Balancing the needs of individuals and services in cancer treatment for people with dementia: A focused ethnographic study

Comorbid Dementia and Cancer Therapy Decision-Making: A Scoping Review

Comorbid dementia complicates cancer therapy decision-making in older adults. We aimed to synthesize the recent literature (<5 years) on the challenges associated with cancer therapy decision-making among older people living with dementia (PLWD) and their caregivers. Of the 20,763 references, 8767 had their title and abstract screened, and eight met the inclusion criteria. Six studies were qualitative, one study employed mixed methods, and one study was quasi-experimental. Most studies were conducted in the UK (89%) and reported homogeneity in race and geography. Breast (56%) and prostate (45%) were the most frequent reported cancers. Five studies (56%) reported multiple types of dementia, with two (22%) indicating stages. The studies indicated that communication between patients, caregivers, and clinical teams might alleviate stress caused by worsening health prospects and potential ethical concerns. Information from this review can lead to better-informed, patient-centered treatment decision processes among older PLWD and cancer, their caregivers, and clinicians.

Radiographers' experiences in working with patients living with dementia in Norway - A qualitative study

INTRODUCTION

Imaging departments are seeing an increase in the number of patients living with dementia (PWD), driven by the ageing population and diagnostic benefits offered by medical imaging. This study explored radiographers' experiences during imaging examinations for PWD.

METHODS

A semi-structured interview guide comprising questions about radiographers' experiences, knowledge concerning PWD, challenges faced, and departmental initiatives was developed. Eight radiographers were interviewed, four working in MRI or general imaging, including CT and four in nuclear medicine, at three hospital trusts in Norway. Data analysis was conducted using inductive content analysis as described by Elo and Kyngäs, following a three-step process of preparation, organising and reporting. The qualified radiographers coded, categorised, and defined the themes and sub-themes to report on the findings.

RESULTS

Three main categories emerged: 1. Radiographers' experiences, which included overall challenges and the radiographers' attitudes. 2. Measures undertaken, outlining the actions radiographers take during procedures, and 3.Competencies, highlighting the knowledge possessed by radiographers. Organisational challenges, such as the absence of overarching protocols and insufficient training for radiographers related to PWD, posed difficulties in effectively conducting procedures. Creating a calm environment, collaborating with caregivers, scheduling adequate time for examinations, and possessing good communication skills were viewed as facilitators for conducting examinations successfully.

CONCLUSION

Radiographers perceived imaging of patients living with dementia to be generally uncomplicated. However, challenges in planning for and communicating with patients, particularly for advanced examinations or acute settings, were reported. Establishing dementia-friendly departments and training radiographers in specific communication techniques could be beneficial.

IMPLICATIONS FOR PRACTICE

There is a need for more dementia-friendly imaging departments and communication training for radiographers working with PWD.

Experiences of hospital care for people with multiple long-term conditions: a scoping review of qualitative research

BACKGROUND

Multiple long-term conditions-the co-existence of two or more chronic health conditions in an individual-present an increasing challenge to populations and healthcare systems worldwide. This challenge is keenly felt in hospital settings where care is oriented around specialist provision for single conditions. The aim of this scoping review was to identify and summarise published qualitative research on the experiences of hospital care for people living with multiple long-term conditions, their informal caregivers and healthcare professionals.

METHODS

We undertook a scoping review, following established guidelines, of primary qualitative research on experiences of hospital care for people living with multiple long-term conditions published in peer-reviewed journals between Jan 2010 and June 2022. We conducted systematic electronic searches of MEDLINE, CINAHL, PsycInfo, Proquest Social Science Premium, Web of Science, Scopus and Embase, supplemented by citation tracking. Studies were selected for inclusion by two reviewers using an independent screening process. Data extraction included study populations, study design, findings and author conclusions. We took a narrative approach to reporting the findings.

RESULTS

Of 8002 titles and abstracts screened, 54 papers reporting findings from 41 studies conducted in 14 countries were identified as eligible for inclusion. The perspectives of people living with multiple long-term conditions (21 studies), informal caregivers (n = 13) and healthcare professionals (n = 27) were represented, with 15 studies reporting experiences of more than one group. Findings included poor service integration and lack of person-centred care, limited confidence of healthcare professionals to treat conditions outside of their specialty, and time pressures leading to hurried care transitions. Few studies explored inequities in experiences of hospital care.

CONCLUSIONS

Qualitative research evidence on the experiences of hospital care for multiple long-term conditions illuminates a tension between the desire to provide and receive person-centred care and time pressures inherent within a target-driven system focussed on increasing specialisation, reduced inpatient provision and accelerated journeys through the care system. A move towards more integrated models of care may enable the needs of people living with multiple long-term conditions to be better met. Future research should address how social circumstances shape experiences of care.

