Multidisciplinary team collaboration in challenging situations

The family and carers of a dying patient may struggle with the changes at end of life, perhaps more so when the patient has a chronic illness, such as multiple sclerosis. Addressing physical, psychosocial and spiritual needs appropriately is important in achieving a peaceful death and healthy bereavement. The purpose of this study is to describe how shared management of a complex situation enables teams to formulate appropriate strategies to manage difficult situations in end of life care. Multidisciplinary team involvement was required in the case of a woman with end stage multiple sclerosis admitted to a major tertiary hospital. The Palliative Care Service was consulted to assist initially with discharge planning and ultimately with end of life care. Complex Psychosocial problems, family dynamics and personality traits were identified, requiring significant input. Collaboration between specialties assisted with addressing the many problems. Lessons learnt from this case will assist in developing clear guidelines for similar situations in the future.