Medicine (St Vincent's) - Theses
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ItemTreatment decision making amongst older people with cancer and their healthcare professionals( 2016)Background: Internationally the population is ageing. As cancer is predominantly a disease of older age, increasing numbers of older people will confront decisions about cancer treatment with their healthcare professionals. Such decisions are potentially more complex at older ages due to an increased risk of comorbid medical conditions, concomitant medication usage, and physical and cognitive limitations. Personal values and preferences, which may differ widely between older people and healthcare professionals, are central to many cancer treatment decisions. The aim of this thesis is to explore treatment decision making amongst older people with cancer and their healthcare professionals. Methods: A variety of sources of data and methodological approaches have been used. The views and experiences of older people with cancer and healthcare professionals were explored using a grounded theory approach. Decision making amongst healthcare professionals within the cancer multidisciplinary team was considered through descriptive statistical analysis and a qualitative hermeneutic approach to observational data collected in cancer multidisciplinary meetings (MDMs). Finally, decision making in oncological consultations was investigated using quantitative content and qualitative thematic analysis of audio-recorded consultations. Results: Older people made cancer treatment decisions within the context of life stage, drawing upon life experiences and personal relationships. Healthcare professionals faced competing tensions when considering treatment recommendations for older people, including between chronological age and other factors influencing perceptions of age, avoiding harming older people due to treatment side effects whilst also avoiding under-treatment, and considering patient preferences whilst respecting family views. In cancer MDMs, discussion of geriatric assessment domains was limited, however, general descriptors of physical status were common. These non-objective lay terms, such as ‘fit’ or ‘well’, could influence treatment recommendations. In oncology consultations decision making items prioritised by healthcare professionals were more likely to be discussed than those prioritised by older people. The specific technical terminology used to discuss biomedical factors contrasted with the non-specific terminology used to discuss physical and social function. However, a conversational style of interaction facilitated patients describing their social supports, physical function, and preferences. Conclusions: Throughout this thesis, lack of language and unspoken factors impacted upon treatment decision making amongst older people with cancer and healthcare professionals. Healthcare professionals appeared inarticulate when discussing geriatric assessment domains and non-medical items, lacking language to facilitate such discussion. Items older people prioritised in decision making were rarely discussed during either cancer MDMs or oncology consultations. Within the medical decision making literature, the broader relational, experiential, social, and cultural context to medical decisions is rarely discussed. A broader, expanded language is required to allow articulation of the many unspoken factors which influence medical decision making. This expanded language is required in interactions between healthcare professionals, in interactions between healthcare professionals and patients and their companions, and also more broadly within the medical literature. Medical decisions are complex, contextual, relational and experiential, as well as biomedical. Healthcare professionals need to recognise these complex factors to be able to place older people’s values and preferences at the centre of their medical care.