OBJECTIVES: The aim of the present study was to disentangle the impact of age and that of cancer diagnosis and treatment on functional status (FS) decline in older patients with cancer.MATERIALS AND METHODS: Patients with breast and colorectal cancer aged 50-69years and aged ≥70years who had undergone surgery, and older patients without cancer aged ≥70years were included. FS was assessed at baseline and after 12months follow-up, using the Katz index for activities of daily living (ADL) and the Lawton scale for instrumental activities of daily living (IADL). FS decline was defined as ≥1 point decrease on the ADL or IADL scale from baseline to 12months follow-up.RESULTS: In total, 179 older patients with cancer (≥ 70years), 341 younger patients with cancer (50-69years) and 317 older patients without cancer (≥ 70years) were included. FS decline was found in 43.6%, 24.6% and 28.1% of the groups, respectively. FS decline was significantly worse in older compared to younger patients with cancer receiving no chemotherapy (44.5% versus 17.6%, p<0.001), but not for those who did receive chemotherapy (39.4% versus 30.8%, p=0.33). Among the patients with cancer, FS decline was significantly associated with older age (OR 2.63), female sex (OR 3.72), colorectal cancer (OR 2.81), polypharmacy (OR 2.10) and, inversely, with baseline ADL dependency (OR 0.44).CONCLUSION: Cancer treatment, and older age are important predictors of FS decline. The relation of baseline ADL dependency and chemotherapy with FS decline suggest that the fittest of the older patients with cancer were selected for chemotherapy.
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INTRODUCTION: In Europe, cancer is one of the predominant causes of mortality and morbidity among older people aged over 65. A diagnosis of cancer can imply a negative impact on the quality of life of the older patients and their families. Despite research examining the impact of cancer on the family, it is unclear what kind of information is available about the types of clinical practice towards older patients with cancer and their families. The aim is to determine the extent, range and variety of research in Europe describing health practices towards families of older patients with cancer and to identify any existing gaps in knowledge.METHODS: Scoping review.RESULTS: A total of 12 articles were included, showing that family interventions are generally based on end-of-life care. Most studies used a qualitative approach and involved different types of family member as participants. Most studies were conducted in the UK.CONCLUSIONS: Review findings revealed limited knowledge about health practices in Europe towards families with an older patient with cancer. This review indicates a need to increase family-focused research that examines health practices that meet the needs of families of older patients with cancer. Seeing cancer as a chronic disease, there is an urgent need for the implementation of family-focused interventions.
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AbstractIntroduction: Involvement of family members in shared decision-making (SDM) processes for older cancer patients has become a topic of increasing interest but can be challenging for physicians. Yet, there is a need to understand the unique features of family involvement in SDM.Objectives: The aim of this study was to identify how and to what extent family members of older patients with cancer, together with patients and physicians, are involved in triadic decision-making processes in clinical practice.Methods: Qualitative observations of 25 consultations between physicians (n=10), patients ≥ 70 years (n=25), and family members (n=30) at the oncology outpatient clinic. Consultations were audiotaped and transcribed. The OPTIONMCC tool was used to evaluate the SDM process. Data analysis followed a thematic deductive approach using Atlas-ti.Results: Patients showed greater participation in the SDM process than family members. Family members' involvement in SDM varied from no involvement to active involvement. Their participation can be characterized by several key factors, including emphasizing the patient's values and goals of care, asking questions about various treatment options, offering assistance in the decision-making process, and providing clarification and organization of the overall care process. Observed physicians' SDM skills were at a low or moderate level. Physicians kept their focus on patients and were responsive to family members but did not actively involve them in SDM.Conclusion: Family members of older patients with cancer showed varying levels of involvement in the SDM process, while physicians were observed to not actively involve them. To increase family involvement in SDM in a way that is beneficial for all parties involved we recommend including patient and family-oriented strategies in SDM training for physicians.
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Background and purpose: Many older patients with cancer have their family members, often their adult children, involved in a process of treatment decision making. Despite the growing awareness that family members can facilitate a process of shared decision making (SDM), literature about SDM pays little attention to family relations and strategies to facilitate family involvement in decision making processes. Therefor this study aimed to 1. explore surgeons' and nurses' perceptions about involvement of adult children in treatment decision-making for older patients; and 2. identify strategies surgeons' and nurses use to ensure positive family involvement. Methods: This study used a qualitative open in-depth interview design. Semi-structured interviews were conducted with 13 surgical oncologists and 13 oncology nurses in two hospitals in the Netherlands. Qualitative content analysis was conducted according to the steps of thematic analysis. Results: Surgeons and nurses indicated that adult children's involvement in decision-making increases when patients become frail. They reported beneficial and challenging characteristics of this involvement. Subsequently, six strategies to stimulate positive involvement of adult children in the decision-making process were revealed: 1. Focus on the patient; 2. Actively involve adult children; 3. Acknowledge different perspectives; 4. Get to know the family system; 5. Check that the patient and family members understand the information; and 6. Stimulate communication and deliberation with adult children.Conclusions and implications: Surgeons and nurses perceive involvement of adult children in treatment decision making for older patients with cancer as beneficial. Adult children can help these patients reach well-informed treatment decisions. Therefor surgeons and nurses stimulate the communication and deliberation between these patients and their adult children. However, involving family in treatment decision making also triggers specific complexities and challenges in treatment decision conversations that seem to call for the development and implementation of practical patient and family-centered strategies.
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Introduction: The implementation of oncology care pathways that standardize organizational procedures has improved cancer care in recent years. However, the involvement of “authentic” patients and caregivers in quality improvement of these predetermined pathways is in its infancy, especially the scholarly reflection on this process. We, therefore, aim to explore the multidisciplinary challenges both in practice, when cancer patients, their caregivers, and a multidisciplinary team of professionals work together on quality improvement, as well as in our research team, in which a social scientist, health care professionals, health care researchers, and experience experts design a research project together. Methods and design: Experience-based co-design will be used to involve cancer patients and their caregivers in a qualitative research design. In-depth open discovery interviews with 12 colorectal cancer patients, 12 breast cancer patients, and seven patients with cancer-associated thrombosis and their caregivers, and focus group discussions with professionals from various disciplines will be conducted. During the subsequent prioritization events and various co-design quality improvement meetings, observational field notes will be made on the multidisciplinary challenges these participants face in the process of co-design, and evaluation interviews will be done afterwards. Similar data will be collected during the monthly meetings of our multidisciplinary research team. The data will be analyzed according to the constant comparative method. Discussion: This study may facilitate quality improvement programs in oncologic care pathways, by increasing our real-world knowledge about the challenges of involving “experience experts” together with a team of multidisciplinary professionals in the implementation process of quality improvement. Such co-creation might be challenging due to the traditional paternalistic relationship, actual disease-/treatment-related constraints, and a lack of shared language and culture between patients, caregivers, and professionals and between professionals from various disciplines. These challenges have to be met in order to establish equality, respect, team spirit, and eventual meaningful participation.
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Introduction: Many older patients with cancer have their family members, often their adult children, involved in a process of treatment decision making. Despite the growing awareness that family members can facilitate a process of shared decision making (SDM), literature about SDM pays little attention to family relations and strategies to facilitate family involvement in decision making processes. Objective: This study aimed to 1. explore surgeons' and nurses' perceptions about involvement of adult children in treatment decision-making for older patients; and 2. identify strategies they use to ensure positive family involvement. Methods: Semi-structured interviews were conducted with 13 surgical oncologists and 13 oncology nurses in two Dutch hospitals. Qualitative content analysis was conducted according to the steps of thematic analysis. Results: Surgeons and nurses indicated that adult children's involvement in decision-making increases when patients become frail. They reported beneficial and challenging characteristics of this involvement. Six strategies to stimulate positive involvement of adult children in the decision-making process were revealed: 1. Focus on the patient; 2. Actively involve adult children; 3. Acknowledge different perspectives; 4. Get to know the family system; 5. Check that the patient and family members understand the information; and 6. Stimulate communication and deliberation with adult children.Conclusion: Surgeons and nurses perceive involvement of adult in treatment decision making as beneficial. However, family involvement can trigger specific complexities and challenges in treatment decision conversations that call for practical patient and family-centered strategies.
