CENTRO DE TRANSFORMACIÓN MINIBLOK – 24

As illustrated in the previous section, although lower status individuals were not the only members of the team to hold patient centred information, StRs and CNSs often had more regular and frequent contact with patients than others. As a result, they were more likely to have detailed knowledge of patients being discussed in the MDT meeting. Given the lower rates of participation and influence of these groups

described previously, this had potential implications for the nature of discussions in the MDT.

To consider this further, the next section goes on to explore the role of patient centred information in MDT meetings, focusing specifically on information about patients’ treatment preferences, and their psychosocial wellbeing.

Information about patient preferences

The most common patient preferences that were shared in the four teams related to whether or not a patient wanted any further tests or treatment, as well as specific preferences for one modality of treatment over another (for example a

144 preference for surgery instead of radiotherapy). When shared, this information could have an important influence on decisions made by the MDT:

Sometimes it’s quite apparent the patient has stated that they don’t want treatment X or whatever. They don’t want surgery or they don’t want chemotherapy. And that obviously strongly influences what the MDM is there to decide. So yes the short answer is if a patient

preference is known beforehand, or we have some idea, then that is useful information. (Consultant Medical Oncologist, Skin, interview)

However, overall, information about patients’ treatment preferences was rarely mentioned in any of the four MDTs. The frequency ranged from between 5 to 8 per cent of the 2,356 cases presented across the teams during the observation period (Table 14).

Table 14: Discussions where patient preferences and psychosocial factors were mentioned in the MDT meeting

Team No. cases

* Includes cases where the same patient was discussed at multiple meetings

** There was very little overlap between mention of patient preferences and psychosocial factors – both were mentioned in the same discussion in less than 2% of cases in all four teams (ranging from 8 cases in Skin to 15 cases in Gynaecology)

***Variables included mention of a patient’s: caring role; disability; English proficiency; marital status; relationship with service; whether in residential care; difficult social or economic circumstances; social support; and a free text variable on social support

In light of the findings that CNSs and StRs were most likely to hold information about patient preferences, but least likely to participate, these figures are perhaps unsurprising. It is likely therefore that to some extent the figures reflect the effects

145 of the power and prestige order, which prioritised contributions from higher status medical and surgical consultants.

However, the influence of status is not the only potential explanation for the fact that preferences were only mentioned in around one in twenty cases. First,

although information about patient preferences was most likely to be presented by a CNS, lower status members of the team were not necessarily the only individuals in the group who had access to this information. There were occasions in all four teams where information about a patient’s preferences was raised by a medical or surgical consultant who also knew the patient:

[Consultant Haematologist] certainly mentions her patients’ wishes when she knows them. And I would hope we [the CNSs] would if we knew them, and they would affect a treatment decision. (CNS, Haematology 2, interview)

In addition, patients with a new diagnosis of cancer formed the largest group of cases in all four MDTs. This meant that in practice patient preferences were not always known at the time of the weekly meeting. In fact, there were occasions when no one in the team had met a patient being discussed. In these cases there was little scope for patient centred information to be shared, regardless of the status hierarchy:

They’re [patient preferences] not really discussed that often. So sometimes that’s perhaps because…a lot of the reviews are before the patient’s known well or has been met, so perhaps the patient’s views are not known. (CNS, Haematology 2, interview)

Furthermore, there were also a range of views about the extent to which patient preferences should influence decision making in the MDT meeting. These

146 differences were apparent both within teams and professional groups, as well as amongst patients. This is illustrated in an example from the observation data from Haematology 2. During discussion of a patient, the team were informed by the StR presenting the case that the patient had refused a bone marrow test and did not want any further investigations or treatment. One consultant haematologist emphasised that the patient’s wishes should be respected. However, another consultant haematologist argued that the team had a responsibility to make the best clinical decision. In this case he proposed that this would be to recommend further assessment and treatment, in spite of the patient’s stated wishes. It was this latter view that was documented in the MDT record, although the MDT Lead

suggested that the issue was discussed further outside of the meeting.

