A case study showcasing “team in action” Tuesday 16 February 2010
<ul><li>At the end of this session we’d like you to: </li></ul><ul><li>Have refreshed your knowledge on the philosophy of ...
<ul><li>Palliative care is an approach that improves the quality of life of patients and their families facing the problem...
<ul><li>Generalist  Palliative Care </li></ul><ul><li>palliative care is best delivered through an integrated approach tha...
<ul><li>The MoH Palliative Care Strategy – 2001 </li></ul><ul><li>The Northland Palliative Care Project - 2001 </li></ul><...
<ul><li>Hospice practices under the Holistic Framework or  Te Whare Tapa Wha (Mason Durie) </li></ul><ul><li>This model co...
<ul><ul><li>North Haven Hospice  – Whangarei and districts </li></ul></ul><ul><ul><li>Hospice Kaipara  – Dargaville and di...
<ul><li>A group of people with a full set of complementary skills required to complete a task, job or project.  </li></ul>
<ul><li>operate with a high degree of interdependence,  </li></ul><ul><li>share authority and responsibility for self-mana...
 
<ul><li>Phil and Betsy </li></ul><ul><li>General Practitioner – Russell and Kerikeri  </li></ul><ul><li>Cancer Society  </...
Surgical Team   DN’s Hospital Pain Team Oncology Dept Radiation Oncologist Radiotherapy Team   Urologist Cancer Society   ...
Phil Hospice MN NHH GP Local Pharmacy Hospital Pharmacy Cancer Society  Urologist Radiotherapy Team  Oncology Dept Radiati...
A new  model?
<ul><li>“ We are most effective as a team when we compliment each other without embarrassment and disagree without fear.” ...
<ul><li>Common purpose </li></ul><ul><li>Preparedness to work together (Bliss et al, 2000)  </li></ul><ul><li>Value/unders...
 
<ul><li>68 year old Kiwi Bloke! </li></ul><ul><li>Married to Betsy for 31 years </li></ul><ul><li>2 children from a previo...
<ul><li>1997 -  Diagnosed with hormonal refractory prostate cancer ->    surgery Radical Prostatectomy  </li></ul><ul><li>...
<ul><li>2009  </li></ul><ul><ul><li>March  – Suprapubic catheter </li></ul></ul><ul><ul><li>MRI shows more changes </li></...
<ul><li>Social/wh ā naugatanga </li></ul><ul><ul><li>Betsy and Phil very private </li></ul></ul><ul><ul><li>estranged from...
<ul><li>Emotional/hinengaro </li></ul><ul><ul><li>boredom,  </li></ul></ul><ul><ul><li>decision making difficulties,  </li...
 
 
Out/Day patient Home visits Telephone calls 2006 7 2007 11 13 2008 15 7 44 2009 6 95 159
 
<ul><li>PalCare </li></ul><ul><li>Referrals </li></ul><ul><li>Phones calls </li></ul><ul><li>MDT meetings  </li></ul><ul><...
<ul><li>Cared for Phil for only 2 yrs vs more time </li></ul><ul><li>Role recognition within the team  </li></ul><ul><li>G...
<ul><li>Clinic vs Home Visits </li></ul><ul><li>Relationship developed over time </li></ul><ul><li>Good communication </li...
<ul><li>Minimal stock held due to cost </li></ul><ul><li>Advance ordering of drugs </li></ul><ul><li>Updates – felt a bit ...
<ul><li>4 IPU admissions over a period of 10 months – 20 days total </li></ul><ul><li>Betsy stayed with him always </li></...
<ul><li>Negatives </li></ul><ul><ul><li>Away from usual environment/support system </li></ul></ul><ul><ul><li>Didn’t like ...
<ul><li>IT was new to WBH </li></ul><ul><li>Consumables Delay </li></ul><ul><ul><li>Bags mixed on site by anaesthetist  </...
<ul><li>IT infusion started – NO PAIN  </li></ul><ul><li>Next day independently mobilising – NIL PAIN </li></ul><ul><li>MR...
<ul><li>Changeover mid way through </li></ul><ul><ul><li>Change of relationship – ending one and building another  </li></...
 
 
<ul><li>IV pamidronate </li></ul><ul><li>Intra-thecal management </li></ul><ul><li>Staffing </li></ul><ul><li>Location </l...
