To achieve teamwork and coordination of care, all members of the healthcare team must talk to each other. The healthcare team includes:
- the patient and their substitute decision-maker, family and carers
- YOU and your colleagues
- acute care clinicians
- care providers in community and aged care
- Aboriginal liaison or health workers
- general practitioner
- district nursing
- community palliative care
- palliative care consultancy service
In end of life care, an effective team:
- enables all disciplines, including graduate and junior clinicians and appropriately trained volunteers, to engage with the broader team, voice concerns, and act on the expressed preferences and consent of the patient
- has experienced team members providing supervision, leadership, support, mentorship and teaching to develop the skills and capacity of inexperienced team members
- recognises, values and supports carers.
Policies and procedures demonstrate the importance of carers of patients in their last 12 months of life. Policies and procedures ensure:
- staff are skilled in therapeutic communication
- family meetings support care and discharge planning. A family meeting may include the treating team, allied health, the palliative care consultancy service, the patient and family.
- referrals to allied health, such as pastoral care, counselling or social work, are supported
- care for families and carers extends to the period after the patient has died.