2.2.4 The role of patient centred information in MDT meetings Defining patient centred care
Patient centred care is underpinned by two key components. First, it relates to treatment decisions that reflect a patient’s preferences, as well as their physical and psychosocial needs (Ouwens et al., 2010). In this way it can be contrasted with disease centred care, which focuses primarily on the illness or disease rather than the individual experiencing it. The second component relates to the involvement of patients in decisions about their care (Ouwens et al., 2010). Given that patients did not attend the cancer MDT meetings I observed, the first component of patient centred care has most relevance for the purposes of this study. Although patients may have been involved in decisions about their care outside of the MDT meeting, my observation did not include the wider cancer care pathway. As a result, I define patient centredness in the context of the MDT meeting as decisions that took into account a patient’s physical, social and emotional needs and preferences.
41 The importance of patient centred information for MDT treatment plans
Patient centred information is important in the MDT context for a number of reasons. While survival rates for cancer in England are improving (House of Commons: Committee of Public Accounts, 2015), the impact of cancer, and treatment, can have lasting effects which are social and psychological, as well as physical (Ouwens et al., 2010, Macmillan Cancer Support, 2014, Macmillan Cancer Support, accessed 4.4.2014). In this context, making appropriate treatment decisions is arguably not “a matter of science alone” (Mulley et al., 2012) (p.1).
Policy makers, healthcare professionals and patients themselves therefore regard patient centred information as central to the decision making process (Barry and Edgman-Levitan, 2012, Lamb et al., 2014b).
The importance of treating each patient as an individual, and as a person with distinct treatment and support needs, is a key theme in current policy documents, ranging from the NHS Constitution, to cancer specific policy and practice guidelines (National Institute for Health and Clinical Excellence, 2003, Department of Health, 2013b, Independent Cancer Taskforce, 2015). A national survey of 2,054 MDT members also indicates that there is agreement amongst healthcare professionals about the importance of this information to the MDT decision making process. Over 90 per cent of respondents to this survey agreed that patient preferences,
demography, comorbidities, psychosocial and supportive issues should always be considered by the MDT (Taylor and Ramirez, 2009). In addition, focus groups with cancer patients suggest that information about physical and psychosocial needs is perceived as critical to making appropriate decisions in the MDT meeting (Lamb et al., 2014b). This does not negate the importance of biomedical information (e.g.
pathology), because patients themselves recognise that without this teams would be unable to make a decision (Lamb et al., 2014b). Nonetheless, there is broad agreement that it is important for clinicians to take patient centred information into consideration alongside the biomedical information necessary to diagnose and treat cancer.
42 One of the reasons so much emphasis is placed on the role of patient centred
information is that it can be fundamental to making decisions that reflect the needs and specific circumstances of each patient (Jalil et al., 2013). For example, if
decisions about treatment are based solely on a patient’s chronological age, without knowledge of their fitness for treatment, frailty, or existing comorbidities, there is a risk that patients will be under, or over, treated. Either outcome is
undesirable: while more intensive treatment can prolong survival, it can also impact significantly on quality of life due to the burden of side-effects (National Cancer Intelligence Network, 2015).
There may also be social circumstances that potentially impact on the treatment that patients are willing, or able, to accept. For example, a patient with cancer who has caring responsibilities may refuse treatment with a specific chemotherapy drug if the side effects will impact on their ability to continue providing care to a loved one. Alternatively, a patient who is afraid of hospitals may not attend scheduled treatment appointments if supportive psychosocial care is not provided alongside the cancer treatment. If treatment plans do not accommodate patient centred information of this nature when it is relevant therefore, it may not be possible to implement the decisions agreed by the MDT (Blazeby et al., 2006, Wood et al., 2008, Raine et al., 2014b).
Mechanisms for incorporating patient centred information into MDT treatment plans
In practice, patient centred decision making in the MDT meeting requires someone in the team to hold information about patients’ views, comorbidities, personal circumstances, and support needs. It also requires that this information is shared, and incorporated into the decision making process. As noted previously, the contribution of CNSs is seen as a key mechanism for integrating this type of information during multidisciplinary discussion (National Institute for Health and Clinical Excellence, 2003). This is because CNSs are responsible for assessing patients’ holistic needs and identifying high risk patients who are likely to need
43 ongoing monitoring and complex care plans (National Cancer Action Team, 2010b, Macmillan Cancer Support, 2014).
In addition, CNSs often spend longer periods of time with patients than other members of the MDT, for example during extended consultations or regular visits on inpatient wards (Sweeney and Tapper, 2006, Kelly and Masterman, 2011). In a series of focus groups, cancer patients themselves described the CNS as the “easiest person to talk to” in the MDT (Lamb et al., 2014b) (p. 4). The role of CNSs in
discussing and sharing information on psychosocial concerns, including social and emotional wellbeing is also well recognised by other professionals, including surgeons, radiologists and oncologists (Catt et al., 2005). As a result CNSs may be more likely to hold patient centred information, and may be better placed to
identify patients’ concerns than other members of the MDT (Amir et al., 2004, Lamb et al., 2013c).
Of course, CNSs are not the only members of the team with patient centred information. Consultant doctors may also be aware of patients’ comorbidities and preferences, or of psychosocial concerns (Lamb et al., 2013c). Junior doctors may also have spent time consulting patients explicitly either on the ward or in clinic and be able to act as their advocate in the MDT meeting (Sharma et al., 2009). The participation of CNSs in the MDT meeting is not therefore the only way to ensure that decision making is patient centred. Nonetheless, given the findings about lower rates of participation among CNSs, it is perhaps unsurprising that patient centred factors have also been shown to play a less central role than disease centred information in MDT meetings (Kidger et al., 2009, Taylor et al., 2012a, Shah et al., 2014).
Barriers to incorporating patient centred information into MDT treatment plans The literature suggests that there are a number of potential explanations for limited discussion of patient centred information in MDT meetings. First, it is possible that
44 this reflects a lack of time in the MDT meeting, which can create barriers to raising psychosocial or other patient centred information (Schofield et al., 2006).
Secondly, it may also be the case that at the point at which a patient is initially discussed, none of the members of the MDT have extensive knowledge of the patient (Raine et al., 2014a). Although it is regarded as best practice for at least one member of the team to have met the patient before an MDT discussion (Lamb et al., 2014b, Sarkar et al., 2014), in reality there are practical barriers to achieving this (Raine et al., 2014a). The pressure to diagnose and treat patients within waiting time targets means that many MDT discussions take place at a very early stage of a patient’s treatment pathway. In this context, patients may not yet know their diagnosis, or be in a position to articulate the factors that they think may impact on their treatment (Taylor et al., 2014). This situation is further exacerbated for MDTs that receive referrals for a specialist opinion from surrounding teams. In these cases, the receiving MDT is reliant on relevant information being included in the referral, which may not include patient centred information (Taylor et al., 2014).
While this is problematic if it impacts on the extent to which teams are able to make patient centred decisions, it is also possible that differences in the frequency with which patient centred information is raised in MDT meetings reflect
appropriate judgements by MDT professionals about when this type of information is most relevant to the decision (Raine et al., 2014b). It may be that patient centred factors are only brought into discussion in those cases where it is likely to influence a decision. If this is the case however, it raises important questions about the factors that trigger the sharing of this type of information, and the approaches used by MDT members to ensure the information is integrated into a treatment plan.