Involving family members in cancer care: focus group considerations of patients and oncological providers

Healthcare provider assessments of caregiver communication behaviors during gynecologic Cancer treatment appointments

Objective

Caregivers often accompany patients to cancer-related medical appointments. Limited research exists on healthcare providers' (HCPs) evaluation of how caregiver communication influences interactions between healthcare providers and patients, particularly during gynecologic treatment visits. HCPs may perceive caregiver communication as helpful or challenging, and these triadic interactions may influence patient outcomes.

Methods

Interviews with ten cancer specialist HCPs (medical assistants/technicians, nurse practitioners/registered nurses, oncologists) addressed experiences interacting with patients and caregivers.

Results

Analyses revealed two themes concerning helpful communication: caregivers managing information and managing patient emotions. Three challenging themes include caregiver communication unsettling healthcare interactions, caregiver presence limiting patient communication, and caregiver engagement challenges.

Conclusion

HCPs evaluate caregiver communication as helpful and challenging. Findings suggest benefits of communication training for gynecologic cancer patients such as requesting privacy when interacting with HCPs, for caregivers to promote awareness of effects of their behavior, and for HCPs to help manage triadic interactions while supporting patient needs.

Innovation

HCP assessment of caregiver communication during gynecologic treatment visits offers unique insights regarding helpful and challenging behaviors contributing to implications for patient care and well-being. Applications may extend to other triadic interactions and cancer settings.

Measuring Team Functioning During the COVID-19 Pandemic: Perspectives of Cancer Care Team Members

Background

In a public health crisis such as COVID-19, cancer teams face significant challenges including acute work disruptions, rapid shifts in clinical practice, and burnout. Within this context, it is crucial to explore team functioning from the perspectives of multiple stakeholders.

Objective

This quantitative pilot study aimed to 1) measure perceptions of multi-stakeholders on key indicators of team functioning (Team Effectiveness, TE, and Team Relational Coordination, TRC) during COVID-19 and its transition, and 2) document whether patient perceptions of TE/TRC are significantly associated with their cancer care experiences.

Methods

A descriptive design with repeated measures was used. Through convenience sampling, participants were recruited from two outpatient cancer clinics at a large university-affiliated hospital, in Montréal, Qc, Canada. Sixty-six participants (ie, 13 healthcare professionals, 40 patients, 6 informal caregivers, and 7 volunteers) completed e-measures at T1 (years 2021-2022) and n = 44 at T2 (year 2023).

Results

At T1, participants reported high perceptions of Team Effectiveness (scale 1 to 6) M = 4.47; SD = 0.7 (Mdn = 4.54; IQR: 4.06-5) and Relational Coordination (scale 1 to 5) M = 3.77; SD = 0.77 (Mdn = 3.81; IQR: 3.12-4.38) with no significant differences in perceptions across the four groups. At T2, no significant changes in TE/TRC perceptions were found. At both time points, patient perceptions of TE/TRC were significantly correlated with positive cancer care experiences (Spearman rank correlation rs ranging from 0.69 and 0.83; p < 0.01).

Conclusion

To our knowledge, this is the first study documenting perceptions of cancer team functioning amidst the pandemic as reported by multiple stakeholders. Significant relationships between patient perceptions of TE/TRC and their cancer care experiences underscore the importance of including patients' views in team functioning processes. Future work should rely on larger sample sizes to further explore key elements of optimal team functioning.

Dilemmas and Strategy When Companion Participation During Appointments Differs from Patient and Companion Expectations

Cancer patients often attend medical interactions with at least one companion. The degree to which companions participate varies, ranging from passive observer to active advocate. However, the structure of the medical interaction often promotes dyadic rather than triadic communication, creating ambiguity about to the degree to which companions can and should participate. Participants (N = 34, 16 dyads) included gynecologic cancer patients who were undergoing chemotherapy treatment (n = 18) and their companions (n = 16); all participants were separately interviewed. Interviews included discussion of dyadic communication patterns within medical interactions. The normative rhetorical theory (Goldsmith, 2019) was applied as a guiding framework. Patients discussed the dilemma they experience when companions are expected but absent. Patients and companions provided positive reports of companion communication when behavior aligned with expectations. Alternatively, patients and companions experience dilemmas when companions participate more than or differently from how patients and/or companions had expected. Companions provided one strategy for managing the dilemma of how to participate in medical interactions. Implications and limitations are discussed.

Physicians' perspectives on family caregivers' roles in elderly cancer patients' therapies: a qualitative, interview-based study

PURPOSE

Clinical communication and facilitating informed and sound medical decisions become challenging as patients age and suffer from age-associated impairments. Family caregivers are perceived as essential actors in addressing these challenges. Here, we explore physicians' perspectives on family caregivers' roles and their involvement in consultations and therapy decision-making situations of elderly cancer patients.

METHODS

We examined 38 semi-structured interviews with physicians from different specialities (oncologists, non-oncology specialists, and general practitioners) in Germany who treated elderly cancer patients. Data were analyzed using reflexive thematic analysis.

RESULTS

We identified five general and distinct perspectives on the involvement of family caregivers in the therapy process. Family caregivers are seen as (1) translators of medical information; (2) providers of support for the patient; (3) providers of information about the patient; (4) stakeholders with relevant points of view regarding the treatment decision; or (5) individuals who have a disruptive influence on the consultation. The interviewed physicians rarely involved family caregivers closely in consultations.

CONCLUSIONS

Although physicians frequently attribute supportive roles to family caregivers, they rarely include them in consultations. Previous studies have found that a triadic setting is often better suited to agreeing upon a patient-centered and needs-based treatment decision for older cancer patients. We infer that physicians too rarely recognize the potential importance of family caregivers. Educators should further integrate family caregiver involvement and its implications in general medical education and professional training.

Partner presence in clinical conversations about sexual health: Breast cancer survivors', partners', and providers' perspectives of triadic interactions

PURPOSE

Breast cancer survivors' (BCSs') sexual health (SH) clinical conversations are rarely studied from a dyadic perspective let alone from a triadic perspective. Using a triadic approach, we evaluated BCSs' comfort discussing SH with partners present and identified factors that can contribute to their comfort level.

DESIGN

Qualitative approach using in-depth interviews.

PARTICIPANTS

93 BCSs, partners, and providers involved in BCS care.

METHODS

In-depth interviews with BCSs, partners, and providers explored triadic perspectives to understand factors informing BCSs' comfort level. Thematic analysis was used to analyze data.

