The palliative care team

Wednesday 1 April, 2015

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A multidisciplinary team Your palliative care team will be made up of medical, nursing and allied health professionals who offer a range of services to assist you, your family and carers throughout your illness, whether you are being cared for at home or in another setting. Volunteers can also offer practical and emotional support, and may form an important part of your team.

Depending on your needs, your palliative care may be coordinated by your GP or a community nurse, or you may be referred to a specialist palliative care service, where the doctors, nurses and allied health professionals are specifically trained to look after people with complex health care issues.

You will have regular appointments with the health professionals in your team so they can monitor you and adjust your care. The most common team members are listed below. You won’t necessarily see all these people – some roles overlap and assistance varies across Australia. Your GP, nurse or palliative care specialist can help you work out which services will benefit you most.

A multidisciplinary team

The people in the palliative care team work together to help meet your physical and emotional needs, and provide support to your family and carers.

General practitioner (GP) or family doctor

  • continues to see you for day-to-day health care issues if you are being cared for at home (and may be able to make home visits)
  • liaises with your nurse and/or palliative care specialist about the coordination of your ongoing care
  • refers you to a palliative care specialist or organises your admission to hospital or a palliative care unit (hospice) if your circumstances change
  • may offer bereavement support to your family and carers, and can refer them to counselling if necessary.

Nurse

  • may be a community nurse or a specialist palliative care nurse and may work for a community nursing service, a specialist
  • palliative care service, a hospital or a residential care facility
  • coordinates other health professionals and works out what care you need, including home nursing or personal care assistance
  • makes sure you have access to medications and other treatments for pain and symptom relief, and talks to you about how to take your medications
  • can suggest practical strategies to help you manage your condition (e.g. how to plan your day).

Palliative care specialist or physician

  • prescribes or recommends treatment for pain, nausea, constipation, anxiety, depression, shortness of breath or any other symptoms you may have
  • usually provides care in a palliative care unit (hospice) or hospital, but may also be able to visit you in your home or residential care facility
  • communicates with and advises the oncologist and your GP so your treatment is well coordinated
  • may refer you and your family to a grief counsellor or psychologist
  • assists with decision-making about care choices.

Cancer specialists (oncologists and surgeons)

  • may diagnose the advanced cancer and refer you to a specialist palliative care team
  • may continue to provide chemotherapy, targeted therapies, radiotherapy or surgery to manage the symptoms of the cancer.

Counsellor or psychologist

  • allows you to talk about any fears, worries or conflicting emotions you may be feeling
  • helps you work through feelings of loss or grief
  • assists you and your family with relationship issues
  • helps you resolve problems so that you can find more pleasure in your life
  • teaches you strategies to handle anxiety
  • may show you meditation or relaxation exercises to help ease physical and emotional pain
  • provides bereavement care to your family and carers.

Pastoral carer, chaplain or spiritual adviser

  • supports you and your family in talking about any spiritual matters on your mind
  • reflects with you about your life and helps you search for its meaning, if appropriate
  • helps you to feel hopeful and develop ways to enjoy your life despite your illness
  • may organise special prayer services for you, if appropriate
  • connects you with other members of your faith
  • may discuss emotional issues, as many are trained counsellors.
If you have cultural or religious beliefs about death and bereavement, or certain family customs, talk to your palliative care team early on. Your customs can often become part of your palliative care plan.

Social worker

  • assesses what sort of support you, your family and carers need and identifies ways you can receive this support
  • provides counselling and emotional support to you, your family and carers, including working through feelings of loss and grief
  • assists with communication within the family, including any relationship issues, and with other health care professionals
  • discusses ways of coping and how to emotionally support your children or grandchildren
  • can help you work out ways to record your memories
  • provides information and referrals for legal matters, financial support, home respite care, meal services, parking schemes, personal alarms, laundry services and aged care services.

