OBRA CIVIL

Other factors that made a decision more complex, and more likely to benefit from multidisciplinary discussion, included situations where patient factors were likely to impact on the team’s ability to deliver treatment. This included elderly or ‘frail’

patients, and vulnerable patients.

Elderly or frail patients

Lower status contributions took on particular importance during discussion of patients described as ‘elderly’. In reality, these were often discussions about the physical frailty of a patient, because there did not seem to be a specific age at which the term elderly was consistently invoked. For example, in Haematology 2, the term elderly was ascribed to a 72 year old. In the Haematology 1 team, chemotherapy treatment was ruled out for an ‘elderly patient’, aged 87, as it was felt to be too much for them to cope with given their physical frailty. However, during the same meeting a decision was made to start a 97 year old patient on chemotherapy.

153 Regardless of these differences, the age or frailty of a patient was often a key

consideration in making a treatment decision:

It may be difficult because maybe the person is older or they have a comorbidity...So yes, ideal treatment would be x and I will try to facilitate…by saying “do you think they are fit enough for this?” Often we see that with the review of patients, so where they have had a response to treatment. We try to decide how much more treatment to give them. There is often a lot more input there from the nursing staff, you know how have they been coping, what do you think or we’ve had these problems... (Consultant Haematologist, Haematology 1, interview)

However, it was an area where there could be disagreement between professionals.

For example, in Haematology 2 a decision was made to follow recommended evidence based protocols by requesting a PET scan for an 81 year old patient [this is a type of scan used to diagnose and stage cancer]. This decision was challenged by a consultant haematologist in the team. He argued that even if the scan highlighted disease, they would not treat the patient with further chemotherapy given her age:

“to spend all this money!” (Consultant Haematologist, Haematology 2, observation field note). However, the patient’s lead consultant responded by saying they were following international guidelines “that are not ageist” and refused to back down (Haematology 2, observation field note).

In this example, there was no input from other professional groups within the team.

However, it is in these cases where decisions are not clear cut that there is perhaps greatest benefit to be gained from including input from lower status members of the team. Where there is a lack of certainty about a patient’s ability to cope with treatment, knowledge of the patient in question and their physical wellbeing could be instrumental to making an appropriate decision. This is particularly true where

154 an over-reliance on evidence based protocols could run the risk of over-treating or over-investigating. As one consultant dermatologist noted:

In this MDT like setting, I think you know protocol driven

medicine…sometimes it can be quite black and white. So patient has X, we need to do Y, whereas actually if you did nothing it would probably be fine. And a lot of the cases here I think there is a tendency to over-treat and over-investigate sometimes. (Consultant Dermatologist, Skin, interview)

This view was echoed by a CNS in Haematology 1, who highlighted the need for careful consideration to be given in these cases: “I do sometimes worry

about…where we draw the line” (CNS, Haematology 1, interview). An StR in the same team also described the need “to be a bit careful…with what you’re exposing elderly and delicate patients to” (Haematology StR, Haematology 1, interview). For these reasons, lower status input could be instrumental in the decision making process, whether the decision was to deliver intensive treatment or to provide only supportive care. This is illustrated in the example below from Skin, where the CNS played an instrumental role in shaping the decision for a 97 year old patient:

Consultant Medical Oncologist (MDT Lead): well first of all how fit is this lady?

Surgical StR: she is 97 CNS: she is 97

Consultant Medical Oncologist (MDT Lead): well let’s not be let’s not be ageist [laughing]

CNS: that’s pushing it a bit

Consultant Medical Oncologist (MDT Lead): how fit is she?...

CNS: she’s 97 she is her age…leave her alone (Skin, observation transcript)

155 Subsequent review of this patient’s medical records indicated that the patient had indeed been ‘left alone’, and had not undergone the tests and investigations that had initially been proposed by the Consultant Medical Oncologist.

Vulnerable patients

Lower status contributions were also important during discussions where concerns had been raised about a patient’s vulnerability. Vulnerability could relate to a patient’s ability to cope with news about their prognosis, or to mental health issues that impacted on their ability to understand what was happening. Vulnerability was also an issue where there were concerns about patients who did not have family or carers readily available to support them through treatment. In all of these cases, there were examples where the contribution of lower status members was

instrumental in helping the team to reach a decision. In one example, a consultant gynaecologist was visibly affected when the pathologist reported that a very young patient, who was described as not doing well psychologically, had metastatic disease. When given the news about the patient’s poor prognosis the consultant responded by hitting the table and exclaiming, “fuck you are joking” (Consultant Gynaecologist, Gynaecology, observation transcript). In this case, contributions from both the CNS and the clinical psychologist ensured that the appropriate psychosocial support would be in place for the patient at their next clinic appointment:

Psychologist: so can I just check when she’ll know [about the spread of her disease]

CNS: she’s coming back on the 4th…will you be around?

Psychologist: yeh perhaps. She’s your [patient] isn’t she [to CNS]?...Are you around on Tuesday [the 4^th]?

