Skye T Dong1, Phyllis N Butow2, Meera Agar3, Melanie R Lovell4, Frances Boyle5, Martin Stockler6, Benjamin C Forster7, Allison Tong8. 1. School of Psychology, The University of Sydney, Sydney, New South Wales, Australia; Psycho-Oncology Co-operative Research Group (PoCoG), The University of Sydney, Sydney, New South Wales, Australia; Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia. Electronic address: skye.dong@sydney.edu.au. 2. School of Psychology, The University of Sydney, Sydney, New South Wales, Australia; Psycho-Oncology Co-operative Research Group (PoCoG), The University of Sydney, Sydney, New South Wales, Australia; Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia. 3. Department of Palliative Care, Braeside Hospital, Neringah Hospital and Greenwich Hospital, HammondCare Palliative & Supportive Care Service, Sydney, New South Wales, Australia; South West Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia; Discipline of Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia. 4. Medical School, The University of Sydney, Sydney, New South Wales, Australia; Department of Palliative Care, Braeside Hospital, Neringah Hospital and Greenwich Hospital, HammondCare Palliative & Supportive Care Service, Sydney, New South Wales, Australia. 5. Medical School, The University of Sydney, Sydney, New South Wales, Australia; Patricia Ritchie Centre for Cancer Care and Research, The Mater Hospital North Sydney, Sydney, New South Wales, Australia. 6. Medical School, The University of Sydney, Sydney, New South Wales, Australia; Department of Oncology, Concord Repatriation Hospital, Sydney, New South Wales, Australia. 7. Department of Palliative Care, Braeside Hospital, Neringah Hospital and Greenwich Hospital, HammondCare Palliative & Supportive Care Service, Sydney, New South Wales, Australia; Patricia Ritchie Centre for Cancer Care and Research, The Mater Hospital North Sydney, Sydney, New South Wales, Australia. 8. Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.
Abstract
CONTEXT: Managing symptom clusters or multiple concurrent symptoms in patients with advanced cancer remains a clinical challenge. The optimal processes constituting effective management of symptom clusters remain uncertain. OBJECTIVES: To describe the attitudes and strategies of clinicians in managing multiple co-occurring symptoms in patients with advanced cancer. METHODS: Semistructured interviews were conducted with 48 clinicians (palliative care physicians [n = 10], oncologists [n = 6], general practitioners [n = 6], nurses [n = 12], and allied health providers [n = 14]), purposively recruited from two acute hospitals, two palliative care centers, and four community general practices in Sydney, Australia. Transcripts were analyzed using thematic analysis and adapted grounded theory. RESULTS: Six themes were identified: uncertainty in decision making (inadequacy of scientific evidence, relying on experiential knowledge, and pressure to optimize care); attunement to patient and family (sensitivity to multiple cues, prioritizing individual preferences, addressing psychosocial and physical interactions, and opening Pandora's box); deciphering cause to guide intervention (disaggregating symptoms and interactions, flexibility in assessment, and curtailing investigative intrusiveness); balancing complexities in medical management (trading off side effects, minimizing mismatched goals, and urgency in resolving severe symptoms); fostering hope and empowerment (allaying fear of the unknown, encouraging meaning making, championing patient empowerment, and truth telling); and depending on multidisciplinary expertise (maximizing knowledge exchange, sharing management responsibility, contending with hierarchical tensions, and isolation and discontinuity of care). CONCLUSION: Management of symptom clusters, as both an art and a science, is currently fraught with uncertainty in decision making. Strengthening multidisciplinary collaboration, continuity of care, more pragmatic planning of clinical trials to address more than one symptom, and training in symptom cluster management are required.
CONTEXT: Managing symptom clusters or multiple concurrent symptoms in patients with advanced cancer remains a clinical challenge. The optimal processes constituting effective management of symptom clusters remain uncertain. OBJECTIVES: To describe the attitudes and strategies of clinicians in managing multiple co-occurring symptoms in patients with advanced cancer. METHODS: Semistructured interviews were conducted with 48 clinicians (palliative care physicians [n = 10], oncologists [n = 6], general practitioners [n = 6], nurses [n = 12], and allied health providers [n = 14]), purposively recruited from two acute hospitals, two palliative care centers, and four community general practices in Sydney, Australia. Transcripts were analyzed using thematic analysis and adapted grounded theory. RESULTS: Six themes were identified: uncertainty in decision making (inadequacy of scientific evidence, relying on experiential knowledge, and pressure to optimize care); attunement to patient and family (sensitivity to multiple cues, prioritizing individual preferences, addressing psychosocial and physical interactions, and opening Pandora's box); deciphering cause to guide intervention (disaggregating symptoms and interactions, flexibility in assessment, and curtailing investigative intrusiveness); balancing complexities in medical management (trading off side effects, minimizing mismatched goals, and urgency in resolving severe symptoms); fostering hope and empowerment (allaying fear of the unknown, encouraging meaning making, championing patient empowerment, and truth telling); and depending on multidisciplinary expertise (maximizing knowledge exchange, sharing management responsibility, contending with hierarchical tensions, and isolation and discontinuity of care). CONCLUSION: Management of symptom clusters, as both an art and a science, is currently fraught with uncertainty in decision making. Strengthening multidisciplinary collaboration, continuity of care, more pragmatic planning of clinical trials to address more than one symptom, and training in symptom cluster management are required.
Authors: Mitra Tewes; Teresa Rettler; Nathalie Wolf; Jörg Hense; Martin Schuler; Martin Teufel; Mingo Beckmann Journal: Support Care Cancer Date: 2018-05-05 Impact factor: 3.603