FINDINGS

Four themes characterize potential benefits of partner presence: 1) partner facilitates information exchange, 2) partner realizes BCS's SH concerns are "a real thing," 3) partner better understands SH challenges, and 4) partner presence encourages relational communication about SH. Five themes illustrate potential complications of partner presence: 1) partner feels/becomes embarrassed, 2) partner is/becomes defensive, 3) partner presence constrains BCS's agency in clinical conversations, 4) partner presence threatens partner's view of BCS as a sexual being, and 5) partner presence increases partner burden.

IMPLICATIONS FOR PSYCHOSOCIAL ONCOLOGY

Providers should (1) initiate conversations about BCS comfort with partner presence, (2) be aware of the interaction between BCS primary and secondary goals, (3) consider how BCS/partner goal conflicts obstruct BCS agency and sexual/relational health, and (4) offer opportunities to clarify goals and expectations, and coordinate therapeutic options.

The role of caregivers in the clinical pathway of patients newly diagnosed with breast and prostate cancer: A study protocol

BACKGROUND

Caregivers may play a fundamental role in the clinical pathway of cancer patients. They provide emotional, informational, and functional support as well as practical assistance, and they might help mediate the interaction and communication with the oncologists when care options are discussed, or decisions are made. Little is known about the impact of dyadic dynamics on patient-doctor communication, patient's satisfaction, or adherence to the therapies. This study protocol aims to evaluate the efficacy of a psychological support intervention on patients-caregivers relationship and their alignment in the treatment decision-making (TDM) process and estimate related improvement in patient' compliance/adherence to treatments.

METHODS

A total of 102 patients-caregivers' dyads will be involved, among breast and prostate cancer patients. The study entails a pre- post- evaluation through psychological questionnaires, with a randomization of participants in two conditions, the experimental one in which subjects participate in a psychological support consultation, and the control one, where dyads do not receive any intervention. A follow up after 6 months from the enrollment is planned.

DISCUSSION

A positive impact of the psychological support intervention on patients' anxiety, depression, distress, and perceived social support is expected. Such improvements can directly affect patients' satisfaction and adherence to treatments. Data gathered from this study may inform health care providers, policy makers, and public health managers about the importance of caregiver's involvement in the cancer care pathway, and the best way to manage it. A further impact is to develop a specific intervention protocol to support caregivers' involvement in cancer care pathway, improve patient's wellbeing, the interaction with physicians and the compliance with the cancer treatment.

"We need to bring them out from the shadows:" A qualitative study of safety net physician leaders' perspectives on caregivers

OBJECTIVE

To explore physician leaders' perspectives on processes and priorities for engaging with caregivers in their clinical practices as well as within their safety net health systems.

METHODS

We conducted in-depth semi-structured interviews with primary care physicians in care management leadership at three California safety net health systems. Interviews explored physicians' experiences managing medically and socially complex patients with caregivers. Using thematic analysis, two qualitative researchers independently analyzed interview transcripts and established consensus with the broader research team through iterative input to derive major themes.

RESULTS

Fifteen physicians completed interviews. Nine participants were women, 8 were White and 10 reported Spanish language proficiency. Participant interviews generated six major themes: challenges uncovering caregiver identities, recognizing variation in caregivers' roles, adapting visit communication strategies to include caregivers, engaging caregivers in patient care, and caring for the caregiver.

CONCLUSIONS

Engaging caregivers is challenging given the limited recognition of caregiver involvement in patient care by health systems. Adapting visit communication to include caregivers requires bridging language and literacy barriers.

PRACTICE IMPLICATIONS

Developing mechanisms to enable the consistent identification of patients' caregivers, facilitate ongoing communication with caregivers, and extend support for them could improve outcomes for vulnerable patients and their families.

Improving breast cancer nurses' management of challenging situations involving family carers: Pilot evaluation of a brief targeted online education module (TRIO-Conflict)

OBJECTIVE

Given the stressful and emotional nature of cancer, challenging interactions between nurses, patients, and family frequently occur. Nurses are rarely equipped with strategies to avoid or de-escalate stressful situations with carers, which can include displays of conflict, anger, or dominance. A brief online education module (TRIO-Conflict) was developed to provide nurses with management strategies to use in situations of conflict. This study aimed to assess the feasibility, acceptability, and potential efficacy of TRIO-Conflict.

METHODS

Nurses were recruited through an Australian breast cancer organisation (McGrath Foundation). Participants completed pre/post module measures of attitudes towards carers, confidence in their skills to effectively navigate challenging interactions with carers, and applied knowledge of management strategies. Data were analysed using Wilcoxon signed-rank tests. Qualitative feedback was analysed using content analysis.

RESULTS

52 nurses completed pre-/post- measures, with 4 semi-structured interviews conducted. Significant improvements in attitudes towards carers (p = .010) and confidence in one's own ability to manage challenging interactions with carers (p < .001) were found, but not knowledge of strategies. Most nurses found TRIO-Conflict very/extremely helpful (87%) and were satisfied with content (94%) and usability (93%).

CONCLUSION

TRIO-Conflict utilised evidence-based learning techniques (provision of example phrases, video vignettes, reflective exercises) to improve nurses attitudes and confidence.

PRACTICE IMPLICATIONS

TRIO-Conflict is a brief, targeted, clinically relevant, and easily accessible online training programme which could be widely disseminated to oncology nurses.

Development and evaluation of novel tool to assess communication skills in adult triadic interviews

OBJECTIVE

Develop and evaluate the reliability and validity of a novel assessment tool for triadic communication.

METHODS

We developed the tool using published opinions of patients and companions regarding effective communication, and used it in a four-station Objective Standardized Clinical Examination (OSCE) with 140 medical students, including one triadic interview station. We conducted multitrait-multimethod (MTMM) and generalizability (G) analyses to assess its performance.

RESULTS

MTMM analyses demonstrated the validity of the instrument in assessing two separate communication traits (with patient and companion), as showed by the high covariation of both traits based on patient and companion's ratings (average r = 0.78) compared to the inter-traits covariation within (average r = 0.50) and across raters (average r = 0.45). G analyses showed that the communication assessment of the single triadic station functioned similar to two independent stations, revealing the novel tool's ability to reliably measure medical students' ability to communicate with patient and companion.

CONCLUSION

Triadic communication skills with patient and companion can be individually assessed within a single OSCE station using this novel tool.

PRACTICE IMPLICATIONS

This tool fills a gap in communication assessments, allowing for reliable evaluation of triadic communication.

In Limbo: Seven Families' Experiences of Encounter with Cancer Care in Norway

INTRODUCTION

Like many other countries, Norway has seen a shift from inpatient to outpatient cancer care, with pathways aimed at improving the integration and coordination of health services. This study explores the perspectives of seven patients and their family members in light of this change. We focus on one particular phase of the pathway: the first encounter. Our interviews were set in the period from referral until the start of treatment.

METHODS

Nineteen individual in-depth interviews were conducted in seven families. Seven patients with cancer and 12 family members were interviewed.