CNS1: yeh I think she’ll need it from what I can gather Psychologist: yeh I’m happy to be around

(Gynaecology, observation transcript)

156 Multidisciplinary discussion also occurred in a small number of cases where a

member of the team wanted to make others aware of a vulnerable patient. During one meeting of the Haematology 1 team, a young patient was described by a consultant clinical oncologist as being completely and utterly shell-shocked after being told he only had three to six months to live. The oncologist reported finding the patient staring at the ceiling with his mouth open after being told that they had exhausted all chemotherapy options. The CNS, consultant haematologists and the oncologist were all actively involved in this discussion, and it served to raise awareness amongst the team of the specific psychosocial needs of this patient.

In other cases (specific to the two Haematology teams), lower status contributions were also important when there was disagreement or uncertainty about whether a patient was able to cope with the treatment involved in a stem cell transplant. Due to the very intensive nature of this treatment, discussion often included reference to a patient’s social or psychological circumstances. This was particularly the case if a patient was deemed to be vulnerable. There were a number of examples where CNSs were able to contribute information that was used to help the team reach a final decision in these cases. In one discussion in Haematology 2, a consultant queried whether a patient with alcohol dependence would be able to comply with therapy: “is he able to do that?” (Consultant Haematologist 7, Haematology 2, observation transcript). It was the CNS who responded:

He messes around but he understands…I don’t think he drinks that excessively when he goes [to the pub from the ward] he does go but.

(CNS, Haematology 2, observation transcript)

These examples illustrate that in cases where a patient’s vulnerability was a concern, lower status contributions could be instrumental in helping the team to reach a decision. They were also important in ensuring that patients were provided with the support they needed following this.

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6.7 Chapter Summary

This chapter began by using status characteristics theory as a framework to explore the patterns of participation and influence in the decision making process. This illustrated that medical and surgical consultants were more likely to initiate participation, had more opportunities to participate, were evaluated more favourably, and had more influence than lower status members of the team. In contrast, some lower status groups reported being reluctant to contribute, and in a small number of cases their contributions were not taken on board or were ignored by higher status members of the team.

Potential explanations for these patterns of participation reflected the legal responsibilities of consultant doctors with a duty of care to their patients (Sidhom and Poulsen, 2006), as well as their extensive clinical training and expertise. In contrast, StRs - as doctors in training - did not necessarily have the knowledge or expertise to make clinical decisions in the MDT setting. In addition, for CNSs, if they had not met the patient being discussed they were unlikely to hold information that they could share with the MDT. These explanations suggested that lower rates of participation from lower status groups were not necessarily in and of themselves problematic, even if they had the potential to be in certain circumstances.

Building on this analysis, Theme II explored the effects of these patterns of participation and influence on efficiency and information sharing, and considered the circumstances in which multidisciplinary discussion took place. Reflecting the literature on functionalist perspectives of hierarchies, teams appeared to capitalise on the expertise of higher status individuals in order to make a considerable

number of decisions quickly and efficiently. Limiting discussion in this way to a subset of higher status members could minimise the amount of time spent on discussion that was unlikely to impact on the treatment plan. Using evidence based protocols to make these decisions was a way of ensuring consistency and promoting

158 equality of treatment for patients. This freed up time to spend on cases that were more challenging or complex.

However, in other cases, it was shown that medical and surgical expertise was not the only important source of information for decision making. Team members valued the MDT meeting as an opportunity to bring together a diverse range of professional groups. Nonetheless, multidisciplinary discussion which included the full spectrum of professionals was potentially challenging for MDTs to achieve. This was because of the finite period of time in the MDT meeting. This meant that opportunities to share certain types of information could impact on the time available for other contributions. This was compounded by the fact that there was some disagreement amongst MDT professionals about the appropriate balance between efficiency and more holistic multidisciplinary discussion in the MDT meeting context.

In spite of these different opinions, it was possible to identify a subset of cases where the knowledge held by lower status groups was incorporated into the decision making process. In all four teams this reflected the nature of the

relationship between lower status groups and patients. These relationships meant that CNSs and StRs were often more likely than other members of the MDT to hold patient centred information. Specifically, this included information about patient preferences and psychosocial factors.

Information about patient preferences was important because doctors were not always aware of patients’ views. Discussing patient preferences during the meeting could therefore enable the team to more fully consider the benefits and drawbacks of different treatment options. Information about psychosocial factors was

important because it enabled the team to consider whether the recommended treatment was appropriate given a specific patient’s context. It was argued that without this information there was a risk that poor decisions would be made.

159 Overall, however, multidisciplinary discussion, which involved lower status groups, was not seen to be necessary or desirable for every case. Instead, it occurred in certain circumstances. This included cases where patients had limited treatment options as a result of the extent of their disease or the fact that it had recurred. It also included cases where there were concerns about a patient’s ability to cope with treatment. This was more likely for patients who were elderly or frail, for patients deemed to be vulnerable in some way, as well as for haematology patients being considered for a transplant. In these cases the knowledge held by lower status members of the team could be instrumental in making sure that the clinical decision agreed by the MDT reflected the context of a specific patient’s

circumstances. Lower status contributions were also a way to counteract the risk of over-treating or over-investigating a patient if evidence based protocols were rigidly followed.

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Chapter 7. Factors that influence multidisciplinary