2. DEATH
THE TERMINAL DISEASE
PHYSICAL
SYMPTOMS
FAMILY
THE TRADITIONAL IDG MODEL
SOCIAL
WORKER
Chaplain
NURSE
DOCTOR

3.  DOCTOR
› HISTORY AND PHYSICAL, FOLLOW-UP VISITS
› ORDERS
› PROBLEM LIST
 NURSE
› INITIAL COMPREHENSIVE ASSESSMENT
› PLAN OF CARE
› IMPLEMENTATION OF POC AND ORDERS
 SOCIAL WORKER
› ADVANCED DIRECTIVES
› FINANCES
› FUNERAL/DISCHARGE PLANS
 CHAPLAIN
› SPIRITUAL ASSESSMENT
› COORDINATION OF VARIOUS SPIRITUAL PROVIDERS

4. NURSE
SOCIAL
DOCTOR DEATH WORKER
PATIENT
CHAPLAIN
FAMILY and
SUPPORT
SYSTEM
THE PATIENT FOCUSED IDG MODEL

5.  ALL TEAM MEMBERS:
› COMPREHENSIVE PATIENT/FAMILY ASSESSMENT
› PATIENT’S GOALS
› DYNAMIC PLAN OF CARE
› PATIENT/FAMILY COUNSELING
› COMMUNICATION
› COORDINATION OF CARE
› ASSESSMENT OF EFFECTIVENESS

6.  PATIENT’S FAMILY AND SUPPORT GROUP
 COMPLIMENTARY THERAPY
 PHARMACY
 MEMBER OF ADMINISTRATION
 VOLUNTEER COORDINATOR
 STUDENTS AND RESIDENTS

7.  THE DAY PRIOR THE IDG THE PATIENT AND
FAMILY ARE INFORMED ABOUT THE NEXT
DAYS’ MEETING
 THE IPU IDG MEETINGS ARE TUESDAYS FOR
THE 7 PATIENTS IN THE “A” HALL AND
THURSDAYS FOR THE “B” HALL
 THE MEETING STARTS RIGHT AFTER THE
NURSES MORNING REPORT
 THE CHAPLAIN BEGINS THE MEETING WITH
AN INSPIRATIONAL READING

8.  A MEMBER OF THE TEAM ENTERS THE
PATIENT ROOM AND ASKS PERMISSION
FOR THE IDG TO COME IN
 THAT TEAM MEMBER INTRODUCES THE
IDG
 IF THE PATIENT IS NONRESPONSIVE THE
CHAPLAIN WILL QUIETLY NARRATE THE
HIGHLIGHTS OF THE MEETING TO THE
PATIENT
 THE PATIENT IS ASKED WHO THEY WANT
PRESENT FOR THE MEETING

9.  THE PATIENT GOALS---SPEAK IN TERMS
THAT THEY WILL UNDERSTAND
› “WHAT IS IMPORTANT TO YOU NOW?
› “WHAT ARE YOUR NEEDS TODAY?
› “WHAT WOULD LIKE TO GET ACCOMPLISHED
WHILE YOU ARE INPATIENT?
› WHAT WOULD YOU LIKE TO GET
ACCOMPLISHED OVER THE NEXT COUPLE
WEEKS?
› HOW CAN WE HELP YOU MEET THESE GOALS?
 ARE THE GOALS BEING MET?
› IF NOT, WHAT CAN WE DO TO HELP?

10.  PREPARE AND SUPPORT THE PATIENT AND
FAMILY FOR DEATH
› “HOW DOES THIS PATIENT WANT TO DIE”
› “WHAT THINGS SHOULD WE ANTICIPATE AND PREPARE
THE PATIENT AND FAMILY FOR
› WRITTEN MATERIAL FOR THE FAMILY TO REFERENCE
 PREPARE, EDUCATE AND TRAIN PATIENT AND
FAMILY FOR POSSIBLE DISCHARGE
 DISCUSS ANY PROPOSED CHANGES TO THE
PLAN OF CARE
› REVIEW MEDICATION PROFILE WITH PATIENT, FAMILY
AND PHARMACIST
› REVIEW MEDICATION EFFECTIVENESS OR SIDE EFFECTS