Occupational therapist and physiotherapist

  • help you manage the physical aspects of your daily activities, such as walking, bathing, and getting into and out of bed and chairs safely
  • advise you on physical aids to improve your mobility, such as a walking frame or a device to help you put on your socks
  • organise equipment hire or modifications to your house for a safer, more accessible environment
  • teach carers and family the best ways to move you or help you sit and stand
  • assist with pain relief techniques, such as positioning your body in a better way, using hot and cold packs, and stimulating certain nerves in your body
  • show you how to exercise to reduce pain and stiffness, and to increase mobility and energy
  • use physical therapy to help clear congestion from your lungs
  • may work with a massage therapist to relieve stiff and sore muscles or swelling.

Pharmacist

  • gives you access to prescription and over-the-counter medications
  • provides information about how to take medications, and any side effects or interactions with other drugs
  • communicates with the prescribing doctor, if necessary
  • helps you with symptom management so you can achieve the best possible quality of life
  • assists you or your carer with keeping track of medications, including the costs on the Pharmaceutical Benefits Scheme (PBS).

Dietitian

  • works out the best eating plan for you and your family
  • helps you choose appropriate food and nutritional supplements
  • tries to resolve any digestive issues, such as poor appetite, nausea or constipation
  • may work with a speech pathologist, who can assess and help you deal with eating and swallowing problems.

Volunteers

  • offer friendship, companionship, a non-judgemental presence and emotional support
  • provide practical support, which might include taking you shopping or to appointments, giving your carer a break, minding children, or doing basic jobs around the house
  • are most helpful when you give them specific tasks so that they don’t have to guess what you need
  • may be accessed through a palliative care service – these volunteers go through a thorough selection process that includes training and criminal history checks
  • can also be found through community volunteer groups – check with your GP or local community centre
  • can be a friend, neighbour or family member – although you may feel embarrassed about asking for help, you will probably find that many people want to do something for you.
"I enjoy helping people out, whether it’s stringing up Christmas lights or helping record someone’s life story. It’s incredibly rewarding and a pleasure to help." - Cheryl

Pat's story

"I was first diagnosed with bowel cancer two years ago. I had a year of intensive treatment and thought I was in remission, but then a PET scan revealed advanced cancer. The oncologist recommended another seven months of chemotherapy treatment. The treatment is palliative – it is trying to stop the cancer spreading further.

"My main worry was transport: 'How will I get to hospital for all these appointments?' My husband is 89 and can drive only in the local area. Our children are all working and I wanted to lessen the impact on them.

"The local community care service put me in touch with a volunteer palliative care group. The volunteers are marvellous. They drive me to all my appointments, but also offer mentoring, succour and friendship. Cancer Council helped me find house cleaning, which has taken such a burden off me and my husband.

"I’ve used many of the hospital services as well. My oncologist arranged a meeting with the counsellor. The social worker gave me practical advice, and the occupational therapist modified our home to suit my illness. My spiritual needs are met by the chaplain, and I know the palliative care coordinator will be there to help me.

"With all these palliative care services, I feel like I have a window of time to get my house in order. I want my transition to be easy for my family. I’ve taught my children how to live, and now I’m teaching them how to die. Strangely, it’s an experience I wouldn’t have missed – it’s brought so many beautiful people into my life and renewed my faith that kindness and love are at the core of all humanity.

"I’d like people with advanced cancer to know that there are a myriad of services. You only have to ask; you are not alone."

Tell your cancer story.


Reviewed by: Dr Michelle Gold, Director of Palliative Care, Alfred Health, VIC; Patricia Chaplin, Consumer; Dr Jan Maree Davis, Area Director, Palliative Care Service, Calvary Healthcare Sydney and St George Hospital, Kogarah, and Conjoint Lecturer, University of New South Wales, NSW; Denise Green, Consumer; Palliative Care Australia; Paula Ryan, Nurse Unit Manager, Cancer & Specialist Palliative Care Service, Rockhampton Hospital, QLD; Pippa Sangster, Telephone Support Group Facilitator, Cancer Council NSW, NSW; Robyn Tucker, Cancer Nurse, Cancer Information and Support Service, Cancer Council Victoria, VIC; Trilby Witton-Oates, Social Worker, Rockhampton Hospital, QLD.

Updated: 01 Apr, 2015