Lesley Batten

Consideration of comorbidity in treatment decision making in multidisciplinary cancer team meetings: a systematic review

BACKGROUND Comorbidity is very common among patients with cancer. Multidisciplinary team meetings (MDTs) are increasingly the context within which cancer treatment decisions are made internationally. Little is known about how comorbidity is considered, or impacts decisions, in MDTs. METHODS A systematic literature review was conducted to evaluate previous evidence on consideration, and impact, of comorbidity in cancer MDT treatment decision making. Twenty-one original studies were included. RESULTS Lack of information on comorbidity in MDTs impedes the ability of MDT members to make treatment recommendations, and for those recommendations to be implemented among patients with comorbidity. Where treatment is different from that recommended due to comorbidity, it is more conservative, despite evidence that such treatment may be tolerated and effective. MDT members are likely to be unaware of the extent to which issues such as comorbidity are ignored. CONCLUSIONS MDTs should systematically consider treatment of patients with comorbidity. Further research is needed to assist clinicians to undertake MDT decision making that appropriately addresses comorbidity. If this were to occur, it would likely contribute to improved outcomes for cancer patients with comorbidities.

Cancer Care Decision Making in Multidisciplinary Meetings

Little research has been undertaken on the actual decision-making processes in cancer care multidisciplinary meetings (MDMs). This article was based on a qualitative observational study of two regional cancer treatment centers in New Zealand. We audiorecorded 10 meetings in which 106 patient cases were discussed. Members of the meetings categorized cases in varying ways, drew on a range of sources of authority, expressed different value positions, and utilized a variety of strategies to justify their actions. An important dimension of authority was encountered authority—the authority a clinician has because of meeting the patient. The MDM chairperson can play an important role in making explicit the sources of authority being drawn on and the value positions of members to provide more clarity to the decision-making process. Attending to issues of process, authority, and values in MDMs has the potential to improve cancer care decision making and ultimately, health outcomes.

Clinicians' views on introducing epidermal growth factor receptor testing in New Zealand

Inequities exist in the outcomes of patients diagnosed with lung cancer in New Zealand, with Māori (the indigenous population) having significantly higher diagnosis rates and poorer survival. We investigated the feasibility of introducing epidermal growth factor receptor (EGFR) testing into New Zealand as one step to address these inequities.

The contradictory effects of timelines on community participation in a health promotion programme

Timelines are universal features of health promotion programmes, which often receive little in the way of detailed analysis. Prospectively, timelines form supportive structures; they assist in planning and provide key milestones. However, they may also simultaneously constrain action or force the prioritization of some actions over others. This article uses the case of one health promotion programme to explore the multiple timelines in action: the contract, evaluation, usual programme phases and specific to a community garden project in the programme, the seasons. This exploration demonstrates the complexity of these timelines and how they affected programme implementation and were reflected in community participation. The discussion also demonstrates the importance of skilled facilitation of programmes, especially those based on a community development approach.

A multicase study of prolonged critical illness in the intensive care unit: Families’ experiences

BACKGROUND It is widely acknowledged a critical illness is a stressful life event for not only the patient but also their family members; when an illness becomes prolonged, the impact is profound. It is suggested that as medical technologies advance, the number of days patients stay in an intensive care unit will increase. Therefore, it is important nurses understand how families experience a prolonged critical illness of their family member in an intensive care unit. OBJECTIVE To explore the trajectory of a prolonged critical illness in the intensive care unit from the experiences of family. METHODS A qualitative, longitudinal, multi-case design consisting of six cases from New Zealand intensive care units. Findings presented in this article only relate to the familys experiences, although patients and healthcare professionals formed part of each case. Data collection methods included observation, conversations, interviews and document review. Analysis was undertaken using thematic analysis, vignette development and trajectory mapping. FINDINGS Relentless uncertainty dominated all phases of the trajectory for the family during a family members prolonged critical illness in the intensive care unit. When faced with a critical illness, family shifted rapidly into a world of unknowns. Family worked hard to navigate their way through the many uncertainties that dominated each phase of their family members illness. CONCLUSIONS Nurses need to understand the levels of uncertainty families endure in order to provide care that meets the philosophical underpinnings of family centred care.

Constructing prevention programmes with a Māori health service provider view

ABSTRACT Mainstream approaches to chronic condition management and prevention inadequately address the needs of Māori, the Indigenous people of New Zealand. Māori health service providers (MHSPs) are uniquely placed to address the critical gap in the prevention of chronic conditions. In this paper, we report qualitative research findings investigating how prevention was being modelled, practiced and measured in selected MHSP settings. Results indicate barriers to achieving wellbeing through health service delivery. The dominant individualistic, medical conditions-focused discourse, along with responding to acute need, is a driver of service delivery norms.There are examples of shifts in organisational structure and delivery configurations that demonstrate that these norms are being challenged and reframed, in some form, by MHSPs. Consolidation of these approaches requires significant work and increased resources as well as a broader systems-level response that prioritises prevention.

TICKING THE BOXES FOR CULTURAL CARE AT END-OF-LIFE

Background Clinical pathways including the Liverpool Care Pathway for the Dying Patient (LCP) construct the documentation of care in ways that can have benefits and consequences. In New Zealand unique cultural goals related to the care of patients and their families were added to the LCP, and research into their use is underway. Aims As part of an investigation into the utility, comprehensiveness and cultural appropriateness of the cultural goals, the aim was to examine the content of cultural care documentation to ascertain documentation practices. Methods A retrospective chart audit of 100 LCP documents, with 25 each from home care, aged residential care, hospital and hospice, and semi-structured interviews with stakeholders including clinical staff and managers. Results A number of patterns emerged including: very high rates (99% of 1360 entries) of the goals being recorded as ‘achieved’, even when one of the goals related to family needs and the family was not present; minimal documentation of cultural needs; and minimal variance documentation. In addition a further pattern related the use of the yes or no format in version 11 (rather than achieved or variance in version 12). A variance was documented only 1% of the time, however when the yes or no format was used, goals were documented as not met 20% of the time. Conclusions Ticking the box, or in this case, documenting an ‘A’ for achieved provides little information or evidence that the cultural goals have been addressed in an appropriate and comprehensive manner. In addition, the variance-reporting format appears to be misunderstood when documenting the care of patients who are unconscious, or families who are not present. The constraints placed on writing a holistic patient story potentially impede the meeting of cultural needs based on beliefs and values.