The view that patient preferences should be considered outside of the meeting, was also expressed by both patients and professionals. During the interviews, a range of professionals across all four teams articulated the view that the MDT meeting was not the final decision making arena. Instead, the patient was seen as the individual responsible for making the final decision about treatment outside of the meeting, particularly if there was more than one option. Again, this reflected the fact that in some cases, teams were discussing management options before they had had conversations with the patient about possible treatment. At this stage, patients’

views and preferences were not necessarily known by anyone in the team. It was argued that in these cases discussions involving patient centred factors should happen after the MDT meeting instead:

I think…patient input in terms of what they would like, comes up subsequent to the MDT and is between that person and the clinician seeing them…and actually I am not sure that is a decision for the MDT to be involved in. (Consultant Haematologist, Haematology 1, interview)

147 However, as noted previously, the MDT meeting was often the only point in time at which all professional groups came together. Given that certain members of the team are more likely to hold patient centred information than others, if this is not shared during the meeting there is a risk that it will not be shared at all. This is further complicated by the fact that the extent to which it is desirable to discuss patient centred factors in the MDT meeting is in itself a patient preference. Some patients themselves emphasised the importance of making the best clinical

decision, almost irrespective of their preferences. This was particularly the case for patients who had been very sick:

When she [Consultant Haematologist] says something to us we just say to her well you’re the boss…and she laughs but that’s how we

feel…there’s no point in going and seeking an expert opinion and then just going and turning your back on it…we accept their advice so therefore really we don’t need to say anything [about our

preferences]…because we, perhaps it’s a bit glib to say we follow blindly but we sort of do. (Patient 161212, Haematology 1, interview)

However, other patients saw information about patient preferences as an essential part of decision making:

What’s the saying, a happy patient is a healthy patient…you have to take their preferences into consideration because, you know, a lot of it obviously is your mental outlook and if you’re…more comfortable with what’s going on, you know, chances are you’ll do better right, and so you definitely have to try…I mean, it has to be part of the equation there’s no doubt about that. (Patient 111308, Haematology 2, interview)

Overall then, information about patient preferences was shared relatively infrequently, reflecting the lower rates of participation amongst CNSs and StRs

148 across the four teams. However, although consideration of patient preferences was sometimes seen as a way to make the best decision in the context of a specific patient, this was not necessarily seen as desirable, or feasible, in every case presented in the MDT meeting. This was because patient preferences were not always known at the time of the initial discussion, and because some patients and professionals wanted the MDT to focus on making the best clinical decision. In addition, there were potentially other points outside of the MDT meeting where this information could be discussed.

Information about psychosocial factors

Similarly, psychosocial information about a patient’s social circumstances or wellbeing, information that gave a sense of the patient as a person, was also relatively rarely mentioned in any of the MDT meetings. The frequency of this ranged from between 4 to 12 per cent of the 2,356 cases presented across the teams during the observation period (Table 14, p. 144). As with information about patient preferences, this information was not always known at the time of an MDT discussion. Again, when it was known, it tended to be shared by a CNS.

The quantitative data show that psychosocial information was least likely to be mentioned in the Skin team (in only 4 per cent of cases presented). However, this was not raised as an issue of concern in the professional interviews, either by higher or lower status individuals. Although the MDT Lead and the CNS acknowledged the limited time to discuss psychosocial factors, they also argued that they were taken into account when this was necessary:

My personal feeling is that I think we don’t have a time limit on a specific case. If a case is complicated and needs a lot of discussion, we take that time. So I don’t actually think much is missing from the MDM. If

anything probably, we already discuss things in sometimes in too great a detail. (Consultant Medical Oncologist, Skin, interview)

149 In contrast, the frequency of psychosocial factors being mentioned in the MDT meeting (in 10 per cent of cases) was more of a concern amongst some of the interviewees in the Gynaecology team. In this team, a range of professionals (including a CNS, an oncology StR, a consultant gynaecologist and a psychologist) expressed the view that the meeting no longer gave a sense of the patient as a whole. It was argued that this made it more difficult for the team to make decisions centred around individual patients, and in the words of one consultant

gynaecologist, risked the team making poor decisions:

Because they’re not sitting with a patient really really really battling to see whether what would be the best treatment in this particular, in this particular patient’s context, sometimes decisions are bad actually.

(Consultant Gynaecologist 5, Gynaecology, interview)

The consultant gynaecologist caveated this with the conclusion that bad decisions were relatively rare. It is also important to acknowledge that the MDT meeting was not the only forum for discussing patients holistically “I think there’s other places to discuss these things as well” (CNS, Skin, interview). Nonetheless, it again highlights the different views about the extent to which this type of information should be shared in the MDT meeting.