 
 
<ul><li>Things don’t always go smoothly </li></ul><ul><li>Trust within and of the team is important  </li></ul><ul><li>The...
<ul><li>A procedure/flowchart to ensure preparation avenues are exhausted for future changes </li></ul><ul><li>Expand the ...
Teamwork is the ability to work together toward a common vision. The ability to direct individual accomplishments toward o...
” Coming together is a beginning. Keeping together is progress. Working together is success.” -  Henry Ford
<ul><li>He aha te mea nui o te ao? </li></ul><ul><li>Maku a ki atu.  </li></ul><ul><li>He tangata. He tangata. He tangata ...
 
<ul><li>Bliss, J., Cowley, S. & While, A. (2000). Interprofessional working in palliative care in the community: a review ...
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Palliative Care A Team Approach Final

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  • The World Health organisation describes palliative care as an approach that improves the quality of life of patients and their families facing the problems associated with life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychological, and spiritual.
  • On the other hand specialist palliative care is required to ……. Directly Direct support/mgt to patients/families with complex needs that exceed the resources of a generalist team Indirectly Provision of advise, support, education and training to other health professionals and volunteers to support their generalist provision of palliative care.
  • . Goal 4 under the CANCER CONTROL PLAN Improve quality of life for those with cancer, their families and whanau through support, rehabilitation and palliative care . 4.1 Carry out research to identify barriers for Maori to accessing palliative care services and methods that improve access. 4.2 Establish specialist care coordination roles/palliative care liaison team for all regional hospitals. (See also 2.7.5 Palliative careaction 1.1.) 4.3 Establish systems for early referral, and clinical pathways between treatment services, community support services and palliative care. 4.4 Work collaboratively with the Northern Cancer Control Network to scope transport and accommodation solutions to enable people with terminal illness to attend treatment in Auckland. Northland District Annual Plan 2009/2010 Goal 5 Under the CANCER CONTROL PLAN Improve the delivery of services across the continuum of cancer control through effective planning, coordination and integration of resources and activity, monitoring and evaluation. Actions Measures and milestones 5.1 Achieve improved coordination of cancer care and support services, and reduce disparities in access to cancer services between Maori and non-Maori. 5.2 Ensure that appropriate programmes and services are accessible to Maori across the cancer control continuum. 5.3 Establish a cancer service monitoring and evaluation system that provides ongoing information about access to cancer services and cancer-related inequalities, particularly for Maori. Northland District Annual Plan 2009/2010 PALLIATIVE CARE Goal 1 Develop a seamless and integrated palliative care service delivery model to optimise delivery of cost effective and high-quality palliative care services. 1.1 Create a hospital-based palliative care team to provide improved access to palliative care services at the time of diagnosis and treatment. 1.2 Establish systems for early referral between treatment services, community support services and palliative care. 1.3 Develop and promote standardised clinical pathways for patients for whom palliative care or a palliative approach would be appropriate. Northland District Annual Plan 2009/2010 PALLIATIVE CARE Goal 2 Ensure timely referral and access to essential palliative care services for all people 2.1 Promote palliative care to relevant acute care clinicians and nurses, general practice and community practitioners as a benefit to clinical practice and to patient care and wellbeing. 2.2 Carry out research to identify barriers for Maori to access palliative care services and methods for improving access. Northland District Annual Plan 2009/2010
  • Hospice practices within the frameworks of the WHO palliative philosophy and that of Te Whare Tapa Wha. Both see the person having “four walls to their house”- physical, emotional, intellectual and spiritual. Holistic care is about nurturing the four quadrants of the person.
  • Hospice Bay of Islands services the mid-north region of New Zealand. Our catchment area has a population base of fewer than 40,000 with approximately 41% of Maori. The service area is a mix of urban and rural.
  • Head cites Larson when she suggests that “Caregiving teams are able to repsond to the complex human problems of people coping with their terminal illness. An individuial caregiver can’t possibly meet all these needs; it requires the expertise of professionals from various disciplines working together to identify issues, problems and opportunities and obtain goals during the course of care. (Larson as cited by Head, p. 199)
  • Crawford and Price refer to the analogy of the hand – where the individual digits of differing ability function and dexterity work together to achieve more than the sum of the individual fingers.
  • I’d like to introduce you to Phil is wife Betsy has given us her full permission to use Phil’s case as a teaching case for this evening so no nom de plumes will be used. She feels he would be “chuffed” to be the centre of this presentation and I’d like to thank Betsy for this and honour Phil and the lessons he has taught us.