RESULTS

Three categories of experiences stood out in the empirical material: 'Being in between different health professionals', 'Overwhelmed by written and oral information' and 'Lack of involvement'.

CONCLUSION

This study provides insight into families' experiences with cancer care from referral until the start of treatment. Our findings indicate that families often experience cancer care as fragmented and confusing. Although evaluations have shown that the introduction of cancer pathways seems to have a positive effect on waiting times and standardization of examinations across hospitals and regions, there is still potential for improvement in coordination between services, family involvement, and emotional and practical support. We argue that our findings highlight the tension between two ideals of professional care: standardization and patient-centredness. The study illustrates shortcomings in translating the ideal of patient-centredness into professional practice.

eTRIO trial: study protocol of a randomised controlled trial of online education modules to facilitate effective family caregiver involvement in oncology

OBJECTIVE

Informal family caregivers play a crucial role in cancer care. Effective caregiver involvement in cancer care can improve both patient and caregiver outcomes. Despite this, interventions improving the caregiver involvement are sparse. This protocol describes a randomised controlled trial evaluating the combined effectiveness of novel online caregiver communication education modules for: (1) oncology clinicians (eTRIO) and (2) patients with cancer and caregivers (eTRIO-pc).

METHODS AND ANALYSIS

Thirty medical/radiation/surgical oncology or haematology doctors and nurses will be randomly allocated to either intervention (eTRIO) or control (an Australian State Government Health website on caregivers) education conditions. Following completion of education, each clinician will recruit nine patient-caregiver pairs, who will be allocated to the same condition as their recruiting clinician. Eligibility includes any new adult patient diagnosed with any type/stage cancer attending consultations with a caregiver. Approximately 270 patient-caregiver pairs will be recruited. The primary outcome is caregiver self-efficacy in triadic (clinician-patient-caregiver) communication. Patient and clinician self-efficacy in triadic communication are secondary outcomes. Additional secondary outcomes for clinicians include preferences for caregiver involvement, perceived module usability/acceptability, analysis of module use, satisfaction with the module, knowledge of strategies and feedback interviews. Secondary outcomes for caregivers and patients include preferences for caregiver involvement, satisfaction with clinician communication, distress, quality of life, healthcare expenditure, perceived module usability/acceptability and analysis of module use. A subset of patients and caregivers will complete feedback interviews. Secondary outcomes for caregivers include preparedness for caregiving, patient-caregiver communication and caring experience. Assessments will be conducted at baseline, and 1 week, 12 weeks and 26 weeks post-intervention.

ETHICS AND DISSEMINATION

Ethical approval has been received by the Sydney Local Health District Human Research Ethics Committee (REGIS project ID number: 2019/PID09787), with site-specific approval from each recruitment site. Protocol V.7 (dated 1 September 2020) is currently approved and reported in this manuscript. Findings will be disseminated via presentations and peer-reviewed publications. Engagement with clinicians, media, government, consumers and peak cancer groups will facilitate widespread dissemination and long-term availability of the educational modules.

TRIAL REGISTRATION NUMBER

ACTRN12619001507178.

Integrating Family Caregivers of People With Alzheimer's Disease and Dementias into Clinical Appointments: Identifying Potential Best Practices

Family caregiver engagement in clinical encounters can promote relationship-centered care and optimize outcomes for people with Alzheimer's disease and related dementias (ADRD). Little is known, however, about effective ways for health care providers to engage family caregivers in clinical appointments to provide the highest quality care. We describe what caregivers of people with ADRD and people with mild cognitive impairment (MCI) consider potential best practices for engaging caregivers as partners in clinical appointments. Seven online focus groups were convened. Three groups included spousal caregivers (n = 42), three included non-spousal caregivers (n = 36), and one included people with MCI (n = 15). Seven potential best practices were identified, including the following: "acknowledge caregivers' role and assess unmet needs and capacity to care" and "communicate directly with person with ADRD yet provide opportunities for caregivers to have separate interactions with providers." Participants outlined concrete steps for providers and health care systems to improve care delivery quality for people with ADRD.

"Non-palliative care" - a qualitative study of older cancer patients' and their family members' experiences with the health care system

Background

Among all cancer patients in the palliative phase, ¾ have reached the age of 65. An aging population will increase the number of people afflicted with cancer, and create challenges for patients, family members and health services. Nevertheless, limited research has focused explicitly on the experiences and needs of older cancer patients in the palliative phase and their families. Therefore, the aim of this study is to explore what older home dwelling cancer patients in the palliative phase and their close family members, as individuals and as a family, experience as important and difficult when facing the health services.

Methods

We used a qualitative descriptive design. Data was collected through family group interviews with 26 families. Each interview consisted of an older home dwelling cancer patient and one to four family members with different relationships to the patient (e.g. spouse, adult children and/or children-in-law). Data was analysed by qualitative content analysis.

Results

The main theme is “Non-palliative care” – health care services in the palliative phase not tailored to family needs. Three themes are revealed: 1) exhausting cancer follow-up, 2) a cry for family involvement, and 3) fragmented care.

Conclusion

The health services seem poorly organised for meeting the demands of palliative care for older home dwelling cancer patients in the palliative phase and their family members. Close family members would like to contribute but health services lack systems for involving them in the follow-up of the patient.

A Qualitative Exploration of Clinician Views and Experiences of Treatment Decision-Making in Bipolar II Disorder

This study qualitatively explored clinicians' views and experiences of treatment decision-making in BPII. Semi-structured interviews were conducted with 20 practising clinicians (n = 10 clinical psychologists, n = 6 GPs, n = 4 psychiatrists) with experience in treating adult outpatients with BPII. Interviews were audiotaped, transcribed verbatim and thematically analysed using framework methods. Professional experience, and preferences for patient involvement in decision-making were also assessed. Qualitative analyses yielded four inter-related themes: (1) (non-)acceptance of diagnosis and treatment; (2) types of decisions; (3) treatment uncertainty and balancing act; and (4) decision-making in consultations. Clinician preferences for treatment, professional experience, and self-reported preferences for patient/family involvement seemed to influence decision-making. This study is the first to explore clinician views and experiences of treatment decision-making in BPII. Findings demonstrate how clinician-related factors may shape treatment decision-making, and suggest potential problems such as patient perceptions of lower-than-preferred involvement.

Crossing the perspectives of patients, families, and physicians on cancer treatment: A qualitative study

Purpose

Patients, family members, and physicians participate in cancer care, but their perspectives about what is helpful during cancer treatment have rarely been compared. The aim of this study was to compare these three perspectives.

