Maureen Holdaway

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.

Barriers to Best Outcomes in Breastfeeding for Māori: Mothers' Perceptions, Whānau Perceptions, and Services

This research explores the perceptions of New Zealand Māori women and their whānau (customary Māori extended family) toward barriers to achieving best outcomes in infant feeding: exclusively breastfed infants at 6 months. Interviews are undertaken with 59 Māori women who have given birth in the previous 3 years and 27 whānau members. Although mothers and whānau members feel positively toward breastfeeding and generally expect to breastfeed exclusively, these expectations are unmet in many cases because of lack of support when establishing breastfeeding; lack of support when life circumstances change; lack of timely, culturally relevant, and comprehensible information; confusion about smoking while breastfeeding; uncertainty about the safety of bed-sharing, and perceived lack of acceptability of breastfeeding in public. The relatively high rates of tobacco use by Māori create a tension for breastfeeding mothers, cited by some as a reason for ending breastfeeding prematurely. J Hum Lact. 25(3):307-316.

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.

Insulin sensitivity and intramyocellular lipid concentrations in young Maori men

Aims  In muscle, resistance to insulin‐mediated glucose uptake is thought to underlie the pre‐Type 2 diabetic condition. In European Caucasian men, insulin sensitivity is negatively associated with intramyocellular lipid (IMCL) content, and this may provide an early marker of diabetes risk. This study was designed to examine the relationship between vastus lateralis IMCL content, aerobic fitness, adiposity and markers of insulin sensitivity in healthy, young Maori men.

Principles and strategies for improving the prevention of cardio-metabolic diseases in indigenous populations: An international Delphi study

The disparity in life expectancy between Indigenous and non-Indigenous populations, including within high-income countries, is driven by a heightened risk of cardio-metabolic diseases. The current study recruited independent panels of experts in Indigenous cardio-metabolic health from Australia, New Zealand and the United States, in order to establish local consensus opinion and initiate dialogue on appropriate prevention strategies. Therefore, a three-round Delphi process was used to consolidate and compare the opinions of 60 experts, 20 from each country. Round one, the experts were asked twelve open-ended questions across six domains: (i) prevention; (ii) consultation; (iii) educational resources; (iv) societal issues; (v) workforce issues; (vi) culture and family. Round two, the experts completed a structured questionnaire based on results from the first round, in which they ranked items according to their importance. Final round, the experts were asked to re-rank the same items after receiving summary feedback about the rank ordering from the previous round. Several themes emerged common to all three countries: (i) socio-economic and education inequalities should be addressed; (ii) educational, behaviour change and prevention strategies should address physical environmental determinants and be responsive to the local context, including being culturally appropriate; and (iii) cultural appropriateness can be achieved through consultation with Indigenous communities, cultural competency training, use of Indigenous health workers, and use of appropriate role models. These findings highlight several key priorities that can be used to initiate dialogue on appropriate prevention strategies. Such strategies should be contextualized to the local Indigenous populations.

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.