module 2 | Activity 6: Communicating among health professionals and between services

As a person’s illness progresses, care may be delivered by multiple providers, services and specialist care teams.  Understanding the values, goals and preferences of the person, their family and carers – and communicating these effectively during transitions within and between care settings – will help to support the delivery of effective, person and family-centred, coordinated care.[1-2]

A key factor influencing the type of service to provide people with life-limiting illnesses is the intensity of their needs and preferences.[1, 3-5] People affected by life-limiting illness can experience a variety of needs that can vary in complexity and severity during the illness trajectory. This includes:[1, 6-8]

• Management of physical symptoms
• Management of psychological, psychiatric and cognitive symptoms
• Understanding of illness and care preferences
• Need for social support
• Culturally specific needs related to language problems and information disclosure preferences
• Need for information about treatment, diagnosis or prognosis
• Spiritual and existential concerns including hope, loss of meaning and uncertainty
• Financial concerns including loss of income and medical costs
• Care coordination and continuity
• Legal concerns including preferences for end-of-life care and advance care directives.

A range of services and health professionals are required to meet each of these needs. Communication within and between services and individuals plays an important role in coordinating this care.  Verbal communication between care providers should be supported by written information to ensure seamless care and to avoid the provision of care that does not align with the person’s preferences.[1]

The benefits of a multidisciplinary approach to care include:

• Increased satisfaction with care for the person and their family
• Greater likelihood of care being provided in accordance with national standards and clinical practice guidelines
• Improved access to information and practical support for the person and their family
• Increased opportunities for health professionals involved in providing palliative care to support each other to manage the emotional aspects of this work.[9]

Case study

Michelle requires care from multiple care providers.

Her bone scan identifies that she also has metastatic deposits on her spine which causes her back pain. Following these results Michelle’s medical oncologist referred her to the radiation oncologist and a plan for palliative radiation therapy has been put into place.

Michelle attends her planning appointment at the radiation therapy department. She sees Jeremy Peters, the radiation therapist, who responds to her questions about palliative radiotherapy. He orientates her to the radiation therapy department and the different types of equipment used in the planning process and the delivery of radiation therapy.