The 'Mutlidisciplinary care principles for advanced disease' provide a flexible definition of MDC, allowing for variation in implementation according to cancer type and the location of service provision. The principles are designed to be relevant for all cancers, across a range of health-care settings. A summary of the principles of advanced multidisciplinary care include:
- patients and their nominated caregivers, where appropriate, are involved in decisions about their care
- a team approach, involving core disciplines integral to the provision of good care, including general practice, with input from other specialties as required
- provision of care in accordance with nationally agreed standards
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ongoing, timely information and communication is facilitated among all team members, including the patients and their nominated caregivers, throughout the cancer journey.
Patients
Patients and their nominated caregivers, where appropriate, are involved in decisions about their care
| Principle of care | Outcome | |
|---|---|---|
|
a |
Patients with advanced disease and their caregivers, where appropriate, should be encouraged to participate as members of the multidisciplinary team in care planning |
Patients and their caregivers, where appropriate, are provided with opportunities and supported to have as much input into their care plan as they wish Consent from the patient prior to communication among team members should be obtained according to local protocols |
|
b |
The patient and their caregivers, where appropriate, should be fully informed of the treatment and care options, including the benefits, risks and possible complications of treatments offered and how to access appropriate support services to enhance quality of life |
Appropriate information is offered to assist decision-making about treatment and care options and made available in a form that is appropriate to the patient’s educational level, language, and culture |
|
c |
The treatment plan for a patient should consider individual patient circumstances and wishes |
The treatment plan is discussed with the patient and their caregivers, where possible, revised as appropriate, and recorded in patient’s file Discussion and decision-making about management options is an ongoing and dynamic process |
|
d |
Patient care is coordinated and not fragmented and the patient and their caregivers, where appropriate, are aware of the communication between team members |
The patient and their caregivers, where appropriate, are regularly informed of the ongoing collaboration and communication between members of the multidisciplinary team about their treatment Patients’ perceived expectations of their care needs are actively sought and met throughout their care |
Team
A team approach involves disciplines integral to the provision of good care, with input from others, as required
| Principle of care | Outcome | |
|---|---|---|
|
a |
A multidisciplinary team approach to care should be considered for all patients with advanced cancer |
A local protocol is established to ensure multidisciplinary discussion for all patients who present with advanced cancer; the patient and their caregivers, where appropriate, are informed of this |
|
b |
The cancer care team should be flexible to include health professionals from allied health, palliative and supportive care, community health, nursing and cancer clinicians, as required |
The cancer care team for each patient is established and known by all team members including the patient, their caregivers and the MDC team agreed point of contact |
|
c |
The team leader and membership may change with the patient’s changing needs over time, while maintaining a focus on optimising patient function and comfort throughout the disease |
The team leader and membership are reviewed in consultation with patients and their caregivers to ensure appropriate care is offered and provided which meets the patient’s changing needs |
Communication and information
Ongoing, timely information and communication is facilitated among all team members, including the patients and their nominated caregivers, throughout the cancer journey.
| Principle of care | Outcome | |
|---|---|---|
|
a |
A communications framework should be established which supports and ensures interactive participation from all relevant team members at regular and dedicated case-conference meetings |
Appropriate communication mechanisms are established to facilitate case discussion by all team members |
|
b |
Timely written communication between all health professionals including GPs is vital to providing optimal care |
Systems are in place to ensure patients’ results are made available to team members in a timely manner |
|
c |
End-of-life (EOL) planning is considered by members of the multidisciplinary team and support services are provided, encouraged and facilitated for all involved |
Health professionals have access to appropriate training and support to enable them to appropriately manage EOL issues |
|
d |
As team membership and care setting (home, hospital, palliative care unit) may change during the course of the disease, communication between the MDC agreed point of contact, patient and caregivers is maintained |
The patient and their caregivers are aware of who bears primary responsibility for their care and their agreed point of contact during the course of the disease |
Standards of care
Provision of medical and supportive care is in accord with nationally agreed standards
| Principle of care | Outcome | |
|---|---|---|
|
a |
All health professionals involved in the management of patients with advanced cancer should practise in accord with guideline recommendations |
Care is demonstrated to be consistent with national evidence-based recommendations and benchmarks, where relevant |
|
b |
Maintenance of standards of best practice is supported by a number of activities which promote professional development |
Systems are established and monitored for the support of professional development |
|
c |
Location, type of service or patient’s understanding of the health system should not be impediments to patient’s access to MDC |
Systems are established to support all patients with advanced disease to have access to MDC |
|
d |
The members of the team should support the multidisciplinary approach to care by establishing collaborative working relationships with appropriate local health care professionals |
Systems are established to support collaborative working relationships and referral links |
|
e |
Use of supportive care services, including palliative care, and psychosocial interventions/support should be encouraged and facilitated |
Systems are established to provide patients with equitable access to all relevant medical and supportive care services |