The "patient patient": the trauma of waiting and the power of resistance for people living with cancer

Essential Advance Care Planning Intervention Features in Low-Income Communities: A Qualitative Study

CONTEXT

Older adults with low socioeconomic status (SES) participate in advance care planning (ACP) at lower rates than those with higher SES. Community feedback is an essential component of intervention design for communities with fewer social and health resources to ensure that the intervention is relevant and meaningful.

OBJECTIVES

To understand the perspectives for potential interventions, we aimed to qualitatively explore participant priorities for ACP intervention development.

METHODS

Using a qualitative descriptive design, we recruited and conducted individual and one-time, semi-structured interviews with older adults (aged 50+) with low income (< $20,000/year) (n = 20), Recruitment methods included flyers and in-person recruitment and purposive and snowball sampling methods. Following a thematic analysis plan, themes emerged from recursive transcript review by two independent coders and inductive categorization of the most robust codes.

RESULTS

Two themes captured participants' perspectives regarding ACP intervention development: 1) specialist advocacy and reliability and 2) person-centered communication. Older adults with low SES prioritize ACP communication that is driven by their goals and that is led by trustworthy specialists that advocate for their needs.

CONCLUSION

Our work highlights that intervention preferences were informed by the prior strain and struggle of waiting on other kinds of health and social services. We propose an adapted model for community research collaboration to promote equity in addition to practice and policy recommendations.

Thinking Time, Shifting Goalposts and Ticking Time Bombs: Experiences of Waiting on the Gender Identity Development Service Waiting List

LOGiC-Q is a prospective longitudinal qualitative study that explores the experiences of children and young people, and their families, who have been referred to the Gender Identity Development Service (GIDS) in the UK. This paper describes the experiences of children and young people and their parents while they are on the waiting list to be seen. Semi-structured interviews were undertaken with 39 families who had been referred to GIDS and were waiting for their first appointment with the service. Both parent and child/young person were interviewed. Analysis of the anonymised interview transcripts was informed by both narrative and thematic approaches, and three predominant narratives around waiting were identified: 1. Positive experiences attached to waiting; 2. Feelings of distress and stuckness; 3. Suggestions for support while waiting. Findings from this study indicate variations in how waiting is experienced depending on the age of the child, and how distressed their body makes them feel. Young people and their parents offered suggestions for how the service could support families on the waiting list. These suggestions related primarily to ways of checking in and providing reassurance that they were at least still on the list as well as ideas about how to make the wait less distressing, rather than necessarily making the wait shorter, which was more spoken about in terms of an ideal rather than a realistic option.

Seating in Doctors' Waiting Rooms: Has COVID-19 Changed Our Choices?

OBJECTIVE

This study investigates preference for five different seating arrangements (e.g., rows, clusters) in a doctor's office waiting room, whether these reduce stress and improve judgments of medical care, and how such choices may have changed over the pandemic (2013 vs. 2021).

BACKGROUND

What is called the doctor's office layout, with chairs lining the perimeter of the waiting room, is criticized by designers, yet little empirical evidence exists to support that assessment.

METHOD

Data collected in 2013 and 2021 used sketches of five different seating arrangements; people saw just one of these. The study examined the effect of time and seating arrangement on anxiety, need for privacy, situational awareness, evaluation of the environment, and perception of the doctor.

RESULTS

There was no significant impact of the seating arrangement on any of the dependent variables, but ratings were higher for situational awareness, need for privacy, evaluation of the environment, and aspects related to the physician in 2021. In addition, seating preferences favored end, not middle seats, and chair selections with the chair back to a wall.

CONCLUSION

In this study, no evidence exists that the doctor's office layout is less preferred than four other seating arrangements, but seat choice shows people prefer end seats (not middle seats) across arrangements. The doctor's office layout may offer a supportive familiarity to people; also, given the percentage of people who visit the doctor unaccompanied, layouts designed to encourage social interaction may not always be appropriate.

The psychological burden of waiting for procedures and patient-centred strategies that could support the mental health of wait-listed patients and caregivers during the COVID-19 pandemic: A scoping review

BACKGROUND

Waiting for procedures delayed by COVID-19 may cause anxiety and related adverse consequences.

