The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 22: Facilitating the Transitionpatient and family remain paramount, and overall suffering is minimized. Team members shareinformation and work interdependently to develop goals with the patient and family. Informationis shared among team members on a regular, organized basis.26 picasIn 1999, Cummings described the interdisciplinary team as a group of individuals working togetherwith a common purpose for the greater good of the patient with advanced disease andfamily. Interdisciplinary team members should include the combined efforts of competent, skilledpractitioners who offer confidential, nondiscriminatory, nonjudgmental and culturally sensitivecare. Each individual has particular expertise and training and is responsible for making decisionsand contributions within the area of their experience and knowledge.The following sections describe the various roles and functions of HIV palliative care interdisciplinaryteam members.Patient and Family CaregiversThe primary member of the interdisciplinary team is the person living with HIV, along withhis or her family. Patients and their caregivers need to be active partners in developing andimplementing the plan of care in order for the other members of the palliative care team tounderstand the complex care of families affected by HIV, their advanced care needs, patient andfamily caregiver concerns regarding approaching death, and HIV-specific bereavement needs. 8Far too often, health care teams see themselves as the “providers” and the patient and family assimply the “recipients” of their care. Advanced HIV disease care planning cannot be conceptualizedin this manner: patients, family members and the interdisciplinary team members mustaddress care planning and support on a mutual, interactive and fluid basis.Medical ProvidersMedical providers include physicians, residents, interns, fellows, nurse practitioners, andphysician’s assistants. Responsibilities of these team members include the following:• Diagnosis• Prognosis• Symptom prevention• Design of treatment plan• Education and communication with staff, patient, and family regarding statusand response to treatment.Medical providers’ decisions should be sensitive to cues of advancing condition related andunrelated to lab test values and diagnostic procedures. Consulting physicians are responsibleto primary medical providers, and should work as part of the team, not as separate specialists.Specialists may include psychiatrists, ophthalmologists, neurologists, dermatologists,oncologists, gynecologists, orthopedists, or providers of any other specialty service.NursesNurses include staff nurses, nurse practitioners, and clinical specialists in HIV, adult health,case management, palliative care, mental health, and home and community health. Nursingresponsibilities include assessment of patients’ physical and mental capacity for self-care, iden-448U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau