CancerWorld: Framing the argument over futile care - overdiagnose, overtreat, overpromise...media focus

Framing the argument over futile care:

We “overdiagnose, overtreat and overpromise”. This was the claim made by numerous newspaper headlines in response to the Lancet Oncology report last September on delivering affordable cancer care. While we do need open and frank discussions about how to curb the spiralling costs of cancer care, it was unfortunate that the media focused so heavily on the cost of futile treatment in the last weeks of life, blaming it all on a culture of excess. This sparked reports that patients would be denied potentially life-prolonging treatments purely on the basis of cost and generated fears that patients might be abandoned in their final months. There is no doubt that we do overtreat and overpromise in the advanced cancer setting. We know, for instance, that many patients receive cancer treatments in the last weeks of their life, and that some of these treatments have no reasonable chance of helping the patient and are associated with severe side-effects that can lead to hospitalisation and even death. We also know that receiving chemotherapy is associated with a delay in referral to palliative care. But blaming this on a culture of excess is too simplistic. Making the right decisions in later stages of advanced cancer is difficult for doctors and patients alike. It is often impossible to predict how long a patient will live, and while we have an increasing number of therapies to choose from, we don’t yet know enough about who stands to benefit and by how much. There can be a huge disconnect between the expectations of patients and families and those of clinicians, adding to the difficulty of conducting honest conversations with patients about their prognosis, treatment options and end-of-life preferences. There are no easy answers. But could we be making things harder for ourselves by posing options in terms of a choice between either fighting cancer or optimising quality of life? An emerging body of evidence shows that integrating palliative care into the mainstream care of cancer patients not only improves their quality of life, but might even help them live longer. Early involvement of palliative care specialists has also been shown to cut down on futile medical interventions and help families cope better with their loss of a loved one. ASCO is now recommending that patients should be offered concurrent palliative care and standard cancer treatments early in the course of their advanced cancer journey. This is in line with efforts to stimulate meaningful interaction between mainstream oncology and palliative care specialists that ESMO and other European professional bodies have been pursuing for some time. However, progress so far has been infuriatingly slow. Greater integration of palliative care requires changes in the way we organise care and train clinicians. We need to get on with this as a matter of urgency. If we fail to take a lead in addressing shortcomings in the way we care for patients with advanced cancer, the simplistic arguments about a wasteful culture of excess could win, and patients will be the losers.

open access: (Canada) How the Medical Culture Contributes to Coworker-Perpetrated Harassment and Abuse of Family Physicians (includes patients, families, education system, co-workers)

How the Medical Culture Contributes to Coworker-Perpetrated Harassment and Abuse of Family Physicians


"At present, little is being undertaken to address the issue of abuse in the workplace of family physicians. The most worrisome finding from our study is that these kinds of practices are a part of the medical culture starting in medical school and carried out throughout medical training and into the work environment. This culture is supported by power imbalances, power structures, and such systemic issues as physician shortages. The criminological broken window theory is helpful to explain why abuse may be perpetuated in the medical system, and it also provides a context for an approach to address the issue."

Controversies in Oncologist-Patient Communication: A Nuanced Approach to Autonomy, Culture, and Paternalism - Cancer Network

"....Several aspects of communication between oncologists and their patients remain contentious:
• Autonomy: To what degree must physicians observe the principle of full disclosure in order to ensure true autonomy and informed decision making on the part of the patient?
• Culture: In caring for patients from different cultures, how should the physician respond to requests of family members who claim that in their culture decision making should be left to the family rather than to the patient?
• Paternalism: How does one balance the need for information with the concern that some patients may be harmed by physicians' honoring requests for either too much or too little information? When should the physician invoke the “therapeutic privilege” of paternalistically overriding a patient request or not seeking the patient's opinion?...."

2011 Implementation Science - The effectiveness of strategies to change organisational culture to improve healthcare performance: a systematic review

Background

Organisational culture is an anthropological metaphor used to inform research and consultancy and to explain organisational environments. Increasing emphasis has been placed during recent years on the need to change organisational culture in order to improve healthcare performance. However, the precise function of organisational culture in healthcare policy often remains under specified and the desirability and feasibility of strategies to be adopted have been called into question. The objective of this review was to determine the effectiveness of strategies to change organisational culture in order to improve healthcare performance.

Results

The search strategy yielded 4239 records. After the full text assessment, two CBA ( controlled before and after studies) studies were included in the review. They both assessed the impact of interventions aimed at changing organisational culture, but one evaluated the impact on work-related and personal outcomes while the other measured clinical outcomes. Both were at high risk of bias. Both reported positive results.

Conclusions

Current available evidence does not identify any effective, generalisable strategies to change organisational culture. Healthcare organisations considering implementing interventions aimed at changing culture should seriously consider conducting an evaluation (using a robust design, e.g. ITS) to strengthen the evidence about this topic.

full free access: Supporting Clinical Practice Decisions With Real-Time Patient-Reported Outcomes JCO

'The worst thing about hospice is that they talk about death': contrasting hospice decisions and experience among immigrant Central and South American Latinos with US-born White, non-Latino cancer caregivers

Abstract:
Hospice care is promoted as a model for improving end of life care and decreasing burden on caregivers. However, hospice use is low in Latinos and little is known about how Latinos make hospice decisions and experience hospice once enrolled. Qualitative methods were used in this study to conduct in-depth interviews and focus groups with 15 Latino bereaved hospice family caregivers and 15 White non-Latino bereaved hospice family caregivers to describe hospice experiences and evaluate whether cultural factors affected the experience. Differences in decision-making and caregiving experience were identified that were influenced by culture. For example, cultural values of denial, secrecy about prognosis and a collective, family-centered system influenced hospice decisions and experience in Latinos but not non-Latinos. This study identifies a significant dilemma: that is, how to discuss hospice with a patient and family who prefer not to discuss a terminal prognosis. Future research is needed to extend these preliminary results; such results may be useful for designing interventions to improve end of life care and caregiving in Latinos.

Cancer, Culture, and Health Disparities: Time to Chart a New Course?

full free access