Methods

Multicenter qualitative study (with previously published protocol) based on 90 semi-structured interviews. Participants (purposively selected until data saturation) came from three different subsamples: (i) patients with cancer (n=30), (ii) their relatives (n=30), and (iii) their referring physicians (n=10, interviewed more than once).

Results

Our analysis found 3 main axes (perceived positive effects of cancer treatment, perceived negative effects of cancer treatment, doctor-physician relationship), each composed of 2 main themes. The findings showed that patients, families, and physicians shared the long-term objective of increasing survival (while reducing side effects). However, patients and relatives also pointed out the importance of living with cancer each day and thus of factors helping them to live as well as possible in daily life. The physicians difficulty in coping with patients suffering may limit their access to elements that can improve patients capacity to live as well as possible.

Conclusions

During cancer treatment (and not only at the end of life), attention should be given to enhancing the capacity of patients to live as well as possible (not only as long as possible) to meet the goals of patient-centered care and satisfy this important need of patients and families.

Distributed Cognition in Cancer Treatment Decision Making: An Application of the DECIDE Decision-Making Styles Typology

Distributed cognition occurs when cognitive and affective schemas are shared between two or more people during interpersonal discussion. Although extant research focuses on distributed cognition in decision making between health care providers and patients, studies show that caregivers are also highly influential in the treatment decisions of patients. However, there are little empirical data describing how and when families exert influence. The current article addresses this gap by examining decisional support in the context of cancer randomized clinical trial (RCT) decision making. Data are drawn from in-depth interviews with rural, Appalachian cancer patients ( N = 46). Analysis of transcript data yielded empirical support for four distinct models of health decision making. The implications of these findings for developing interventions to improve the quality of treatment decision making and overall well-being are discussed.

Is "Active Surveillance" an Acceptable Alternative?: A Qualitative Study of Couples' Decision Making about Early-Stage, Localized Prostate Cancer

The objective of our study was to describe decision making by men and their partners regarding active surveillance (AS) or treatment for early-stage, localized prostate cancer. Fifteen couples were recruited from a cancer center multispecialty clinic, which gave full information about all options, including AS. Data were collected via individual, semi-structured telephone interviews. Most patients were white, non-Hispanic, had private insurance, had completed at least some college, and were aged 49-72 years. Ten chose AS. All partners were female, and couples reported strong marital satisfaction and cohesion. All couples described similar sequences of a highly emotional initial reaction and desire to be rid of the cancer, information seeking, and decision making. The choice of AS was built on a nuanced evaluation of the man's condition in which the couple differentiated prostate cancer from other cancers and early stage from later stages, wanted to avoid/delay side effects, and trusted the AS protocol to identify negative changes in time for successful treatment. Treated couples continued to want immediate treatment to remove the cancer. We concluded that having a partner's support for AS may help a man feel more comfortable with choosing and adhering to AS. Using decision aids that address both a man's and his partner's concerns regarding AS may increase its acceptability. Our research shows that some patients want to and do involve their partners in the decision-making process. Ethical issues are related to the tension between desire for partner involvement and the importance of the patient as autonomous decision-maker. The extended period of decision making, particularly for AS, is also an ethical issue that requires additional support for patients and couples in the making of fully informed choices that includes AS.

Patient-centered care in lung cancer: exploring the next milestones

In this editorial, the authors comment on a recently published review paper by Molassiotis et al. on the developments made over the past 40 years in supportive care for patients with lung cancer. During this period, a paradigm shift promoting patient-centered care (PCC) has led to an important change in the approach of supportive cancer care, from a purely disease-centered approach, measuring survival-related outcomes, to recognizing the importance of quality of life outcomes as well. This change of understanding in supportive and palliative care for patients with lung cancer can be further advanced through the understanding that there is a need to address bio-psycho-spiritual concerns and health belief models, within the context of the family socio-cultural environment, for both patients and their caregivers. There is also a need to address the psycho-spiritual effects of cancer on those health care professionals treating patients with lung cancer, in order to reduce compassion fatigue and increase resilience. Future directions for supportive care for patients with lung cancer may include the development of a patient-tailored treatment approach, assisted by the integration of a multidisciplinary team of health care providers and evidence-based complementary medicine practices, within conventional supportive care practice.

Communicative characteristics of interactions between surgeons and Chinese women with breast cancer in oncology consultation: a conversation analysis

BACKGROUND

While previous studies have analysed features of interaction in cancer consultations using observational coding frames, relatively little attention is being given to how actual interactions are sequentially organized and achieved by participants in the course of talk-in-interaction. Research into the interactional practices in consultations, which involves Chinese patients, is largely absent.

OBJECTIVE

To provide insight into the talk-in-interaction in surgical-oncology consultations in the context of a Chinese medical setting.

METHODS

Thirty-one consultations involving 31 patients with breast cancer and eight surgeons were videotaped. The recordings were transcribed verbatim and analysed using conversation analysis.

RESULTS

The manner in which surgeons delivered the diagnostic results was fairly similar across all the consultations. Most surgeons gave the diagnosis in a very straightforward and abrupt manner at the outset of the consultation with no mitigation. While patients in our study conformed to the traditional information giving and receiving roles, how information was presented by surgeons shaped the subsequent sequential organization of surgeon-patient interaction and turn-taking patterns. More importantly, there was a tendency by the surgeons to move from issues of psychosocial nature to clinical matters regardless of the topics taken up in the specific encounter.

CONCLUSIONS

This study demonstrated the potential of conversation analysis as a context-sensitive method that enabled researchers to gain a more thorough understanding of dynamics of interaction in cancer consultations, thereby informing training interventions for surgeons. Our findings underscore the importance of discursive practices in shaping and encouraging (or discouraging) patient participation in oncology consultation.

Depression of Family Caregivers Is Associated with Disagreements on Life-Sustaining Preferences for Treating Patients with Dementia

Background

Family caregivers may not agree with patients with dementia regarding attitudes toward end-of-life preferences, and the effects of this type of disagreement are not well understood. This study sought to identify such a disagreement and its predictors.

Methods

A cross-sectional sample of 84 family caregivers and patients with dementia was recruited from memory clinics. We used the Mini-Mental State Examination, Neuropsychiatric Inventory, Clinical Dementia Rating, and Katz index of independence in activities of daily living to assess patient symptoms, functions, and severity of dementia. Caregivers completed questionnaires on perceived patient end-of-life care preferences, caregiver end-of-life care preferences for patients, Zarit Burden Interview (ZBI), Center for Epidemiological Studies–Depression Scale (CES-D), and knowledge of clinical complications of advanced dementia.

