Ms Ang Bee Lian, 5 April 2018
Why is a multidisciplinary team (MDT) especially important in complex cases? Through experience, we know that the range of perspectives and knowledge from professionals of different disciplines is required for holistic case management. This is especially so for cases involving the elderly. The elderly tend to face “fragmented health care and social services systems; complicated, sometimes distant or dwindling families who are uninformed, in-conflict or exhausted; fundamental questions about life, death, obligations, and choice; profound spiritual and ethical dilemmas (and) complex legal options” (Grooh, 2014).
As such, the greater amount of expertise present in MDTs will allow for deeper understanding of individuals which can help in deciding how to better support them. The value of having MDTs is more than the sum of each professional’s expertise and contributions. A standard practice for interventions in complex cases involving older persons should therefore include the establishment of MDTs.
What in essence is multidisciplinary work? MDTs comprise members from different disciplines. There are various models and ways to structure a MDT but some common themes comprise members seeing each other, listening to each other and recognising the value of each other’s contributions in a deliberate way in order to address the problem at hand.
It is important for team members to be respectful of other professionals, to be willing to receive constructive criticism, to be patient in listening to others, to be able to communicate in non-technical language and to have the client’s well-being in mind.
A good team leader and coordinator is essential to ensure the value add of a MDT. Coordination is often an underestimated skill, but it is crucial to facilitating team meetings, gatekeeping and deciding which cases merit review by a MDT. Good coordination monitors the progress of decisions made by the MDT and ensures appropriate follow up by the relevant team members. It also ensures that the right professionals and people are present when a case is being discussed (Breckman, Callahan, & Solomon, 2015).
Bringing the right people together is not always easy as individuals of agencies tend to hold on to their respective perspectives. Getting consensus therefore requires the coordinator to have strong administrative skills and the ability to communicate well and facilitate discussions with professionals from various disciplines.
When working with the elderly, it is common to come across vulnerable adults. A vulnerable adult is someone who is by reason of mental or physical infirmity, disability or incapacity, incapable of protecting himself or herself from abuse, neglect or self-neglect (MSF, 2017). In such cases, the first and primary challenge for professionals is often in determining the cognitive capacity of the victim – to know if he or she understands the consequences of a particular decision, activity or event and is able to make decisions in his or her own best interests.
Directing assessment of cognitive capacity is easier said than done. Orchestrating it requires creativity and ingenuity by stipulated professionals and in a timely and accurate manner. When it is done, the assessment guides the MDT on the follow-up actions to take.
Embedded within this is the challenge of having someone who has “full capacity in one area of life yet lack capacity in another” (Breckman, Callahan, & Solomon, 2015). One example of this is someone who can manage daily tasks well without assistance but has a poor grasp of finances and doesn’t understand the consequences of ‘giving’ that money to someone else (Breckman, Callahan, & Solomon, 2015).
Furthermore, while a few professionals may be mandated to make cognitive assessments, and all professionals may understand the relevance of cognitive capacity, not all practitioners always evaluate it in the same way or reach the same conclusions. Whatever the differences in views, having practitioners from different disciplines work together is necessary to widen the options for follow up. To address this challenge, most MDTs would want to have some control over the process of obtaining a cognitive capacity assessment so that there is access to important information to make timely and good decisions in a case (Breckman, Callahan, & Solomon, 2015). This is also where the coordinator can play a role. When one professional’s views and recommendations conflicts with someone else’s assessment, they can discuss it with other team members with facilitation by the coordinator.
When working with vulnerable elderly, it is necessary for professionals to give them as much dignity and autonomy as possible. Professionals should ask, even if it is a hard question, or even if they think they already know the answer, and then listen to the answer as openly and completely as they can.
Under the Vulnerable Adults Bill, which has recently been introduced in Parliament1 , it is proposed for the State to be given powers to intervene to protect and ensure the safety of vulnerable adults where necessary. This is crucial in cases where cognitive capacity is significantly diminished, or where access to a suspected victim is denied.
Perhaps the unsolvable dilemma for MDT with elder abuse and neglect is that of older persons who continue to live with an adult child with mental illness or substance abuse issues. Despite their advanced age, frail condition and the abuse they have endured, they feel an obligation to care for their child at home. In such a situation, both persons are in need of help. Removing either one or both of the persons especially when they do not have cognitive capacity is often not a good option. At best, practitioners can counsel these older persons and support them in the care of the adult child even though it often compromises their health and wellbeing.
This is where motivational interviewing can help to prepare them to receive help and even placement out of home at some point. Elder abuse and neglect work is filled with ethical dilemmas. One recurring dilemma is how to help an older person while minimising the negative repercussions on an abuser who may at times, also has needs. The dilemma is compounded by the difficulty of balancing the older person’s safety with his/ her own right to make choices in life.
The complexities and uniqueness of each elder abuse or neglect case makes what is considered a reasonable case outcome more varied. While the desire to preserve the dignity and safety of every elderly person is present across professionals, different professionals have varying opinions of what is considered a reasonable or good outcome. According to Geriatrician Mark Lachs, some may want the abuser removed from the home; others may want the abuser to get help and others may want the abuser to get treatment for a mental health condition even when it is most difficult to get it (Breckman, Callahan, & Solomon, 2015).
The ability to pull and pool together resources to build a sustainable safety net for the older person continues to be the biggest challenge with each case and sometimes with evolving circumstances. If we make an effort to collaborate and consolidate our resources across disciplines, it is a step forward in making this possible.
1 The Vulnerable Adults Bill was introduced in Parliament on 20 March 2018.
Breckman, R., Callahan, J., & Solomon, J. (2015). Elder Abuse Multidisciplinary Teams: Planning for the Future. Elder Abuse Multidisciplinary Teams: Planning for the Future
Grooh, H. (2014). Providing Care Management with a Multidisciplinary Team: Managing Quality.Journal of Aging Life Care.
Ministry of Social and Family Development (MSF). (2017) Stop Family Violence - Abuse of Vulnerable Adults. Retrieved from Ministry of Social and Family Development: www.msf.gov.sg/publications/Pages/Stop-Family-Violence-Abuse-of-Vulnerable-Adults.aspx
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MS ANG BEE LIAN
Director-General of Social Welfare