Hospital-Based Interdisciplinary Palliative Care: Got Social Work?

Background: Social work has been integral to the development of palliative care (e.g. Saunders, 2001), which is by definition interdisciplinary and inclusive of the social work scope of practice (AAHPM, 2010). Palliative physician leaders have acknowledged the importance of the social work role on the palliative care team (Meier & Beresford, 2008). Yet, as hospital-based palliative care programs increase in numbers, social work is not always present or fully utilized on the interdisciplinary team which impacts quality of care and full implementation of interdisciplinary service in this setting.

Methods: Data on palliative care social work from a larger comparative case study on hospital-based palliative care were analyzed for this paper. These data are from semi-structured in-person interviews with key informants from in three large (700+ inpatient beds) healthcare systems. These healthcare systems were located in the same large metropolitan area and all had teaching and research missions.

Respondents were selected initially by asking for suggestions from each palliative care program’s director, and then purposive snowball sampling from subsequent respondents. These programs had all been in existence from between two to seven years. Social workers (n = 5), nurses (n = 5), physicians (n = 5), hospital executives (n = 4) and administrators (n = 3), were interviewed (total n = 22). Interviews typically lasted approximately 1-2 hours, recordings were transcribed and qualitatively analyzed in Atlas-ti following the procedures for “open coding” (Strauss & Corbin, 1998) in which codes were developed and later used to identify themes. These were compared within and across cases (Yin, 1989) using matrices (Miles & Huberman, 1994) organized by conceptual domain. Qualitative research group colleagues reviewed de-identified quotes and matrices, where codes and themes were validated, in addition to “member-checking” with respondents from each case to ensure the trustworthiness of the findings (Lincoln & Guba, 1985; Padgett, 1998).

Findings: Key themes illustrating barriers to communication were: hierarchical hospital structure, lack of understanding of the social work role and scope of practice, disciplinary tension, and territorialism. Overcoming these barriers occurred on a case-by-case basis predicated on informal personal communication and social networks. From these data it is clear that hospital-based palliative care teams are not consistently fully interdisciplinary. Given that the programs studied were relatively mature and located in large institutions with more than average resources, this is cause for concern if we intend to fully implement the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care.

Conclusions: These findings echo previous research on the social work role on interdisciplinary hospice teams (Oliver & Peck, 2006; Reese & Raymer, 2004; Reese & Sontag, 2001). Enhancing interdisciplinary communication will facilitate greater implementation of palliative care social work in the hospital. A more efficient and systematic approach to integration and utilization of social work is needed to facilitate full implementation of interdisciplinary palliative care in the hospital.