Results

The self-disclosure rates of patient preferences were 34.5% for tube feeding, 39.3% for cardiopulmonary resuscitation, and 45.2% for mechanical ventilation. For patients who had disclosed preferences, the disagreement rate between them and their caregivers was 48.3% for tube feeding, 48.5% for cardiopulmonary resuscitation, and 60.3% for mechanical ventilation. Caregiver depression (i.e., CES-D ≥16) was associated with disagreements on cardiopulmonary resuscitation (adjusted odds ratio (aOR) = 6.6, 95% CI = 1.4–31.1, P = 0.01) and mechanical ventilation (aOR = 14, 95% CI = 2.2–87.2, P = 0.005) preferences.

Conclusion

The preferences of end-of-life issues differed greatly between dementia patients and their caregivers. Depression in caregivers is associated with such discrepancy.

"We both just trusted and leaned on the Lord": a qualitative study of religiousness and spirituality among African American breast cancer survivors and their caregivers

PURPOSE

Most breast cancer (BC) survivorship research focuses on the general population of survivors. Scant research investigates the potentially unique experiences of minorities, especially during and after the difficult transition from primary treatment to post-treatment. This qualitative study explored African American BC survivors' and caregivers' quality-of-life in the post-treatment period with a focus on social and spiritual well-being.

METHODS

Participants included a convenience sample of African American women with stage I-III BC (N = 23) who completed treatment 6-24 months before enrollment. Primary caregivers (N = 22) included friends, spouses and other family members (21 complete dyads). Participants completed separate semi-structured telephone interviews. Template analysis was used to evaluate themes related to religiousness and spirituality, both across and within dyads.

RESULTS

After treatment, religiousness and spirituality played a major role in both survivors' and caregivers' lives by: (1) providing global guidance, (2) guiding illness management efforts and (3) facilitating recovery. Participants described a spiritual connectedness with God and others in their social networks. Dyad members shared the goal of keeping a positive attitude and described positive growth from cancer. Few future concerns were expressed due to the belief that survivors were healed and "done" with cancer. Beyond practical and emotional support, provision of spiritual assistance was common.

CONCLUSIONS

Results highlight the principal, positive role of religiousness and spirituality for African American BC survivors and caregivers after treatment. Findings emphasize the need to assess the importance of religious and spiritual beliefs and practices, and if appropriate, to provide resources that promote spiritual well-being.

Information and support for co-survivors during or after cancer treatment: Consideration of Un Abrazo Para la Familia as a model for family-focused intervention in cancer rehabilitation

OBJECTIVE

The development and evaluation of Un Abrazo Para La Familia, [A Hug for the Family] is described. Un Abrazo is discussed as an effective model of education, information-sharing, and skill-building for use with low-income co-survivors of cancer.

PARTICIPANTS

Sixty co-survivors participated. The majority were women and all reported being Hispanic.

METHODS

Using quantitative data (N=60), the needs, concerns, and characteristics of the co-survivor population served through Un Abrazo are presented. Further, we offer three qualitative case studies (with one co-survivor, one survivor, and one non-participant) to illustrate the model and its impact.

RESULTS

The median level of education level of co-survivors was 12 years. The majority were unemployed and/or identified as homemakers, and indicated receipt of services indicating low-income status. Half reported not having health insurance. The top four cancer-related needs or concerns were: Information, Concern for another person, Cost/health insurance, and Fears.

CONCLUSIONS

Recognizing the centrality of the family in addressing cancer allows for a wider view of the disease and the needs that arise during and after treatment. Key rehabilitation strategies appropriate for intervening with co-survivors of cancer include assessing and building upon strengths and abilities and making culturally-respectful cancer-related information and support accessible.

A qualitative study of the dimensions of patients' perceptions of facial disfigurement after head and neck cancer surgery

The study aim was to explore the underlying dimensions of patients' perceptions and experiences of facial disfigurement following surgery for cancer treatment, using a qualitative approach based on individual in-depth interviews. Data analysis and interpretation consisted of separating responses into phrases or statements with a single thematic aspect. Subsequently, a number of dimensions and categories were created using a deductive-inductive content analysis. Three main categories emerged: discovering of the cancer, coping with the disease and disfigurement, and reconstructing a new identity. The initial stage elicited feelings of fear, denial, and guilt as a reaction to the stigma and prejudice. Coping strategies included resignation and acceptance, deepening religiosity, reinforcement of familiar cohesion, and creation of a social network of solidarity and support. The final stage comprised incorporation of the altered facial image, rehabilitation possibilities, reconstruction of personality and self-image, and the feeling of having overcome the disease. It was concluded that individual experiences are complex, challenging, and have striking effects on their lives. There is an urgent need for training and improvement in human resources to manage these patients in a multidisciplinary approach, aimed at their reintegration into society and reducing the prejudice and stigma of the disease and disfiguration.

Physician-patient-companion communication and decision-making: a systematic review of triadic medical consultations

OBJECTIVE

To systematically review quantitative and qualitative studies exploring physician-adult patient-adult companion (triadic) communication and/or decision-making within all medical encounters.

METHODS

Studies were identified via database searches and reference lists. One author assessed eligibility of studies, verified by two co-authors. Data were extracted by one author and cross-checked for accuracy. Two authors assessed the quality of included articles using standardized criteria.

RESULTS

Of the 8409 titles identified, 52 studies were included. Summary statements and tables were developed for each of five identified themes. Results indicated companions regularly attended consultations, were frequently perceived as helpful, and assumed a variety of roles. However, their involvement often raised challenges. Patients with increased need were more often accompanied. Some companion behaviours were felt to be more helpful (e.g. informational support) and less helpful (e.g. dominating/demanding behaviours), and preferences for involvement varied widely.

CONCLUSION

Triadic communication in medical encounters can be helpful but challenging. Based on analysis of included studies, preliminary strategies for health professionals are proposed.

PRACTICE IMPLICATIONS

Preliminary strategies for health professionals include (i) encourage/involve companions, (ii) highlight helpful companion behaviours, (iii) clarify and agree upon role preferences of patient/companions. Future studies should develop and evaluate specific strategies for optimizing triadic consultations.

Sleep and sleep-wake disturbances in care recipient-caregiver dyads in the context of a chronic illness: a critical review of the literature

CONTEXT

Alterations in sleep-wake patterns of care recipients and their informal caregivers are common in the context of a chronic illness. Given the current notion that sleep may be regulated within and affected by close human relationships, concurrent and interrelated sleep problems may be present in care recipient-caregiver dyads.

OBJECTIVES

To critically analyze evidence regarding concurrent sleep patterns or changes in care recipient-caregiver dyads in the context of a chronic illness and address methodological and research gaps.

METHODS

Using a wide range of key terms and synonyms, three electronic databases (Medline, CINAHL, and Embase) were systematically searched for the period between January 1990 and July 2011.