OBJECTIVE

To synthesize research on the mental health impact of waiting and patient-centred mitigation strategies that could be applied in the COVID-19 context.

METHODS

Using a scoping review approach, we searched 9 databases for studies on waiting lists and mental health and reported study characteristics, impacts and intervention attributes and outcomes.

RESULTS

We included 51 studies that focussed on organ transplant (60.8%), surgery (21.6%) or cancer management (13.7%). Most patients and caregivers reported anxiety, depression and poor quality of life, which deteriorated with increasing wait time. The impact of waiting on mental health was greater among women and new immigrants, and those of younger age, lower socio-economic status, or with less-positive coping ability. Six studies evaluated educational strategies to develop coping skills: 2 reduced depression (2 did not), 1 reduced anxiety (2 did not) and 2 improved quality of life (2 did not). In contrast, patients desired acknowledgement of concerns, peer support, and periodic communication about wait-list position, prioritization criteria and anticipated procedure date.

CONCLUSIONS

Findings revealed patient-centred strategies to alleviate the mental health impact of waiting for procedures. Ongoing research should explore how to optimize the impact of those strategies for diverse patients and caregivers, particularly in the COVID-19 context.

PATIENT OR PUBLIC CONTRIBUTION

Six patients and four caregivers waiting for COVID-19-delayed procedures helped to establish eligibility criteria, plan data extraction and review a draft and final report.

The level of agreement between rapid-on-site evaluation of endoscopic ultrasound fine needle aspirate and surgical histological diagnosis in gastrointestinal lesions

OBJECTIVE

Endoscopic ultrasound (EUS) is the main tool for biopsy via fine needle aspiration (FNA) from gastrointestinal (GI) lesions including pancreatic, upper gastrointestinal, and adjacent lesions. The variable diagnostic yield and delay until the final pathological results can affect treatment planning and cause patient anxiety. We aimed to assess the agreement of rapid on-site evaluation (ROSE) of EUS-FNA with the surgical histological diagnosis of patients who underwent resection.

METHOD

A retrospective study was performed including all patients 18 years or older who underwent EUS-FNA with ROSE for GI lesions. For patients who underwent surgical resection, the correlation between ROSE and the surgical histological diagnosis was evaluated with the kappa coefficient.

RESULTS

Overall, 73 patients who underwent EUS-FNA with ROSE were included, of whom 22 (30.1%) had curative resection. The final pathological diagnosis from surgery showed 17 malignant and 5 benign lesions. Among the benign lesions, ROSE correctly identified 2 (diagnostic accuracy of 40%), while among the malignant lesions, ROSE correctly identified 14 (diagnostic accuracy of 82.4%), yielding a fair kappa coefficient of 0.366 (95% CI 0.035-0.697). When classifying the lesions as either malignant vs benign or suspicious of malignancy, the kappa coefficient increased to 0.58 (95% CI 0.180-0.975) for the subgroup of pancreatic lesions, with diagnostic accuracy of 81.2% for the malignant category.

CONCLUSIONS

A high level of agreement for malignancy was found between FNA-EUS with ROSE and the final surgical histological diagnosis. ROSE can be used as an adjuvant diagnostic tool to optimise patient management and decrease delay-related anxiety.

Avoir sa santé en main : le sentiment d'habilitation tel que perçu par les jeunes adultes souffrant d'un cancer avancé

Contexte

Le sentiment d'habilitation sur sa santé (health related empowerment) est un concept fondamental des soins centrés sur la personne. Toutefois, on en sait peu sur la manière dont ce concept s'articule chez les jeunes adultes ayant un diagnostic de cancer avancé.

Objectif

Explorer le sentiment d'habilitation à la lumière des expériences de soins de santé vécues par les jeunes adultes en phase de cancer avancé.

Cadre et participants

Douze jeunes adultes (âgés de 21 à 39 ans) ont été recrutés dans un grand centre de cancérologie de Montréal, au Québec.

Méthodologie

Des entretiens en profondeur durant entre 36 et 90 minutes ont été menés individuellement, enregistrés et retranscrits mot pour mot, puis analysés par thèmes.