11.  IS MORE THAN A LIST GENERATED FROM A
SINGLE COMPREHENSIVE ASSESSMENT
 IT IS A DYNAMIC PROCESS THAT IS UPDATED
AS THE PATIENT’S ILLNESS AND GOALS
CHANGE
 SHOULD REFLECT THE PATIENT’S ACTIVE
PROBLEM LIST
 POC INCLUDES:
› PHYSICIAN ORDERS
› MEDICATION PROFILE
› HOSPICE AIDE ASSIGNMENTS
› VISIT FREQUENCIES
› EQUIPMENT NEEDED

12.  THE IDG ASSIGNS A SCRIBE TO DOCUMENT
KEY ELEMENTS OF THE MEETING
 THE NURSE HAS A COMPUTER PRINTOUT OF
THE CURRENT POC TO REVIEW AT THE
MEETING AND THEN MAKES THE CHANGES
IN THE COMPUTER AFTERWARDS
 ORDERS NEEDED FOR POC GIVEN AND
SOMETIMES CARRIED OUT ON SITE AS
NEEDED
 EACH TEAM MEMBER DOCUMENTS THE
MEETING IN THEIR DAILY NOTE

13.  THE PATIENT AND FAMILY ARE ALWAYS
ASKED IF THEY HAVE ANY FURTHER
QUESTIONS
 TEACHING POINTS REVIEWED
 PATIENT HOSPICE AND INPATIENT ELIGIBLITY
REVIEWED
 STAFF FEEDBACK
 FOLLOW-UP ON ANY ADDITIONS TO THE
POC
 COMMUNICATION WITH COMMUNITY
HEALTHCARE PROVIDERS

14.  IDG 418.56
› IDG WORKS TOGETHER TO MEET THE NEEDS
OF THE PATIENT AND FAMILY
 ESTABLISHES/REVISES PLAN OF CARE
 COORDINATES CARE AND SERVICES

15.  EVERYONE IS ON THE SAME PAGE TALKING
ABOUT:
› PATIENT GOALS
› PLAN OF CARE
› EFFECTS OF TREATMENT
› PROGNOSIS
› FAMILY DYNAMICS
 ISSUES CAN BE ADDRESSED AS THEY COME UP
 CHANGES IN POC AND NEW ORDERS CAN BE
IMPLEMENTED ON THE SPOT

16.  PATIENT’S SYMPTOMS MANAGED
IMMEDIATELY
 ALL TEAM MEMBERS SHARE KNOWLEDGE
 INVOLVEMENT OF PATIENT AND FAMILY
 SHARED DECISION MAKING
 PATIENTS AND FAMILIES HAVE
DESIGNATED TIME THAT THEY KNOW ALL
TEAM MEMBERS WILL BE PRESENT

17.  DIRECT PATIENT AND FAMILY INVOLVEMENT
MORE DIFFICULT THAN TABLE DISCUSSIONS
 MAY TAKE SLIGHTLY MORE TIME
 PATIENTS OR FAMILIES MAY NOT BE USED TO
A GROUPA OF PEOPLE IN THE ROOM ALL AT
ONCE. HOWEVER MANY TEACHING
INSTITUTIONS FOLLOW THIS MODEL
 TEAM MEMBER MAY FEEL “INHIBITED” IN
PERFORMING DUTIES IN A GROUP SETTING
 FAMILIES MAY FEEL INHIBITED IN DISCLOSING
INFORMATION IN A GROUP SETTING

18.  IMPLEMENT MORE MEASUREMENT TOOLS FOR
ASSESSING EFFECTIVENESS OF CARE
 INTRODUCING THE “CONCIERGE INPATIENT
BOOK”
 5 MIN “FAST FACT” REVIEWS WEEKLY
 INCREASE COMMUNICATION AND
COUNSELING SKILLS
 DAILY TEAM ROUNDS
 WAYS TO INCREASE WILLING PARTICIPATION IN
TEAM ROUNDS