ABSTRACT

Supportive decision making in palliative care can be understood as an approach to decision making about care that involves the individual with the ill-health, family and care providers, and where such decisions address total pain and reflect whole-person care. Total pain recognises pain as multi-dimensional and is fundamental to understanding palliative care. People experiencing life-limiting ill-health are frequently under the care of several intra- inter-disciplinary teams such as mental health, medical and specialist palliative care teams. Supportive decision making requires members of the team to work in an integrated way. For supportive decision making to feature in their combined care, a shift is needed away from the consultation-type relationship that typifies cross team collaboration. Within a consultative-type relationship a team provides input, when requested, based on their disciplinary expertise. Such a relationship militates against the capacity of teams to engage fully with the person’s whole ill-health experience. This is because each team continues to view the person’s needs through its specialist lens resulting in more fragmented decision making. Supportive decision making has two major requirements. First, intra- inter-disciplinary teams need to work more collaboratively through ongoing discussions and meetings. Each team and discipline needs to be fully aware of and interrogate its respective culture, values and language, and be willing to engage with those of other teams and disciplines. Second, decision making should reflect the person’s wishes for care. This, in turn, requires the adoption of advanced care planning discussions as an integral part of the care process and working closely with the person’s family. Decision making becomes a shared process that moves along a continuum from patient-driven decision making, through to partnership with care providers, and eventually to physician-driven decision making at end-of-life. Supportive decision making is thus an organisational concern since it is influenced by how different teams can work together and how the system can facilitate this. This is illustrated in the example of a woman who attends the mental health service and who has developed motor neuron disease (MND) with a life expectancy of approximately two years. The mental health, palliative care and neurology teams must work with the individual in supporting her through the shock of what is happening, address her suffering and symptoms, and engage in advanced care planning. At its heart, supportive decision making is a whole-person approach to care and the application of palliative care principles by all those involved in the care of such individuals.