RESULTS

Ten studies met prespecified selection criteria and were included for analysis. Study quality was fair to good on average. Seven studies were conducted in the context of dementia or Parkinson's disease, two in the context of cancer, and one study included a group of community elders with mixed related comorbidities and their informal caregivers. Bidirectional associations in the sleep of care recipient-caregiver dyads seem to exist. Concurrent and comparable nocturnal sleep disruptions also may be evident. Yet, inconsistencies in the methods implemented, and the samples included, as well as uncertainty regarding factors coaffecting sleep, still preclude safe conclusions to be drawn on.

CONCLUSION

The dyadic investigation of sleep is a promising approach to the development of truly effective interventions to improve sleep quality of care recipients and their caregivers. Nevertheless, more systematic, longitudinal dyadic research is warranted to augment our understanding of co-occurrence and over time changes of sleep problems in care recipient-caregiver dyads, as well as to clarify covariates/factors that appear to contribute to these problems within the dyad and across time and context of illness.

"Like a Mexican wedding": psychosocial intervention needs of predominately Hispanic low-income female co-survivors of cancer

Although recent work has recognized that the influence and consequences of cancer extend beyond the individual receiving the diagnosis, no studies have focused on the specific psychosocial intervention needs of female co-survivors in low-income populations. In this qualitative study, the co-survivors, 16 women, representing 10 low-income families and predominately Hispanic, were interviewed about their experience of having someone in their family diagnosed with cancer. Several themes emerged from the data, including family stress, lack of skill in coping with the effects of cancer (e.g., depression of their loved one), a need for financial help, a willingness to share with others, and reliance on faith to see them through the cancer experience. Whereas no agreement existed as to where and how to provide an intervention, participants reported that tailoring an intervention to family needs and delivering it in a way that was accessible to them was important.

"I wish I'd told them": a qualitative study examining the unmet psychosexual needs of prostate cancer patients during follow-up after treatment

OBJECTIVE

To gain insight into patients' experiences of follow-up care after treatment for prostate cancer and identify unmet psychosexual needs.

METHODS

Semi-structured interviews were conducted with a purposive sample of 35 patients aged 59-82 from three UK regions. Partners were included in 18 interviews. Data were analyzed using constant comparison.

RESULTS

(1) Psychosexual problems gained importance over time, (2) men felt they were rarely invited to discuss psychosexual side effects within follow-up appointments and lack of rapport with health care professionals made it difficult to raise problems themselves, (3) problems were sometimes concealed or accepted and professionals' attempts to explore potential difficulties were resisted by some, and (4) older patients were too embarrassed to raise psychosexual concerns as they felt they would be considered 'too old' to be worried about the loss of sexual function.

CONCLUSION

Men with prostate cancer, even the very elderly, have psychosexual issues for variable times after diagnosis. These are not currently always addressed at the appropriate time for the patient.

PRACTICE IMPLICATIONS

Assessments of psychosexual problems should take place throughout the follow-up period, and not only at the time of initial treatment. Further research examining greater willingness or reluctance to engage with psychosexual interventions may be particularly helpful in designing future interventions.

Treatment decision-making in cancer care: the role of the carer

AIMS AND OBJECTIVES

This study explores the role of the carer in treatment decision-making in cancer care.

BACKGROUND

Literature about involvement in treatment decision-making tends to focus on patients and clinicians, with the carer rarely included. The absence of carers is problematic because the management of illness is often carried out in the context of complex networks of relationships. Although current policy encourages health care practitioners to work in partnership with family members, implementation is troubled by a lack of understanding of the significance of interpersonal relationships and interactions and the role of the relationship throughout the course of the illness experience. Despite awareness, there is little systematic, coherent analysis of the complexity of these interactional dynamics and, in particular, consideration of the implications for involvement and treatment decision-making.

DESIGN

Qualitative, longitudinal.

METHODS

Three serial semi-structured interviews with 66 patients and 43 carers within the first year following a diagnosis of cancer. A descriptive and thematic approach to data analysis was adopted.

RESULTS

Carers are involved in treatment decision-making in cancer care and contribute to the involvement of patients through their actions during, before and after consultations with clinicians. Carers can act as conduits for information from patient to clinician and from clinician to patient. They can also act as facilitators during deliberations, helping patients to consider whether to have treatment or not and which treatment.

CONCLUSIONS

Our study has highlighted the deficiency of models that fail to acknowledge the role of the carer in the treatment decision-making process. We propose the adoption of a relational approach by the inclusion of the carer in conceptual frameworks and recommend triadic (patient, carer and professional) models of involvement.

RELEVANCE TO CLINICAL PRACTICE

Cancer care clinicians should recognise and actively involve the carer as well as the patient in treatment decision-making.

Caregivers' participation in the oncology clinic visit mediates the relationship between their information competence and their need fulfillment and clinic visit satisfaction

OBJECTIVE

Caregivers maintain critical roles in cancer patient care. Understanding cancer-related information effects both caregiver involvement and ability to have needs met. This study examines the mediating role caregiver's clinic visit involvement has on the relationships between caregiver's information competence and their need fulfillment and clinic visit satisfaction.

METHODS

Secondary analysis of 112 advanced lung, breast, and prostate cancer caregivers participating in a large clinical trial. Caregiver information competence was assessed at pretest. Involvement, need fulfillment, and visit satisfaction were assessed immediately following the clinic appointment.

RESULTS

Involvement correlated with information competence (r=.21, p<.05), need fulfillment (r=.48, p<.001), and satisfaction (r=.35, p<.001). The correlation between information competence and need fulfillment (r=.26, p<.01) decreased when controlling for involvement (r=.19, p=.049), demonstrating mediation, and accounted for 24.4% of the variance in need fulfillment. The correlation between information competence and satisfaction (r=.21, p=.04), decreased and was non-significant when controlling for involvement (r=.15, p=.11), demonstrating mediation, and accounted for 13% of variance in visit satisfaction.

CONCLUSION

Caregiver's clinic visit involvement mediates the relationships between their information competence and their need fulfillment and visit satisfaction.

PRACTICE IMPLICATIONS

Efforts to improve the caregiving experience, and potentially patient outcomes, should focus on system-wide approaches to facilitating caregivers' involvement and assertiveness in clinical encounters.