  • Common purpose Preparedness to work together (Bliss et al, 2000) – no gate-keeping Value/understand the role &amp; contribution of each member rather than be threatened by it (Bliss et al, 2000) Interaction of the team to produce the final product Members cover each other’s weaknesses and maximize each others strengths Careful documentation Recognition of the challenges
  • I’d like to introduce you to Phil is wife Betsy has given us her full permission to use Phil’s case as a teaching case for this evening so no nom de plumes will be used. She feels he would be “chuffed” to be the centre of this presentation and I’d like to thank Betsy for this and honour Phil and the lessons he has taught us.
  • (only 10 documented liaisons though)
  • Feedback from District Nurses Betsy often came to them for supplies rather than a HV Phil and Betsy were very independant but more open once a relationship was built up good communication between teams ie hospice and Helen Brown-continence nurse Phil never complained NDHB challenged amount of incontinence supplies- limited to 2 pads daily which DNs were concerned about especially as palliaitive (they are way over budget). Phil often required more than 2 pads.
  • Feedback from pharmacist. No real issues Drugs were ordered well in advance especially ketamine- minimal stock held due to cost although they are part of the team feel they are on the outer when patients condition changes, they do ask for some info/update but aware that this is not always possible
  • which intimidated both Phil &amp; Betsy
  • Paperwork/experience to back it up Paperwork transferred from Akld DHB Consumables Delay 2 wks to source premixed bags Funding of such – not normal practice
  • Over the next 2 weeks team were on call for North Haven Hospice and Hospice Mid-Northland for support.
  • IT was a new thing for NDHB – incr stress on pain team protecting theirs and the wider team; professional accountability (protocols/procedures, safety, education) “ ..the immediate effect that the analgesic regime had on Mr Crump made it all worthwhile….. If only for a short time”
  • If you should ask me, what is the greatest thing in this world? I would answer, it is people, it is people, it is people
  • Palliative Care A Team Approach Final

    1. 1. A case study showcasing “team in action” Tuesday 16 February 2010
    2. 2. <ul><li>At the end of this session we’d like you to: </li></ul><ul><li>Have refreshed your knowledge on the philosophy of palliative care </li></ul><ul><li>Be able to discuss the “team” working in palliative care within Northland </li></ul><ul><li>Identify how you could fit into this team now </li></ul><ul><li>Identify opportunities within your practice for increased team participation for the future. </li></ul>
    3. 3. <ul><li>Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychological and spiritual. </li></ul><ul><li>World Health Organisation (2003) </li></ul>
    4. 4. <ul><li>Generalist Palliative Care </li></ul><ul><li>palliative care is best delivered through an integrated approach that focuses on the needs of the patient and their family and whanau. </li></ul><ul><li>Such an approach should recognise and define the respective roles of all players, both specialist and generalist, within a collaborative framework across a given geographical area </li></ul>
    5. 5. <ul><li>The MoH Palliative Care Strategy – 2001 </li></ul><ul><li>The Northland Palliative Care Project - 2001 </li></ul><ul><li>The Palliative Care Strategic Action Plan 2007 </li></ul><ul><li>NDHB Annual Plan 2009/2010 </li></ul>
    6. 6. <ul><li>Hospice practices under the Holistic Framework or Te Whare Tapa Wha (Mason Durie) </li></ul><ul><li>This model compares health to the four walls of a house: all four are necessary to ensure strength and balance” </li></ul>Social/ Whanaungatanga Physical/Tinana Emotional/Hinengaro Spiritual/Wairua Hospice Framework
    7. 7. <ul><ul><li>North Haven Hospice – Whangarei and districts </li></ul></ul><ul><ul><li>Hospice Kaipara – Dargaville and districts </li></ul></ul><ul><ul><li>Hospice Mid-Northland – Mid North region </li></ul></ul><ul><ul><li>Far North Hospice – Far North region </li></ul></ul>
    8. 8. <ul><li>A group of people with a full set of complementary skills required to complete a task, job or project. </li></ul>
    9. 9. <ul><li>operate with a high degree of interdependence, </li></ul><ul><li>share authority and responsibility for self-management, </li></ul><ul><li>are accountable for the collective performance and </li></ul><ul><li>work toward a common goal and shared reward(s). </li></ul>
    10. 11. <ul><li>Phil and Betsy </li></ul><ul><li>General Practitioner – Russell and Kerikeri </li></ul><ul><li>Cancer Society </li></ul><ul><li>Surgical Team </li></ul><ul><li>Urologist </li></ul><ul><li>ACH – Oncology Department/Radiotherapy Team </li></ul><ul><li>Hospice Mid-Northland </li></ul><ul><li>Whangarei Oncology Centre </li></ul><ul><li>North Haven Hospice </li></ul><ul><li>Kerikeri District Nurses </li></ul><ul><li>Pharmacists – Russell, Kerikeri, WBH/ACH </li></ul><ul><li>Pain Team – Whangarei Hospital </li></ul>
    11. 12. Surgical Team DN’s Hospital Pain Team Oncology Dept Radiation Oncologist Radiotherapy Team Urologist Cancer Society Hospital Pharmacy Local Pharmacy GP NHH Hospice MN Phil
    12. 13. Phil Hospice MN NHH GP Local Pharmacy Hospital Pharmacy Cancer Society Urologist Radiotherapy Team Oncology Dept Radiation Oncologist Hospital Pain Team DN’s Surgical Team
    13. 14. A new model?
