Organising a Case Conference
Nurses will often identify the need for a palliative care case conference. They should check with their organisation whether there are specific processes and documentation that can be used to support a palliative care case conference.
The nurse may need to confirm if the GP will be participating and will need to check the requirements for MBS recognition of a case conference for payment purposes.
The nurse is likely to be well placed to understand who are the key people involved in providing care to the older person and who should be involved in the case conference.
Nurses will also be able to discuss with the older person whether they want to attend and who from their family or friends involved in their care that they would want to be involved.
Older people often are involved with a number of different care providers.
The number and type of service providers may differ if the person is living at home or is living an aged care facility.
Care providers may include:
- Family Carer
- Case Manager
- Careworkers
- General Practitioner
- General Practice Nurses
- Mental Health Nurses
- Palliative Care Nurses
- Allied Health staff
- Community Pharmacist
- Local Hospital services
- Volunteers
- Friends
- Geriatrician
- Specialist Medical Consultant
- Old Age Psychiatrists
- Wound Care Nurse
- Consultant
- Specific Support Group / Association (eg, MS Society, Cancer Council)
Each provider’s role is important to the person and could inform the activities of others providing care. Over time, the multidisciplinary team composition can change to reflect changes in the older person’s needs.
However, a palliative care case conference does not necessarily have to include everyone who is involved with the older person but it should involve those who are critical to the care decision-making and care delivery.
Older people living in the community will rely on help from their family. Older people in residential care will often have family members who continue to be actively involved in their care.
Family means those that are closest to the older person in terms of affection - this may include friends, extended relatives or kinships as well as biological family.
Family members often act as a carer. They may help the older person in many ways through:
- Providing assistance in
- Activities of daily living,
- Emotional support,
- Recognising deterioration and increased need.
- Advocating for the older palliative person when necessary.
- Understanding and respecting the older person’s wishes.
- Participating in decision-making as per the older person’s wishes.
- Liaising with service providers on behalf of the older person.
The carer’s knowledge and skills should be acknowledged by inclusion in a palliative care case conference.
A structured process can make the case conference more useful:
Introduction
- Introduce yourself and invite others to introduce themselves stating their role on the team.
- Review the meeting’s goals and clarify specific decisions that will need to be made before the case conference ends.
- Establish ground rules for conducting the conversation in a non-patronising or threatening way.
For example, you might begin:
‘We would like to hear from all of you. However, if possible, could one person please speak at a time?
Each person will have a chance to ask questions and express their views.’
Identify the legal decision maker
- Remember that if the older person is competent, they are the legal decision maker.
- If there are nominated substitute decision-makers (SDMs) attending and the older person is competent, the SDM may assist but is not to be the person deferred to for decision-making unless the older person indicates that this is their preference.
- If the older person is not competent, then the designated SDM or ‘person responsible’ should be referred to with regard to decision-making.
Determine what the older person / family already knows:
- ‘What is your understanding of your current medical condition?.'
- Ask about the past one to six months: what has changed (eg, functional decline, weight loss, recent hospital admissions, changes to medications).
- Identify the preferences of the older person and family regarding how much detail they wish to be told about the trajectory of dying with the illness.
- Review the current status, prognosis and treatment options for the specific disease(s).
- Allow all healthcare professionals to have their say about what they consider beneficial or non-beneficial treatment under the circumstances.
- Review any issues that arise from the older person, family or healthcare team members.
- Enquire about family circumstances and resources and what will be required from them in the remaining time that is left.
- Ask the older person and their family separately and in turn if they have any questions about the current status, prognosis and treatment options of the disease.
Decision-making (when the older person is competent):
- Ask the older person: ‘What decision(s) about your healthcare, lifestyle or medical treatments are you considering?.’
- Ask each family member: ‘Do you have questions or concerns about the plan being discussed?.’
- Ask each family member ‘How can you support the older person?.’
Decision-making (when the older person is deemed not to have decision-making capacity):
- Ask each family member in turn: ‘What do you believe this person would choose if they could speak for themselves?.’
- Ask each family member: ‘What do you think should be done?.'
- Ask the family if they would like the case management team to leave the room to allow a private family discussion.
- When the care management team returns, confirm with the family the decisions that have been made.
When there is no consensus between parties at the case conference:
- Use time as an ally: schedule a follow-up conference in the near future.
- Try further discussion if time permits and people are agreeable:
- ‘What values are your decisions based upon?’.
- ‘How will the decision affect you and other family members?’.
- ‘What would the older person say if they could speak?’.
- Identify other resources to facilitate decision-making (eg, spiritual / religious affiliations, CareSearch website)
Wrapping up the case conference:
- Summarise consensus, disagreements and decisions.
- Outline action plan and the outline of the care plan.
- Confirm who is responsible for the components of the plan.
- Caution against unexpected outcomes.
- Identify substitute decision maker or person responsible required for ongoing communication if the older person is not competent or does not wish to enter into further decision-making.
It is important to document the key issues and outcomes of the case conference as well as provide this information to participants of the conference:
- Complete a Palliative Care Case Conference Summary Sheet:
- Offer a copy of the conference summary to the older person and/or family members, general practitioner and relevant others.
- Amend the person’s care plan to reflect the outcomes and action plan from the case conference.
- Provide any written information that you feel would assist the older person and/or family in relation to issues that were raised during the case conference.
It should be made clear who is to be responsible for actions / tasks and when these actions/tasks are expected to be resolved or completed.
Identify who will be responsible for case conference follow up.