Activity 3: Principles of multidisciplinary care

The National Breast and Ovarian Cancer Centre developed multidisciplinary care principles for advanced disease. [1] These broad principles are relevant across all care settings. Key components of effective multidisciplinary care include:

Patient-defined goals of care

Patients and their nominated caregivers, where appropriate, are involved in decisions about their care.

Includes:

• Supporting patients and their caregivers to participate in care planning. This includes explaining the concept of the multidisciplinary care team approach and may or may not include participation in a care planning meeting.
• Informing patients and caregivers that their case may be discussed at a team level and with health professionals they have not met, and obtaining patient consent for this.
• Providing information to the patient and caregiver.
• A process of establishing goals of care, and re-evaluating treatment and care plans at critical times.
• Identification of a designated point of contact and care coordinator.

A team approach

Input from as many professions as required is achieved.

Includes:

• The patient, caregivers, and the patient’s general practitioner.
• Flexible and evolving membership that reflects the patient’s care needs.
• Implementing a process to review and audit team functionality.

Ongoing information and communication

Ongoing, timely information and communication is facilitated among all team members, including patients and their nominated caregivers throughout the patient’s trajectory.

Includes:

• Establishing communication mechanisms and frameworks that facilitate input from all team members.
• Contingency planning and forward planning, including advanced care planning.
• Support and debriefing opportunities for team members.

Standards of care

Provision of care is in accordance with nationally agreed standards.

Includes:

• Consistency with national evidence-based recommendations and benchmarks.
• Linkages with/referral to specialist and community-based services, including palliative care services. [1]

These four principles recognise the importance of:

• The patient and their caregiver involvement in the care planning process.
• Care coordination.
• Continuity of care. [1]

Thinking points

REFERENCES

1. National Breast and Ovarian Cancer Centre. (2008). Multidisciplinary care principles for advanced disease: a guide for cancer health professionals. National Breast and Ovarian Cancer Centre, Surry Hills.