    14. 15. <ul><li>“ We are most effective as a team when we compliment each other without embarrassment and disagree without fear.” </li></ul><ul><li>Unknown </li></ul>
    15. 16. <ul><li>Common purpose </li></ul><ul><li>Preparedness to work together (Bliss et al, 2000) </li></ul><ul><li>Value/understand the role & contribution of each member (Bliss et al, 2000) </li></ul><ul><li>Interaction of the team </li></ul><ul><li>Members cover each </li></ul><ul><li>Careful documentation </li></ul><ul><li>Recognition of the challenges </li></ul>
    16. 18. <ul><li>68 year old Kiwi Bloke! </li></ul><ul><li>Married to Betsy for 31 years </li></ul><ul><li>2 children from a previous marriage- </li></ul><ul><li>Gary (44), Kerry (42). </li></ul><ul><li>Engineer </li></ul><ul><li>Resident of Tapeka Point, Russell until 2008 when moved to Kerikeri </li></ul><ul><li>Referred to Hospice Mid-Northland by the Cancer Society in 2006 for Symptom Control (Pamidronate) </li></ul>
    17. 19. <ul><li>1997 - Diagnosed with hormonal refractory prostate cancer -> surgery Radical Prostatectomy </li></ul><ul><li>1998 -biochemical relapse -> orchidectomy (1998), </li></ul><ul><li>2000 - DXR to prostate bed </li></ul><ul><li>2005 - bone scan showed increased update and several areas </li></ul><ul><ul><ul><ul><ul><li>Treatment with localised DXR R) sacro-iliac joint ilium, sterum, R) lat & post rib, thoracic spine, R) shoulder, Lumbosacral spine </li></ul></ul></ul></ul></ul><ul><li>2005 – commenced on monthly IV Pamidronate infusions that -> 3/52 as disease progressed </li></ul><ul><li>2007 - Strontium </li></ul><ul><li>2008 - MRI shows widespread sclerotic metastases & degenerative changes in cervical spine </li></ul><ul><ul><ul><ul><ul><li>March - localised DXR to thoracic spine (T9-. T12), R) lower pelvis and hip. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Bone scan shows increased areas of uptake. Further DXR to clavicle and rib </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>July – DXR to R) ant rib, L) med clavicle, L) mid axillary rib, L) shoulder </li></ul></ul></ul></ul></ul>
    18. 20. <ul><li>2009 </li></ul><ul><ul><li>March – Suprapubic catheter </li></ul></ul><ul><ul><li>MRI shows more changes </li></ul></ul><ul><ul><ul><ul><ul><li>April - localised DXR to T8->L3 for T9 nerve impingement and L1 SCC, R) iliac crest </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>July – localised DXR from skull vault to C3 </li></ul></ul></ul></ul></ul><ul><ul><li>September – cystoscopy </li></ul></ul><ul><ul><li>Sept – Dec – increased bladder spasm/pain -> removal of SPC </li></ul></ul><ul><ul><li>Dec 2 – Intrathecal catheter inserted </li></ul></ul><ul><ul><li>Dec 18 th – Intrathecal catheter blocked & palliative sedation therapy commenced </li></ul></ul><ul><ul><li>Dec 22 nd – Phil passed away at home </li></ul></ul>
    19. 21. <ul><li>Social/wh ā naugatanga </li></ul><ul><ul><li>Betsy and Phil very private </li></ul></ul><ul><ul><li>estranged from daughter, </li></ul></ul><ul><ul><li>little contact with son, </li></ul></ul><ul><ul><li>family overseas, </li></ul></ul><ul><ul><li>kept MDT isolated to HMN. </li></ul></ul><ul><li>Spiritual/wairua </li></ul><ul><ul><li>to be at home, </li></ul></ul><ul><ul><li>strong connection to the sea, </li></ul></ul><ul><ul><li>no religious beliefs </li></ul></ul>
