Purpose

Toguri et al. (2020) highlights the underutilization of advance care planning (ACP), despite evidence which shows that ACP positively impact patient care during end-of-life (EOL). ACP is particularly valuable for patients with advanced or metastatic cancers, and for this reason researchers aimed to establish the needs and experiences of ACP of oncology patients and their families, as well as perceptions of physicians.

Design

Interviewers sought to understand the phenomenon of the lived experience of patients ACP as it related to their understanding of treatment options and wishes for care. Because of this, the research is considered a descriptive qualitative study.

Sampling

In total 18 participants took part in this study, which includes 4 patients, 4 family members and 10 oncologists. A specific cancer and/or stage was not sought and all patients self-identified as either having advanced cancer (at diagnosis or recurrence) or as suitable for ACP due to their overall state of health. Families also self-identified as having an immediate family member with advance cancer, either spouse, child, or sibling (Toguri et al., 2020). Interestingly, family member and patient participants had no relation to one another, and therefor were considered to have provided 8 independent perspectives on ACP.  Additionally there were 10 physicians, either radiation or medical oncologist, however there is no specification on the number of participants from each specialty. Although Toguri et al. (2020) does explain that all oncologists were active within their positions of providing patient care, the providers where not necessarily providers of care for the patients (or patients of the family member) involved.

Data collection method

The collection of data was achieved via a single one-on-one interview preformed either by phone or in person. Interviewed patients/families and oncologist lasted 38-64 minutes and 26-69 minutes respectively. All interviews were transcribed verbatim by a transcriptionist from audio recordings. During which, every interviewee was provided the same definition of ACP. What followed were semi-structured questions to identify participants viewpoints and understanding of ACP, components of its initiation and ways to improve the discussion of such. Provider data was analyzed separately from family/patient data which were analyzed as one dataset. After the interviews were transcribed, they were read and reread. Using thematic analysis, two researchers independently reviewed data and identified themes through the application of coding schemes which identified recurrent themes. To ensure saturation of data, data collection and analysis continued until no new themes were identified (Toguri et al., 2020).

Summary of findings

Overall patients and families expressed a positive perception of ACP and described its discussion as having given them the opportunity to plan for medical emergencies which may occur in the future. By doing so, they described having a better understanding of their disease progression (Toguri, et al., 2020). Patients also describe feeling empowered, believed they should not feel rushing into making treatment decisions and should be given time to digest their prognosis. Patients believed ACP should occur shorty after diagnosis and expressed the desire of knowing early on what their prognosis was. On the other hand, families expressed having relief from stress when being a part of ACP discussions, and noted having prior negative experiences with late end-of-life discussion and/or the lack of ACP. Although patients expressed feeling as though they have regained some autonomy, they believe that their oncologist should initiate the ACP discussion. Collectively patients and family members felt that health care providers lacked understanding of their informational needs during ACP discussions. They made reference to limited access to service, including palliative care, and poor communication between the interdisciplinary care team.

Oncologist primarily identified barriers to ACP, noting limited formal training and the lack of system coordination as hindering the ACP process and leading to fragmentation of services. They explained how family dynamics may hinder ACP if patients and families are at opposites ends of the spectrum of disease acceptance. They describe the initiation of ACP as being a complex process with variable timing. However, agreed that patients and families having previously discussed goals of care helped to facilitate the ACP process. The providers describe using clinical judgment for when to discuss ACP as well as how much information to provide the patient. Both of which they say are driven by the extent of disease and how respective they believe they patient and family to be. This is in stark contrast to the stated preferences of patients and families within this study. Providers believe that ACP requires an interdisciplinary team, including but not limited to nurses, family doctors, spiritual care and palliative care. They also express that an uptake in clinical documentation of ACP has the potential to improve continuity of care for patients with advanced oncologic disease, acknowledging that ACP improves patient care.

Strengths of the study

This study provided multiple quotations from separate participants which were categorized by an identified overarching theme. The detail provided from the interviews along with the finding of this study aligning with prior research suggest that the results of this study hold high transferability.

Limitations

Because this study was conducted in Canada, and its small sample size, it may not be generalizable. Additionally, the patients and families’ participants had limited experience with ACP which means their experience with ACP discussions may not fully encompass its emotional impact (Toguri et al., 2020). This may have influenced the positive perspectives of ACP in these individuals.

Recommendations

Because of the small sample size, and self-identification of patient/family participants, it may be useful for researchers to conducted further studies within this same population, with more patient participants and clinical parameters for “advanced” cancer diagnosis. Given the fact that the Oncologist agree that ACP requires a team approach, additional insight on the perceptions of other members of the healthcare team (nurses, advanced practice providers, palliative care etc) would provide great benefit moving forward.  Formal training for healthcare providers should be establish and implemented to overcome the barrier associated with inadequate training or vastly different opinions on how and when to have an ACP discussion, so that these discussions are more reflective of the patients desires for prognostic awareness.

Reference

Toguri, J., Grant-Nunn, l., & Urquhart. (2020). Views of advanced cancer patients, families, and oncologist on initiating and engaging in advance care planning: A qualitative study. BMC Palliative Care, 19(1), 1-11. https://web-p-ebscohost-com.chamberlainuniversity.idm.oclc.org/ehost/pdfviewer/pdfviewer?vid=0&sid=1e943afb-e61e-4057-b6e1-9958bce9db11%40redis

Our expert nursing writers at Nursing Assignment Service can do your NR 505 Week 4 Collaboration  Cafe Assignment, place your order here. Links to an external site.