Introduction
In the report,Health Professions Education: A Bridge to Quality1, ‘cooperation’, ‘communication’, and ‘coordination’ are identified as essential competencies that all healthcare professionals need to have. It implies the importance of collaborative teamwork in providing comprehensive care. Accordingly, Western countries have implemented this collaborative approach through multidisciplinary teams (MDTs) at all levels of healthcare delivery, drawing membership from professionals across different disciplines and specialties. Besides, physicians, it MDTs also include nurses and other non-clinical healthcare professionals like occupational therapists, spiritual healers, psychosocial counsellors and so on to provide comprehensive and holistic care to patients. There are multiple evidences to support importance of MDT in hospitals. Most promisingly, it decreases length of stay, improves health outcome, enhances inter-personal communication, yields patient satisfaction2,3, and reduces workplace burnout of the caregiving staff4. A number of palliative care literature also unanimously support multidisciplinary collaboration as a key to holistic care by addressing physical, emotional and spiritual distress of patients at the end-of-life; it also helps formulating comprehensive, person-centric care goals5.6. However, few literature also point out drawbacks of multidisciplinary teamwork like physicians’ difficulty in fostering long-term relationships with professionals from other disciplines, uneven distribution of work load, unequal recognitions, heterogeneity in orientation of the caregivers and so on7. Moreover, in the present time, when disease-specific treatment has emerged as a dominant model of caregiving in biomedicine, maintaining a multidisciplinary approach is difficult. Professional boundaries have crept into MDTs, leading to “Invisible boundaries”, as Libertii and Gorli8 describes the situation where physicians compartmentalize themselves into watertight specialized disciplines leaving no scope for collaboration. Specialist physicians in the capacity of being appointed as the ‘primary consultant’ usually follow a paternalistic model in planning care goals for the patients, deciding treatment modalities, and unilaterally conveying decisions to other members in the team. To utter dismay, they pay least attention to opinions of other physicians, and also to the preferences of the patients under their supervision. It is as if they own patients9. Such an approach adversely affects patient care10-13, and is particularly inimical to end-of-life care. Professional boundaries seem to increase the unmet need for palliation, as most specialist physicians feel palliative care not to be their prerogative14. Similar results emerge from works of Gardiner et al.15 and Powell and Davies16.
In India, implementing inter-professional collaboration in caring for dying patients is all the more difficult. Firstly, most hospitals follow a consultative model of palliative care. It means the care is available to terminally ill patients only on referral from the concerned primary; palliative care is not an integral part of treatment protocol. Second, specialist physicians-led MDT have very little representation of non-clinical caregivers like spiritual carers, occupational therapists, community nurses and so on. And finally, unlike West, where MDTs are available at different levels of healthcare delivery system17, in India MDT formation is limited to hospital staff, making it highly disadvantageous for the physicians to network with stakeholders beyond institutional boundary18. Apart from these few insights, there is lack of information as how ‘eolc’ is managed in MDTs; what are the challenges and drawbacks. This study presents a number of observations from a multispecialty hospital to address to the information lacunae. It lays special focus on intra/inter-professional boundaries that are potentially disadvantageous to MDTs.