    20. 22. <ul><li>Emotional/hinengaro </li></ul><ul><ul><li>boredom, </li></ul></ul><ul><ul><li>decision making difficulties, </li></ul></ul><ul><ul><li>Betsy became his voice, </li></ul></ul><ul><ul><li>decrease concentration, </li></ul></ul><ul><ul><li>philosophical </li></ul></ul><ul><li>Physical/tinana </li></ul><ul><ul><li>Multiple pain sites- predominately skeletal and bladder/pelvic origin </li></ul></ul><ul><ul><li>Escalating pain management including </li></ul></ul><ul><ul><ul><li>methadone, </li></ul></ul></ul><ul><ul><ul><li>ketamine, (oral and subcutaneous) </li></ul></ul></ul><ul><ul><ul><li>pamidronate, </li></ul></ul></ul><ul><ul><ul><li>intrathecal catheter and </li></ul></ul></ul><ul><ul><ul><li>IV narcotics. </li></ul></ul></ul>
    21. 25. Out/Day patient Home visits Telephone calls 2006 7 2007 11 13 2008 15 7 44 2009 6 95 159
    22. 27. <ul><li>PalCare </li></ul><ul><li>Referrals </li></ul><ul><li>Phones calls </li></ul><ul><li>MDT meetings </li></ul><ul><li>Visits to IPU at NHH, hospital liaison team etc </li></ul>
    23. 28. <ul><li>Cared for Phil for only 2 yrs vs more time </li></ul><ul><li>Role recognition within the team </li></ul><ul><li>Good communication with specialists and HMN Support & training with IV Pamidronate – access </li></ul><ul><li>Shared decision making </li></ul><ul><li>Ongoing care of Betsy </li></ul><ul><li>“ Phil’s care exemplifies good teamwork” </li></ul>
    24. 29. <ul><li>Clinic vs Home Visits </li></ul><ul><li>Relationship developed over time </li></ul><ul><li>Good communication </li></ul><ul><li>Liaison with Continence Nurse (Helen Brown) </li></ul><ul><li>Cost implications of products </li></ul>
    25. 30. <ul><li>Minimal stock held due to cost </li></ul><ul><li>Advance ordering of drugs </li></ul><ul><li>Updates – felt a bit on the “outer” </li></ul>
    26. 31. <ul><li>4 IPU admissions over a period of 10 months – 20 days total </li></ul><ul><li>Betsy stayed with him always </li></ul><ul><li>Positives </li></ul><ul><ul><li>Ketamine did offer some benefit </li></ul></ul><ul><ul><li>Better than being admitted to hospital </li></ul></ul><ul><ul><li>Relationship building with staff </li></ul></ul><ul><ul><li>North Haven Hospice Staff – increased skills for mgt of IT infusion. </li></ul></ul><ul><ul><li>“ should have done this some time ago” - on top of world & walked to front door. </li></ul></ul>
    27. 32. <ul><li>Negatives </li></ul><ul><ul><li>Away from usual environment/support system </li></ul></ul><ul><ul><li>Didn’t like being away from home </li></ul></ul><ul><ul><li>Stayed in room a lot of the time (sometimes with door shut!) </li></ul></ul><ul><ul><li>3 rd visit had different family dynamics of another IPU patient. </li></ul></ul>
    28. 33. <ul><li>IT was new to WBH </li></ul><ul><li>Consumables Delay </li></ul><ul><ul><li>Bags mixed on site by anaesthetist </li></ul></ul><ul><li>Competency & confidence of ward staff managing infusion </li></ul><ul><li>Planned infusion time delayed due to other high category patients. </li></ul><ul><li>No theatre space and no bed -> ICU bed found </li></ul>
    29. 34. <ul><li>IT infusion started – NO PAIN </li></ul><ul><li>Next day independently mobilising – NIL PAIN </li></ul><ul><li>MRI done – IT stopped -> extreme pain </li></ul><ul><li>Trans -> North Haven Hospice </li></ul><ul><li>On-call 24/7 for hospice staff </li></ul>
    30. 35. <ul><li>Changeover mid way through </li></ul><ul><ul><li>Change of relationship – ending one and building another </li></ul></ul><ul><ul><li>Change of prescription and methods of working </li></ul></ul>
