Medicine (St Vincent's) - Theses
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ItemTowards the integration of palliative care in advanced cancer: an exploration of patient, family and community perceptions of palliative care and views of communication( 2018)Since its inception, palliative care practice has evolved to respond to the emerging evidence base and the needs of the population it serves. This has resulted in the increasing health system focus on models of early integration of palliative care, enabling improved quality of life, prevention of suffering, and the achievement of goals considered important by people with serious illness and their families. Yet, population data from international jurisdictions including those such as Australia with “advanced” systems of integrated care suggest a picture of missed opportunities, with many patients accessing palliative care late in the illness course. This thesis explored patient, carer, and community perceptions of palliative care, and their views of communication about this concept – including at the hospital for those who are experiencing serious illness and in the community more broadly. This was explored with the broader aim to improve engagement with palliative care, and ultimately facilitate the provision of quality care for those with serious illness. Consistent with the Medical Research Council Framework for the development of complex interventions, empirical work was undertaken using mixed methodology over two phases. Exploratory qualitative interviews were undertaken with patients with advanced cancer and their carers. These data informed the development of a public health intervention to communicate information about palliative care to the broader community, which was tested in an online randomised pilot trial. Patients and carers reported inherently negative perceptions of palliative care, understood as inpatient nursing care, relevant only when no other anti-cancer treatment options remained. Patients revealed the difficulties faced in speaking about death other than in implicit terms, with this topic perceived to be outside the realms of medical consultations. Instead, patients perceived health professionals used the term ‘palliative care’ as a tool to talk about dying. ‘Palliative care’ was understood as a euphemism for death, and personified to mean my death, in turn also becoming ‘unspeakable’. Carers reported their needs for communication about palliative care to be ideally staged overtime, providing education about the tasks of palliative care separate from referral. Once death was imminent, carers wanted open communication with their health professionals, including spoken acknowledgement that death was close, using simple, direct language, and including the words ‘death’ and ‘dying’. A narrative communication intervention was demonstrated to be an acceptable approach to provide education about palliative care to community members. Participants reported significant improvement in attitudes to palliative care post intervention compared to baseline. An evidence-based narrative spoken by a health professional was found to hold the most promise for further investigation in a definitive trial. The results of thesis have significant implications for achieving the routine integration of palliative care in clinical practice. They highlight key opportunities to target education and improve communication about palliative care, and can inform future public health efforts to develop a systematic, evidence-based approach to community engagement. As such, this work provides the next steps to begin to transform experiences of end of life care within health systems.
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ItemExamining non-melanoma skin cancer trends in Australia using data from Medicare Australia( 2014)Background: Non-melanoma skin cancers (NMSC) are the most common cancer in Australia, costing the Australian Government $511 million in 2010. NMSC incidence studies have typically utilised face-to-face interview methods that rely on self-reporting of skin cancers. Studies overseas have employed national medical system billing data to examine trends in NMSC. The work in this thesis has adopted this novel approach for evaluating skin cancer trends. Objectives: 1. Determine the completeness of Medicare Australia (MA) in capturing skin cancer cases. 2. Examine the up-to-date incidence rates of NMSC to 2012. 3. Examine rates of recurrent and incompletely excised (residual) NMSC in Australia. Methods: Data from MA, Medicare Benefits Online and Victorian Cancer Registry (VCR) from 2004-2008 were extracted for use in this thesis. MA and VCR melanoma cases were compared. Regression and a paired-samples t-test was performed. NMSC incidence was estimated by determining the number of separate patients treated for a NMSC. The proportion of recurrences and residuals were calculated. Results: Medicare Australia data were found to correlate with the VCR data set. Incidence rates for NMSC were 856 per 105 people in 2012. This incidence was forecast to increase to 1636 per 105 in 2015. 1.54% of NMSC required treatment for a recurrence and 1.26% of NMSC required retreatment for incomplete excision. Conclusion: This thesis has contributed the following: 1. Demonstration of a correlation between MA and VCR melanoma data, suggesting that MA could potentially be used for examining trends in other skin cancers including NMSC. 2. An up-to-date incidence of NMSC in Australia to 2012. 3. Proportion of NMSC that required treatment for residual lesions. 4. Proportion of NMSC that required treatment for recurrent lesions.