by Dr Katherine Regan, Clinical Psychologist, Wales, UK
Dr Regan shares her experiences working in close collaboration with a specialist palliative care team at Velindre Cancer Centre in Cardiff, Wales. She discusses why collaborative working across both areas is a useful model for the future and how both fields can learn much from one another.
The following account is a reflection on joint working between clinical psychology and specialist palliative care services. This was in the context of weekly palliative care meetings within a multidisciplinary team (MDT) structure and also shared clinical encounters on the wards and in outpatient clinics in a large tertiary cancer centre in Wales between 2013 and 2014. At the time, I was completing my PhD thesis in clinical psychology and also working as a clinical psychology trainee and I have outlined my findings and thoughts on this experience in the following paragraphs.
Being a part of the Palliative Care MDT
As a clinical psychology professional having just started working in a tertiary cancer centre, I was asked whether I would like to join the weekly specialist palliative care meetings. Multi-disciplinary team (MDT) working is a fundamental cornerstone to the delivery of holistic, compassionate palliative care services (NICE, 2004), so I was keen to see this process in action, as someone who had not previously worked on a palliative team before. It provided me not only with an understanding of how palliative care as a specialty works, but a number of other reflections, too. For instance, I was someone who was experiencing this sometimes scary, daunting, even sad sounding specialty for the first time, with perhaps similar notions and preconceptions as touched on in an article by Mark Taubert (Taubert, 2013), but these were very swiftly cast aside.
From an early stage, the meetings felt like a safe space where insights into patient care were discussed refreshingly candidly and openly. All its members, independent of their professional background, contributed very actively; additional perspectives were actively encouraged. In these meetings I was able to discuss my concerns and queries from a psychology professional’s perspective, such as enquiring about patient consent, care planning, involving friends or family and offering insight into assessing psychological wellbeing and risk. Topics such as pain management, communicating with patients and families and end-of-life care-planning came up frequently. Areas of uncertainty were flagged, and the excellent Cancer Research Wales Library in Velindre Cancer Centre were sometimes able to provide same-day evidence for clinical queries, which were fed back at each palliative MDT meeting. Through enhancing my understanding of medical and palliative issues, I was better informed when supporting my own clients, having a deeper understanding of the medical and supportive healthcare context that surrounds them.
My regular MDT involvement developed into providing teaching for the team on skills in assessing and managing psychological risk and extended to developing bespoke teaching/supervision sessions for the team on issues suggested by the team (e.g. using mindfulness in practice and anxiety in cancer/palliative patients).
I was privileged to observe the team at work and witness their style of communication with palliative patients. Palliative care doctors and nurses were able to have meaningful conversations with patients about their choices, treatments, wishes, and preferences within the end-of-life context. Their communicative style appeared to enhance making shared, patient-informed decisions about end-of-life care. These conversations were happening in a very respectful and emotionally-containing way, despite the distressing context for patients and families. Topics of conversation were wide-ranging, from specifics surrounding cancer pain management to use of social media as a support mechanism through prolonged inpatient hospital stays.
The team recognised the coping strategies patients and families can rely on during times of distress and pain, and were able to normalise these responses as opposed to pathologise them. These skills in formulating/contextualising the problem, instead of placing ‘problems’ within the patient, mirrors the aim of clinical psychological assessment and intervention-planning.
In a setting where clinicians and patients are making life-changing decisions concerning the risks and benefits of proposed cancer treatments, the communication skills of palliative care professionals will be hugely beneficial if an avenue for sharing these skills with other cancer care professionals is developed.
Challenges and hurdles facing Palliative Care and Psychology Teams in Cancer Settings
The intuition about a patient’s experience of distress was very genuinely displayed in many of our MDT discussions. However this skill may also represent a barrier to clarifying patients’ understanding, expectations and wishes in end-of-life care, for both psychology and palliative care professionals. It is well understood that when professionals identify, or strongly empathise, with patients it can feel even more difficult to see those patients struggle with their life-limiting condition. This level of identification with patients may inadvertently influence our assumptions, or conclusions, about what these patients may be thinking, frightened of, or hope for, as we start to imagine how we would be coping in those circumstances. Discussing death and dying is uncomfortable, and even the best communicators can fall victim to psychological defences that arise in order to deal with this discomfort e.g. avoiding asking difficult questions in order to rescue the patient from their existential anxieties, or interrupting silences that may feel uncomfortable but should be left to give the patient time to formulate their distress.