    31. 38. <ul><li>IV pamidronate </li></ul><ul><li>Intra-thecal management </li></ul><ul><li>Staffing </li></ul><ul><li>Location </li></ul><ul><li>Long term patient </li></ul><ul><li>Team networking-???? </li></ul>
    32. 41. <ul><li>Things don’t always go smoothly </li></ul><ul><li>Trust within and of the team is important </li></ul><ul><li>There is a difference for access for Northland </li></ul><ul><li>Engaging the team long term – how to keep this up </li></ul><ul><li>Leadership – who and when </li></ul><ul><li>Nothing ventured nothing gained </li></ul><ul><li>It bought time for Betsy & Phil to work through the transition from life to death </li></ul>
    33. 42. <ul><li>A procedure/flowchart to ensure preparation avenues are exhausted for future changes </li></ul><ul><li>Expand the team (prn) & work within it – documentation of a “team plan/MoU” </li></ul><ul><li>Question long term management of cases such as this - ? Whether different options are offered </li></ul><ul><li>Interprofessional Education (Bliss et al, 2000) </li></ul><ul><li>Policy development to facilitate closer collaboration. (Bliss et al, 2000) </li></ul>
    34. 43. Teamwork is the ability to work together toward a common vision. The ability to direct individual accomplishments toward organizational objectives. It is the fuel that allows common people to attain uncommon results. Andrew Carnegie
    35. 44. ” Coming together is a beginning. Keeping together is progress. Working together is success.” - Henry Ford
    36. 45. <ul><li>He aha te mea nui o te ao? </li></ul><ul><li>Maku a ki atu. </li></ul><ul><li>He tangata. He tangata. He tangata . </li></ul>
    37. 47. <ul><li>Bliss, J., Cowley, S. & While, A. (2000). Interprofessional working in palliative care in the community: a review of the literature . Journal of Interprofessional Care. 14 (3). Retrieved 6 January 2010 from www.sagepub.com </li></ul><ul><li>Crawford, G. & Price, S. (2003). Team working: palliative care as a model of interdisciplinary practice. MJA Vol 179. Retrieved 6 January 2010 from www.sagepub.com </li></ul><ul><li>Head, B. (2002). The blessings and burdens of Interdisciplinary teamwork. Home Health Care Nurse 20(5). Retrieved 6 January 2010 from www.sagepub.com </li></ul><ul><li>Lemieux-Charles, L. & McGuire, W (2006). What do you know about health care team effectiveness? A review of the literature . Med Care Res Rev 2006. Retrieved 6 January 2010 from www.sagepub.com </li></ul><ul><li>Ministry of Health and New Zealand Cancer Control Trust. (2003). The New Zealand cancer control strategy. Wellington: Author. </li></ul><ul><li>Ministry of Health. (2001a). The New Zealand palliative care strategy. Wellington: Author. </li></ul><ul><li>Northland District Health Board. (n.d.) District annual plan 2009-2010 . Whangarei: Author. </li></ul><ul><li>Northland District Health Board. (2006). Northland Palliative Care Strategic Action Plan 2006-2011 . Whangarei: Author </li></ul><ul><li>O’Connor, M., Fisher, C., & Guilfoyle, A. (2006). Interdisciplinary teams in palliative care: a critical reflection. International Journal of Palliative Care. 12(3). Retrieved 6 January 2010 from www.sagepub.com </li></ul><ul><li>Palliative Care Expert Working Group to the Cancer Control Steering Group. (2003). Palliative care report. Retrieved February 25, 2007 from the Google database. </li></ul><ul><li>Palliative Care Service Specifications Review Group. (2006). Consultation draft: Specialist palliative care tier two service specifications. 03.12.2006. Wellington: Author </li></ul>

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