title: A multidisciplinary approach in providing transitional care for patients with advanced cancer.
abstract: Patients living with a diagnosis of an advanced life-limiting malignancy often have concerns regarding symptom burden, physical and psychosocial impact on life, and questions surrounding end-of-life processes. Due to the complex care needs of patients with advanced life-limiting illness it is our experience that both a multidisciplinary and interdisciplinary approach to care can optimize the patient and family illness experience for this vulnerable population. Progressive metastatic illness often necessitates care in multiple settings including an ambulatory clinic, inpatient hospital ward, at home, and at an in-patient hospice or palliative care unit. Palliative care teams are typically composed of clinicians from various disciplines who work in multiple settings and can act as a link between community, ambulatory and in-patient care-settings. The team often includes physicians, advance practice nurses [nurse practitioners and clinical nurse specialists (CNSs)], nurses, social workers, chaplains, and other allied health clinicians. The result of this team approach, in collaboration with oncology providers, makes palliative care an ideal model for providing care through the many transitions that are inherent to patients living with advanced malignancy.
authors.affiliation: The Lilian and Benjamin Hertzberg Palliative Care Institute, The Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, NY 10029, USA.
authors.forename: Erica M
authors.initials: EM
authors.lastname: Tuggey
authors.affiliation: The Freeman Centre for The Advancement of Palliative Care, North York General Hospital, University of Toronto, 4001 Leslie Street, Suite 3S 375, Toronto, Ontario M2K 1E1, Canada. Email: warren.lewin@nygh.on.ca.
authors.forename: Warren Harris
authors.initials: WH
authors.lastname: Lewin
keywords: Multidisciplinary; advanced malignancy; palliative care; transitional care