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Many older patients with cancer depend on their family members for care and support and involve their family members in treatment decision-making in different stages of the cancer trajectory. Although family involvement is advocated in person-centered care, little is known about family involvement in decision-making specifically for older patients, and evidence-based strategies are scarce. The aim of this scoping review is to provide deeper understanding of factors influencing family involvement in treatment decision-making for older patients with cancer. Four databases were searched for quantitative-, qualitative- and mixed-method empirical studies describing factors influencing family involvement in treatment decision-making for older patients with cancer: PubMed, EMBASE, CINAHL and PsycINFO. Three independent researchers reviewed the papers for eligibility and quality and contributed to the data extraction and analysis. Twenty-seven papers were included, sixteen quantitative studies, nine qualitative studies and two mixed-method studies. Five categories of factors influencing family involvement emerged: 1) patient characteristics, 2) family member characteristics, 3) family system characteristics, 4) physician’s role and 5) cultural influences. These factors affect the level of family control in decision-making, treatment choice, decision agreement, and levels of stress and coping strategies of patients and family members. This review reveals a complex interplay of factors influencing family involvement in treatment decision-making for older patients with cancer that is rooted in characteristics of the family system. The findings underscore the need for development and implementation of evidence-based strategies for family involvement in treatment decision-making as part of patient-centered care for older patients with cancer.
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INTRODUCTION: There is a growing interest in the involvement of family members of older patients with cancer in decision-making processes. The aim of this study is to identify how and to what extent family members, together with patients and physicians, are involved in triadic decision-making processes in clinical practice.MATERIALS AND METHODS: This study was conducted using an exploratory observational design. The Observer Patient Involvement Scale for patients with Multiple Chronicle Conditions (OPTION MCC) was used to assess the interaction in triadic decision-making between patients, family members, and physicians. Physicians' behaviour was scored on a Likert-scale ranging from 0 (not observed) to 4 (executed to a high standard), while the behaviour of patients and their family members was scored on a scale from 0 (no or minimum participation) to 2 (active participation). Atlas.ti software was used to facilitate coding, and the SPSS statistical analysis platform was used to explore correlations between the shared decision-making (SDM) skills of the physician and the participation of patients and their family members. RESULTS: In total, ten physicians performed 25 consultations with older patients and 30 family members. Patients showed higher levels of participation in the SDM process than family members (OPTION MCC mean scores 0.96 vs 0.61). Physicians' SDM skills were observed at a low or moderate skill level (OPTION MCC mean score 1.81). Exploratory correlation analysis showed that higher physician scores were related to higher levels of both patients' and family members' involvement in the decision-making process. The level of family members' involvement in SDM varied from no involvement at all to active involvement. Qualitative analysis of family involvement revealed that relatives are likely to: emphasize patients' values and goals of care; inquire about different treatment options; assist in the deliberation process; and ask for clarification of the further medical process. Physicians showed responsive behaviour towards family members but seldom actively involved them in the SDM process. DISCUSSION: The study findings suggest that there is a need to include strategies to facilitate family involvement in current SDM models for older patients with cancer. Healthcare professionals in geriatric oncology might benefit from additional training covering family dynamics and managing challenging situations.
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Screening for psychological distress in patients with cancer is currently being debated in the British Journal of Cancer. Screening has been recommended, as elevated levels of distress have been consistently observed and clinicians tend to overlook the need of psychological support (Carlson et al, 2012; Carlson et al, 2013; National Comprehensive Cancer Network, 2013). On the other hand, it has been argued that screening should not be implemented, as the true benefit of screening and subsequent treatment of psychological distress is far from being definitively proven (Coyne, 2013). Recent findings on human resilience in the face of potentially traumatic events (PTEs) provide a new perspective on detecting and treating psychological distress in patients with cancer. Humans show strong resilience in the face of potentially traumatic events, such as cancer diagnosis and treatment (Bonanno et al, 2011). This observation leads us to propose two alternative approaches towards detecting and treating psychological distress in patients with cancer: ‘screening for psychological distress’ and ‘supporting resilience and case finding’.
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