Web-based cancer communication and decision making systems: connecting patients, caregivers, and clinicians for improved health outcomes

Over the cancer disease trajectory, from diagnosis and treatment to remission or end of life, patients and their families face difficult decisions. The provision of information and support when most relevant can optimize cancer decision making and coping. An interactive health communication system (IHCS) offers the potential to bridge the communication gaps that occur among patients, family, and clinicians and to empower each to actively engage in cancer care and shared decision making. This is a report of the authors' experience (with a discussion of relevant literature) in developing and testing a Web-based IHCS-the Comprehensive Health Enhancement Support System (CHESS)-for patients with advanced lung cancer and their family caregivers. CHESS provides information, communication, and coaching resources as well as a symptom tracking system that reports health status to the clinical team. Development of an IHCS includes a needs assessment of the target audience and applied theory informed by continued stakeholder involvement in early testing. Critical issues of IHCS implementation include 1) need for interventions that accommodate a variety of format preferences and technology comfort ranges; 2) IHCS user training, 3) clinician investment in IHCS promotion, and 4) IHCS integration with existing medical systems. In creating such comprehensive systems, development strategies need to be grounded in population needs with appropriate use of technology that serves the target users, including the patient/family, clinical team, and health care organization. Implementation strategies should address timing, personnel, and environmental factors to facilitate continued use and benefit from IHCS.

'They're doing surgery on two people': a meta-ethnography of the influences on couples' treatment decision making for prostate cancer

BACKGROUND

Current orthodoxy suggests that patients need to be provided with full information about their care and that treatment options should be discussed with patients and family members. This imperative is especially challenging when there is a lack of consensus about treatment effectiveness and equivocacy over different types of interventions. In the case of prostate cancer, evidence is contested as to the efficacy of different treatments. Thus, involving patients and their family members in treatment choices is complex and little is known about how patients and their partners process these decisions when there is uncertainty about different outcomes. This paper has reviewed the literature on the way couples approach such decision making in relation to treatment for prostate cancer.

OBJECTIVE

A meta-ethnographic synthesis of published qualitative papers that focused on the influences on patients', and their partners' treatment decision making for prostate cancer, was conducted in order to identify and understand barriers and facilitators which impact on this process.

RESULTS

Our synthesis indicates that the couples' relationship 'dynamic' provides a contextual background against which treatment decisions are negotiated and made.

DISCUSSION AND CONCLUSIONS

We propose that the findings from this synthesis can enhance the potential for shared decision making for patients, and their partners, when facing a treatment decision for prostate cancer. By understanding the couples' relationship dynamic pre-diagnosis, clinicians may be able to tailor the communication and information provision to both patients and their partners, providing a personalized approach to treatment decision making.

Psychometric evaluation of the Health Information Orientation Scale: a brief measure for assessing health information engagement and apprehension

The Health Information Orientation Scale (HIOS) was developed from a need to briefly assess information orientation in a health context and underlying reasons for information seeking or avoidance. Using data from a larger longitudinal study of informal cancer caregivers, this study examines psychometric properties of the HIOS, including confirmatory factor analysis (CFA), reliability and construct validity through associations with information competence, coping and distress. CFA supported two conceptually unique factors: Information Engagement and Information Apprehension. Each factor demonstrated adequate reliability and construct validity, providing promising findings regarding Information Engagement and Information Apprehension, specific to a health context.

The importance of relationships in the experience of cancer: a re-working of the policy ideal of the whole-systems approach

PURPOSE OF THE RESEARCH

This paper outlines the importance of interpersonal familial relationships in how people experience cancer.

METHODS AND SAMPLE

This paper draws on data from a longitudinal, qualitative study which aimed to explore the experiences of people with cancer within the first year following diagnosis. The sample included fifteen men with colorectal cancer, 3 women with colorectal cancer, twelve women with breast cancer, nine women with gynaecological cancer, six women with lung cancer, eleven men with lung cancer and ten men with prostate cancer. Four people died during the course of the study and ten people chose to withdraw.

KEY RESULTS

Close interpersonal relationships were clearly core mediating features in how the illness was experienced; for example, presenting for symptom investigation was often the result of ongoing interaction and debate between partners. We use the idea of the 'joint ownership of cancer' to elucidate the role of relationships in experiencing and understanding the disease. We propose a re-working of the notion of a whole-systems approach to include not just partnership working within health and social care agencies, but centralising the patient's interpersonal relationships as critical in each aspect of their experience of cancer.

CONCLUSIONS

The findings are discussed in terms of the need for service delivery and research to be mindful of the relational aspects and implications of illness. Nurses can play a key role in how this is operationalised in supporting people affected by cancer in the context of their relationships.

The Cancer Communication Assessment Tool for Patients and Families (CCAT-PF): a new measure

OBJECTIVES

Caregivers and cancer patients frequently have conflicting and unmet communication needs. The Cancer Communication Assessment Tool for Patients and Families (CCAT-PF) is a new instrument that assesses congruence in patient-family caregiver communication for both research and clinical purposes.

METHODS

The scale was developed using a sample of 190 lung cancer patient-caregiver pairs. Standard psychometric procedures were used to develop and test the scale including qualitative item pool development, item reduction and ascertainment of scale properties.

RESULTS

The multiple correlation of the 18-item CCAT-PF scale with the longer 30-item scale was 0.94. All but three items had less than 20% variance accounted for when each item was regressed on the remaining 17, indicating that responses to an individual item were not readily predicted by the remaining items. Test re-test reliability was 0.35 and Cronbach's alpha was 0.49 as the CCAT-PF scale represents the sum of mostly independent items. Higher CCAT-PF scores were significantly correlated with greater patient depression, greater patient perceived family conflict, lower patient-caregiver assessment and well-being and less expressiveness and family cohesion. For both patients and caregivers, physical, functional and emotional well-being were not associated with CCAT-PF scores.

CONCLUSION

The CCAT-PF is a brief but reliable and valid tool. Although administering both family and patient versions is optimal, administering it to a patient or family caregiver only also produces reliable information.

Factors influencing intrafamilial communication of hereditary breast and ovarian cancer genetic information

What factors influence intrafamilial communication of hereditary breast and ovarian cancer (HBOC) genetic risk information? Such information can have health implications for individuals who undergo genetic testing, but it can also have implications for their blood relatives. This literature review adopts an ecological model to summarize factors at the individual, familial, and community levels, as well as cross cutting factors relating to the complexity of HBOC genetic information and responsibilities that this information can give rise to. These factors are complex and may result in conflicting senses of responsibility. Faced with the task of communicating HBOC genetic information, the response may be to attempt to balance the potential negative impact of the information on the well-being of the informee (eg, can s/he handle this information?) against the potential health benefit that the knowledge could result in. This balancing represents an effort to reconcile conflicting approaches to protecting family members, and is a moral dilemma. This review sheds light on the factors that contribute to resolve this dilemma.