During my work with the team I became aware of the teams interest in self-care, especially within the context of receiving frequent referrals for patients who had become distressed while admitted on the wards. It could be easy to feel that palliative care’s role was to ‘fix’ patients when they become upset, through medication and support. This is often a shared experience for psychological services, where an influx of referrals can occur in the context of a patient’s distress over diagnosis, prognosis or end of curative treatment.
If both psychology and palliative care are thought of as services that can ‘rescue’ patients from their (understandable) distress, joint-working may have an impact on improving a wider understanding of our services. Sharing our professional goals, values and skills in managing distress and communication has been beneficial between palliative and psychology services; therefore it may prove beneficial to share this understanding, jointly, with other professionals within cancer services.
However, challenges for maintaining and developing a clinically effective working relationship between psychology and palliative care exist. Finding the time and space for palliative care professionals to develop psychologically-informed techniques in managing distress and pain, and feel confident about them, is difficult. Perhaps continuing to cultivate a reciprocal relationship between psychological services and palliative care is one solution, where a venue to discuss and learn from cases can be developed. Creating opportunities for psychology to model or share their clinical practice with palliative care colleagues may also normalise the use of psychologically informed communication skills and strategies.
Cultivating Compassionate Care through MDT working
The experience of being ‘assimilated’ into the palliative care MDT leads to a conclusion that a pre-requisite to delivering compassion in care is cultivating compassionate care within multidisciplinary relationships. As a professional outside of the palliative care team I was welcomed into a team that values being proactive, emphasizes active participation, agency and being collaborative– which is what psychologists recognize as key facets to developing clinically effective therapeutic relationships for psychological interventions (e.g. Cognitive Analytic Therapy, Ryle and Kerr, 2002).
Self-care within cancer services is a challenge in itself. Cultivating a MDT that cares for its team members, as well as its patients may enhance delivering compassionate care, as it is thought that compassionate role models can energise staff and enhance others’ ability to be compassionate. (Chellel et al, 2013) Having strategies for promoting self-care can increase personal and professional wellbeing and improve patient care. Sanchez-Reilly and Morrison et al (2013) describe validated methods for enhancing self-care for professionals when caring for patients with life-limiting cancer. These strategies include:
1) create a network of peers and co-workers and stay connected with them on an ongoing basis,
2) improve communication and management skills by seeking additional training,
3) practice meaning-based coping by sharing personal and professional sources of meaning and incorporating into daily practice.
Upon reflecting on the working relationship established between psychology and palliative care, it was apparent that the MDT itself embodied these strategies intuitively. Compassion is a value recognised by healthcare professionals, patients and the public yet it can be difficult to describe it. It is represented in many ways; a word, a smile, an act of kindness, or by listening to another person. The evidence shows that compassion is seen in small things that make a big difference to one’s comfort (Compassion in Practice, 2013). Compassion makes people – patients and professionals- feel cared for, and can be embodied within an MDT that makes one feels proud to be a part of.
Chellel, A, Ramage, C and Watters, P (2013) A Theory of Compassion as Revealed by the Narratives of Nurses, Patients and Relatives. Brighton: Brighton and Sussex University Hospitals Trust.
NHS England (2013).Compassion in Practice – One year on. http://www.england.nhs.uk/wp-content/uploads/2013/11/comp-pract-1yr-on.pdf (accessed on September 30th, 2014).
National Institute for Clinical Excellence (NICE) (2004). Improving Supportive and Palliative Care for Adults with Cancer. http://www.nice.org.uk/guidance/csgsp (accessed on September 30th 2014).
Ryle, A. and Kerr, I.B. (2002) Introducing Cognitive Analytic Therapy: Principles and Practice. Chichester, Wiley.
Sanchez-Reilly, S., Morrison, L. J., Carey, E., Bernacki, R., O’Neill, L., Kapo, J., … & deLima Thomas, J. (2013). Caring for oneself to care for others: physicians and their self-care. The Journal of Supportive Oncology, 11(2), 75.
Taubert M Palliative Care- A depressing specialty? BMJ blog http://blogs.bmj.com/bmj/2013/10/14/mark-taubert-palliative-care-a-depressing-specialty/ (accessed on 06/11/2014)