ACHPN Interdisciplinary Team Collaboration and Care Coordination 2

Question 1

A palliative care team is caring for a patient from a cultural background that discourages direct disclosure of terminal prognosis. How should the IDT approach this situation?

Accepted Answer

Explore with the family and patient what level of information they wish to receive and honor their preferences within legal and ethical boundaries

Answer

Provide full disclosure regardless of cultural preferences to ensure informed consent

Answer

Withhold all prognostic information from the patient and family

Answer

Delegate the decision to the hospital ethics committee without team discussion

Question 2

Which of the following documentation practices BEST supports continuity of care across the palliative care IDT?

Accepted Answer

A shared, integrated care plan updated after each IDT meeting and accessible to all team members

Answer

Separate verbal handoffs between each discipline at shift change

Answer

Individual discipline notes kept in separate charts

Answer

Weekly email summaries sent only to the attending physician

Question 3

A family member requests that the hospice team not tell the patient they are dying. The patient has capacity. What is the most appropriate IDT response?

Accepted Answer

Discuss the family's concerns while affirming the patient's right to information, and explore a communication approach that addresses both

Answer

Agree to withhold the information to preserve family harmony

Answer

Immediately tell the patient everything without family involvement

Answer

Discharge the family member from the care team decision-making process

Question 4

Which element is MOST essential when coordinating care transitions from inpatient palliative care to home hospice?

Accepted Answer

A structured handoff that includes goals of care, symptom management plan, family support needs, and 24-hour contact information

Answer

Ensuring the patient signs all paperwork before transfer without team review

Answer

Providing only medication reconciliation documents at discharge

Answer

Scheduling a follow-up appointment in 30 days without interim contact

Question 5

In palliative care, SBAR (Situation, Background, Assessment, Recommendation) is most useful for:

Accepted Answer

Standardizing clinical communication during urgent handoffs or escalations between IDT members

Answer

Documenting patient wills and advance directives

Answer

Writing narrative nursing notes in the medical record

Answer

Conducting family care conferences

Question 6

A hospice nurse identifies that a patient's pain is no longer controlled on the current regimen. Which IDT coordination step should occur FIRST?

Accepted Answer

Document the change, reassess comprehensively, and notify the prescribing clinician with SBAR communication

Answer

Notify the family and adjust medications independently

Answer

Wait until the next scheduled IDT meeting to discuss the change

Answer

Consult the social worker to address emotional aspects of pain

Question 7

Which characteristic BEST distinguishes a high-functioning palliative care IDT from a multidisciplinary team?

Accepted Answer

Team members engage in shared decision-making, mutual learning, and blurred role boundaries in service of patient goals

Answer

Team members work independently and report findings to a team leader

Answer

Disciplines maintain strict professional silos to protect scope of practice

Answer

Only physicians and nurses collaborate; other disciplines are consultants