mind and soul. Information and psychological support. spiritual support. Emphasis on family-centered care. Advocate the practice of yoga and meditation. Emotional support includes autonomy, competence, and connection. Autonomy represents the desire for action, self-organization, and experience. Competencies represent the achievement of valuable outcomes based on impact and achievement. Connection can be described as feeling connected to others and giving them love and care.

Link: Palliative care strategies, therefore, include not only mental or emotional and psychosocial support, but also practical or physical existential support for living a healthy life and maintaining or achieving a better quality of life. It is very important to support the patient, family and loved ones by comforting them in life.

Multidisciplinary Team Work Principles

Topic: Potential for coordinated and integrated palliative care for patients and their families.

Description: Engage multidisciplinary team members in the home care of palliative care patients based on a ‘pain management strategy’.

Evidence: A multidisciplinary team approach includes medical professionals grouped from different disciplines and roles. To work together in groups or teams to achieve optimal patient care and achieve common goals. A multidisciplinary team approach is important because it provides an opportunity to coordinate multiple clinical and social services that may be important to patients and their families. A multidisciplinary team will hold meetings to discuss the components of palliative care and other areas of health care. For example, for patients with metastatic colorectal cancer listed in a particular case study, the multidisciplinary team included an oncologist, a chemotherapist, a general practitioner, a physical therapist, a psychologist, a social worker, a counselor, a working It includes therapists and palliative care workers, working together. A group or team for better patient outcomes.

A multidisciplinary team works together to organize and coordinate health services to meet the essential and other needs and supports of palliative care patients and their families. Different professionals differ based on the expertise and skills they possess. It helps teams improve diagnostic procedures, assess disease, plan strategies for treatment options, and manage care according to shared decision-making. Considering the wishes of patients and their families, counselors and psychologists play an important role in mental health management, emotional and psychological support to achieve better health outcomes and quality of life. Mental and emotional health are very important as they can affect or exacerbate a patient’s physical health, impacting their quality of life. Palliative care nurses are critically important in ensuring the comfort and needs of patients and their families when caring for critically ill patients in home care. Palliative care also includes advance care planning (ACP) to document the patient’s decision-making process during or before an emergency to appropriately prepare for the situation and consider the patient’s wishes. A palliative care team also provides services to manage pain and other related symptoms. Palliative care practitioners discuss treatment options and symptom management in home health settings. Collaborate with all health care providers to coordinate care services (Fernando & Hughes, 2019).

An integral part of palliative care is ‘pain management’ (Morrison & Morrison, 2006). Pain relief is an important factor in improving a patient’s quality of life. Pain management includes managing unpleasant sensations, unusual experiences, and fear of pain. Nursing strategies for managing pain include: Physical therapy, such as hot and cold compresses, massage, exercise, yoga, and hydrotherapy. Psychotherapy, such as cognitive-behavioral therapy, relaxation techniques, and meditation. Physical techniques such as acupuncture and community support groups. Therefore, the primary goal of pain management is to restore a patient’s sense of order in chronic pain and improve their quality of life.

Link: Therefore, a multidisciplinary team approach is an important aspect in assessing a patient’s illness, along with a palliative care plan to provide comfort and mental or emotional support to the patient and their family. Additionally, pain management is an important part of managing chronic pain in critically ill patients to maintain quality of life.


Cancer Australia. (2022). Multidisciplinary care. Cancer Australia. Retrieved 21 April 2022, from

Fernando, G. V. M. C., & Hughes, S. (2019). Team approaches in palliative care: a review of the literature. International journal of palliative nursing, 25(9), 444-451.

Morrison, L. J., & Morrison, R. S. (2006). Palliative care and pain management. Medical Clinics, 90(5), 983-1004.

Rietjens, J., Korfage, I., & Taubert, M. (2021). Advance care planning: the future. BMJ supportive & palliative care, 11(1), 89-91.

Smithard, D., Mitchell, L., & Patel, F. (2019). Ethical considerations of care towards the end of life. Nursing And Residential Care, 21(3), 146-150.

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