The Common Sense Guide to Improving Palliative Care > Advance Care Planning > 3.4 Choosing a Team

Sick To Death book cover This extract from the online edition of The Common Sense Guide to Improving Palliative Care is used with permission.

Advance Care Planning: Choosing a Team

You have already identified the problem and created an aim statement. Now you need to invite other people who can help you reach your goals to join your team. Together, identify opportunities for improvement. For each patient population, try to recruit clinicians and others who are closest to them, such as physicians, nurses, social workers, and chaplains. Think beyond the obvious people, however, and you will discover others who can help make your program work. An admissions clerk, for instance, can help some projects by asking patients about whether they have an advance directive and where it is filed. If community adoption of a routine advance care planning (ACP) process is part of the goal, your team can enlist colleagues who work in other settings to assist with procedures that assure that ACPs transfer with the patient or to recruit key players in your community.

Team Delta

The original force behind Team Delta was a unit nurse who had experienced too many overwhelmed families faced with complex medical treatment decisions for loved ones who were near death and could not communicate. She recruited a few of her coworkers, including a social worker, and sought advice and ideas from the facility's medical director. In order to raise awareness of the problem, Team Delta decided to focus on the team leader's unit as a starting point and involve the rest of the facility over time. In addition, they focused on new admissions, unstable patients, and severely demented residents as the first set of residents (and their families) to target. The team quickly realized that they would need help from a number of others in the facility, including the director of nursing, the staff educator, certified nursing assistants (CNAs) on the floor, and families. In addition, they would need help from the information specialists to flag charts electronically and to help measure their progress.

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