'Getting through' not 'going under': a qualitative study of gender and spousal support after diagnosis with colorectal cancer

Many studies have found that people with cancer value family support. Feminist work suggests that women carry most responsibility for practical and emotional support in families, but few qualitative cancer studies explicitly incorporate a gender perspective. We undertook secondary analysis of in-depth interviews with 33 married or cohabiting respondents with colorectal cancer in the UK to compare men and women's accounts of 'spousal' support. Both men and women described the vital role that their partners played in providing emotional and practical support. Mutual support and reciprocity were also key features of narratives; both men and women reported controlling their emotions to protect spouses and preserve 'normal' household routines. Traditional gender roles had some influence; some women organised 'cover' for domestic work and childcare when they were ill, while some men focused on making sure that their families were financially secure and partners were 'protected' from the effects of their stomas. Our findings illustrate the complexity of gendered constructions and performances of 'care' and contribute to debates about gender and emotional labour.

Caregivers' differing needs across key experiences of the advanced cancer disease trajectory

OBJECTIVES

Familial caregivers are providing increasing amounts of care to advanced cancer patients. Increased understanding of caregivers' needs is vital in providing necessary support to lessen caregiver burden and morbidity. Current literature has identified caregiver and patient needs at broad stages of the cancer trajectory; however, such broad stages may be too general to inform a practice of targeting specific interventions when they have the greatest utility. This study examines a variety of particular needs across a number of more discrete illness-related transition experiences specifically in the advanced cancer disease trajectory.

METHODS

One hundred fifty-nine female informal caregivers of people with advanced cancer completed a needs assessment survey.

RESULTS

Analyses of these cross-sectional retrospective-report data reveal that cancer caregiver needs vary across specific key experiences occurring within the broader stages of illness identified by current literature. Furthermore, caregivers have unique needs during bereavement.

SIGNIFICANCE OF RESULTS

Although the sample characteristics are demographically limited, this study provides preliminary evidence that the broad stages are not specific enough increments for effectively examining caregiver needs and supports the need for more precise distribution of cancer-related information at more discrete times in the illness course.

Pilot Testing of a Question Prompt Sheet to Encourage Family Caregivers of Cancer Patients and Physicians to Discuss End-of-life Issues

Family members of patients with advanced illness have many questions. Unfortunately, several barriers prevent caregivers from discussing their questions with the physicians caring for the patient. Although question prompt sheets can be helpful in overcoming barriers to communication, few have been developed for family caregivers. The goal of this study, therefore, was to develop and test the acceptability and feasibility of a short question prompt sheet designed to encourage discussions about end-of-life concerns in an outpatient palliative care clinic. Our results demonstrated that caregivers wanted to discuss a variety of questions, primarily questions about medications, symptoms, support services, and what to expect. All caregivers thought that the question prompt sheets was easy to understand and felt comfortable completing it in clinic and the majority reported that the question prompt sheets made it easier for them to ask questions.

Parental bereavement and the loss of a child with intellectual disabilities: a review of the literature

Inequalities in health care and other risk factors mean that children with intellectual disabilities are more likely to predecease their parents. Research on the effects on family members when a child with intellectual disability dies is sparse. In the present review, the authors describe 5 studies of bereavement in intellectual disability and then turn to general parental bereavement research to inform the field of intellectual disability. Questions for future research and some implications for services and professionals are discussed. In particular, professionals should be aware of dissatisfaction with care pre-loss, disenfranchised grief, and post-loss support needs of family members.

Whatever It Takes: Informal Caregiving Dynamics in Blood and Marrow Transplantation

PURPOSE/OBJECTIVES

To describe the dynamics of commitment, expectations, and negotiation from the perspective of caregivers of patients undergoing blood and marrow transplantation (BMT).

RESEARCH APPROACH

Descriptive, exploratory, qualitative methodology.

SETTING

Comprehensive cancer center in a major southern U.S. city.

PARTICIPANTS

40 caregivers of patients undergoing BMT.

METHODOLOGIC APPROACH

Story theory guided audiotaped dialogues with caregivers.

MAIN RESEARCH VARIABLES

Commitment, expectations, and negotiation.

FINDINGS

Commitment is an enduring responsibility that encourages supportive presence, inspires life changes to make the patient a priority, and leads to a self-affirming, loving connection. Expectations are clarified as expectation management, which is envisioning the future and yearning to return to normal, taking one day at a time, gauging behavior from past experiences, and reconciling treatment twists and turns. Role negotiation is appropriate pushing by a caregiver toward patient independence after getting a handle on complex care and attending to patient voice (patient preferences and wishes).

CONCLUSIONS

Commitment, expectation management, and role negotiation sustain informal caregivers in their role.

INTERPRETATION

Acknowledging caregivers' contributions, giving focused information as needed, and providing a safe environment in which to build coherent caregiving stories can assist caregivers. Research is needed to confirm the effectiveness of interventions with caregivers and to understand patients' role in the dynamics of informal caregiving.

What is a health expectation? Developing a pragmatic conceptual model from psychological theory

INTRODUCTION

Examination of the existing literature in respect of health expectations revealed both ambiguity in relation to terminology, and relatively little work in respect of how abstract theories of expectancy in the psychological literature might be used in empirical research into the influence of expectations on attitudes and behaviours in the real world. This paper presents a conceptual model for the development of health expectations with specific reference to Alzheimer's disease.

METHOD

Literature review, synthesis and conceptual model development, illustrated by the case of a person with newly diagnosed, early-stage Alzheimer's disease, and her caregiver.

OUTCOME

Our model envisages the development of a health expectation as incorporating several longitudinal phases (precipitating phenomenon, prior understanding, cognitive processing, expectation formulation, outcome, post-outcome cognitive processing).

CONCLUSION

Expectations are a highly important but still relatively poorly understood phenomenon in relation to the experience of health and health care. We suggest a pragmatic conceptual model designed to clarify the process of expectation development, in order to inform future research into the measurement of health expectations and to enhance our understanding of the influence of expectations on health behaviours and attitudes.

Measuring discord in treatment decision-making; progress toward development of a cancer communication and decision-making assessment tool

Families, as a unit, play an important role in the process of making decisions about care for and with adult cancer patients. Families often step in as the patient's advocate and primary decision-maker as the patient's condition deteriorates. How well caregivers fulfill that role may depend on the level of congruence between the family members and the patient. Disagreements may jeopardize processes of decision-making and treatment choice. To facilitate the clinical assessment process and to provide a tool for research, we are designing an instrument that can validly and reliably assess the level of family discord concerning the treatment of late stage cancer as they consider participation in clinical trials, palliative care and salvage treatment such as chemotherapy designed to decrease tumor burden without hope of cure. Development of the instrument is a four step process to develop and test the instrument: (1) formative interviewing with lung cancer patients and their family caregivers to identify and develop a comprehensive list of domains and items; (2) refinement of the items' wording with a sample of 43 patients and 67 family caregivers; (3) testing the reduced item pool to determine statistical and content validity and reliability with an initial of sample of 42 patients and their primary caregivers; (4) examination of the 30-item scale's properties with 160 lung cancer patients and their primary caregivers.