'A real fine balancing act': A secondary qualitative analysis of power imbalance in comorbid cancer and dementia in an outpatient treatment setting

AIMS

Studies of health services reveal a focus on provision of scheduled care at the expense of patient need, placing the health service in a position of power and the patient as passive recipient. This secondary qualitative analysis of a focused ethnography draws on the Foucauldian concept of power as pervasive and relational, to examine how an imbalance of power is manifested in situations where people with both cancer and dementia are being treated for cancer.

DESIGN

Secondary qualitative analysis of a focused ethnographic study.

DATA SOURCES

In the original study, qualitative data were gathered from observation and interviews with people with cancer and dementia (n = 2), caregivers (n = 7) and staff (n = 20). The study was conducted in the outpatient departments of two teaching hospitals in England between January 2019 and July 2021. Data from all sources were analysed for this secondary analysis using constant comparison.

RESULTS

The principal theme was balance, encapsulating the competing priorities involved in delivering cancer treatment. There was tension between maintaining safety and ensuring an individual's right to treatment, and difficulty reconciling the needs of the system with the needs of individuals.

CONCLUSION

The pervasive nature of power can be harnessed to enhance the agency of people with cancer and dementia by incorporating principles of shared decision making.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

We recommend incorporating the principles of personalized care to achieve more equitable power relations, reduce health inequalities and ensure that cancer treatment offered to people with dementia is safe and appropriate.

REPORTING METHOD

EQUATOR (COREQ) guidelines have been used for reporting.

PATIENT OR PUBLIC CONTRIBUTION

Patients and the public were involved in designing the original research questions and the study protocol including documentation such as interview topic guides and participant information sheets.

Cancer care for people with dementia: Literature overview and recommendations for practice and research

As many countries experience population aging, patients with cancer are becoming older and have more preexisting comorbidities, which include prevalent, age-related, chronic conditions such as dementia. People living with dementia (PLWD) are vulnerable to health disparities, and dementia has high potential to complicate and adversely affect care and outcomes across the cancer trajectory. This report offers an overview of dementia and its prevalence among patients with cancer and a summary of the research literature examining cancer care for PLWD. The reviewed research indicates that PLWD are more likely to have cancer diagnosed at an advanced stage, receive no or less extensive cancer treatment, and have poorer survival after a cancer diagnosis. These cancer disparities do not necessarily signify inappropriately later diagnosis or lower treatment of people with dementia as a group, and they are arguably less feasible and appropriate targets for care optimization. The reviewed research indicates that PLWD also have an increased risk of cancer-related emergency presentations, lower quality processes of cancer-related decision making, accessibility-related barriers to cancer investigations and treatment, higher experienced treatment burden and higher caregiver burden for families, and undertreated cancer-related pain. The authors propose that optimal cancer care for PLWD should focus on proactively minimizing these risk areas and thus must be highly person-centered, with holistic decision making, individualized reasonable adjustments to practice, and strong inclusion and support of family carers. Comprehensive recommendations are made for clinical practice and future research to help clinicians and providers deliver best and equitable cancer care for PLWD and their families.

Understanding the cultural environment of the outpatient care setting for patients with dementia receiving cancer treatment: A qualitative study

INTRODUCTION

People with dementia have poorer cancer outcomes than those without dementia, and experience inequalities in access to, and quality of, care. Outpatient environments, where radiotherapy, chemotherapy and immunotherapy cancer treatments typically take place, have largely been excluded from research. This study was conducted to understand provision of treatment and support and experiences of care for people with dementia undergoing cancer treatment in the outpatient setting.

MATERIALS AND METHODS

Using observation, interviews and document analysis, data were collected to scrutinize the cultural environment of ambulatory care, comprising the physical fabric of the care setting; interactions, behaviours and perceptions of those in the care setting; and the organizational, clinical and interactional processes involved in care delivery. The study was conducted in the outpatient oncology departments of two large teaching hospitals in England between January 2019 and July 2021.

RESULTS

Data were gathered from a wide range of sources, including 15 h of observation, and interviews with patients (n = 2), caregivers (n = 7) and staff (n = 20). Evidence from this study suggests that the cultural environment of the outpatient care setting reflects and supports the standardized processing of people for cancer treatment. Dementia introduces a wider set of care requirements not catered for by this standardized treatment model and associated processes. Data showed that the needs of patients with dementia could be addressed most effectively when individualized care, as opposed to standardized care, was offered.

CONCLUSION

There is work to be done in outpatient cancer services to ensure responsiveness to individual patient need. This could be achieved by having an established way (or ways) of eliciting needs, preferences and expectations, a belief that a person's needs and expectations are legitimate and that effort should be made to address them, with the ability to accommodate these needs and expectations.

PATIENT OR PUBLIC CONTRIBUTION

Patients and caregivers were involved in the study design and development of study materials including the interview topic guide. They also assisted with discussion and clarification of study findings.