NHPCO NewsLine Spring 2022 - 10

continued
Our assessment focuses on what is happening in all of the
dimensions that are helping or hindering the patient and
family from attending to what is important to them at
this time. Services are chosen by the patient and family
and evaluation is based on their perception of how well
they have reached their end-of-life goals. This process can
happen whether the patient has nine hours, nine days or
nine months to live-always focusing on what is most
important to the patient and family at any given moment.
Assessment by any discipline goes beyond identifying a
problem in the dimension they are most comfortable
assessing, such as the physical dimension assessed by a
nurse. All disciplines approach assessment from the
perspective of identifying how any issue or problem is
affecting all dimensions. For instance, all disciplines
approach patient and family-identified problems of pain
with a broader vision of how it is simultaneously affecting
the patient's and family's other dimensions, including their
functional abilities, interpersonal relationships, sense of
well-being and sense of spirituality. In palliative care, the
disciplines don't own problems or care plans-they are not
ours to own. It is not our experience, it is the patient's and
family's experience. All disciplines must be competent at
some level to respond to all of these dimensions and adept
at collaboration with an interdisciplinary team to
optimally transform this end-of-life experience.
Comparing how a patient and family are discussed in an
interdisciplinary care plan meeting will illustrate these
differences. In a disease-focused model, the following
might be used to introduce a patient and family, usually
" reported " by the nurse:
Mr. Jones is a 78-year old patient with COPD. He was on O2
prn. With his increased dyspnea at rest and bilateral
congestion, he is using his oxygen on a continual basis. He is
anxious at night, has trouble walking from his bed to his
living room and is demanding. The doctor changed his inhaler
this week because he was not compliant with taking his
other medications since he didn't like the aftertaste. The
HHA visits four times a week to assist with his personal care.
They are not asking for any other help at this time.
The discussion becomes problem-focused, often identifying
the patient as a disease first, then perhaps mentioning
how this is affecting the rest of the patient's life (although
this part is often not a focus). In contrast, team dialog in
the Experience Model focuses on the patient and family's
values, goals and wishes as the starting point:
Mr. and Mrs. Jones have shared 58 years together since they
met and married in college. They have stated that what is
most important to them at this time is for Mr. Jones'
symptoms to be controlled enough to allow him to spend
quality time with his children and grandchildren who live
close by. Mr. Jones wants to be able to communicate his
thoughts and wishes to each of his grandchildren before he
dies. He is also concerned about how his wife will be cared
for after he is gone. Mrs. Jones is hoping that she has
enough strength and endurance to stay by his side and care
for him until the end. They define themselves as practicing
Catholics and state that their faith has given them strength.
Their usual activities, before Mr. Jones could no longer
participate, included golf and travel. They now enjoy reading,
movies, writing letters, and listening to old-time music.
Once the interdisciplinary team has been introduced to
patients and families through the story of their lives and
what is important to them, the team can consider the
following question: What is happening with this patient and
family that is helping or hindering the patient and family
from getting to what is important to them at this time?
Each team member approaches his/her assessment from
this perspective by supporting those aspects that are
helping the patient and family reach their goals, reframe
their hope and experiences, or by helping them meet the
challenges of those aspects that are hindering them from
reaching their goals. Symptoms that take away the
patient's ability to focus on what is important to him are
minimized or controlled so his energies can be used to reach
his goal of spending quality time with his family. Additional
activities that help the patient create and communicate his
legacy, such as life review with his children, are critical
aspects of service. The team can provide additional
caregiving support to his wife so she can endure the
All disciplines approach assessment from the
perspective of identifying how any issue or
problem is affecting all dimensions.
10
Newsline / Spring 2022
NHPCO NewsLine Spring 2022

Table of Contents for the Digital Edition of NHPCO NewsLine Spring 2022