Résultats

Tout au long de l'expérience du cancer, les participants ont témoigné du désir soutenu de participer activement à leur traitement et à leurs soins. Quatre thèmes sont ressortis des données décrivant les processus d'attente, de prise en charge de la maladie, de mise en action et de recadrage. Sous-jacents à ces thèmes se trouvent les notions de conscience du corps, les obstacles à surmonter pour obtenir des soins, l'optimisation de la santé et la réflexion sur l'héritage qu'on laisse derrière soi.

Conclusions

De façon générale, les participants voulaient demeurer en contrôle de la situation malgré les multiples difficultés inhérentes à un cancer de stade avancé. Si elles sont corroborées par d'autres recherches, ces conclusions pourraient orienter les approches de soins en oncologie afin qu'elles soient véritablement adaptées aux besoins des jeunes adultes.

Waiting for care: Chronic illness and health system uncertainties in the United States

Structures of power and inequality shape day-to-day life for individuals who are poor, imposing waiting in multiple forms and for a variety of services, including for healthcare (Andaya, 2018a; Auyero, 2012; Strathmann and Hay, 2009). Constraints, such as the age requirements for Medicare, losing employer-provided health insurance, or the bureaucracy involved in filing for disability often require people to wait to follow recommendations for medical treatments. In 2016–2017, we conducted 52 narrative interviews in St. Louis, a city with significant racial and economic health inequities and without Medicaid expansion. We interviewed people with one or more chronic illnesses for which they were prescribed medication and who identified as having difficulties affording their prescriptions. Throughout the interviews, participants frequently recounted 1) experiences of waiting for care, along with other services, and 2) the range of strategies they utilized to manage the waiting. In this article, we develop the concept of active waiting to describe both the lived experiences of waiting for care and the responses that people devise to navigate, shorten, or otherwise endure waiting. Waiting is structured into healthcare and other social services at various scales in ways that reinforce feelings of marginalization, and also that require work on the part of those who wait. While much medical and public health research focuses on issues of diagnostic or treatment delay, we conclude that this conceptualization of active waiting provides a far more productive frame for accurately understanding the emotional and physical experiences of individuals who are disproportionately poor and made to wait for their care. Only with such understanding can we hope to build more just and compassionate social systems.

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Poor and chronically ill people wait to receive medical care and social services.

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People wait actively, making decisions to manage the repercussions of waiting.

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The idea of delaying care is inadequate to explain realities of illness and poverty.

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Waiting broadens and deepens structural vulnerability for marginalized people.

Taking control over our health: Empowerment as perceived by young adults living with advanced cancer

Background

Health-related empowerment is a key concept in person-centred care. However, little is known of its core elements in young adults diagnosed with advanced cancer.

Objective

To explore empowerment in the context of young adults' healthcare experiences who are now in advanced stages of cancer.

Setting & Participants

Twelve young adults (aged 21 to 39 years) were recruited from a large cancer centre in Montreal, Quebec.

Methods

In-depth interviews lasting between 36 and 90 minutes were conducted individually, audio-recorded, transcribed verbatim, and analyzed using thematic analysis.

Results

Throughout the cancer trajectory, participants reported a sustained desire to be actively involved in their treatment and care. Four themes emerged from the data representing processes of waiting, managing, acting, and revisiting. Subsumed under these were notions of body ownership, facing obstacles to care, optimizing health, and (re)considering their legacy.

Conclusions

Overall, participants wanted to remain in control of their situation despite the multiple challenges related to advanced cancer. If corroborated further, these findings should inform supportive cancer care approaches that are truly tailored to the needs of young adults.

Childhood eye cancer from a parental perspective: The lived experience of parents with children who have had retinoblastoma

OBJECTIVES

This study aimed to explore the lived experience of parents with children who have had retinoblastoma.

METHODS

The study adopted a qualitative approach using the data collection method of written accounts. Eleven parents were recruited via snowball sampling from across the UK. Parents were asked to retrospectively produce a written account of their experiences. These narrative autobiographical accounts were analysed using thematic analysis.

RESULTS

Data analysis elicited three themes: waiting and misdiagnosis; emotional rollercoaster; and support needs. Parents described experiencing prolonged periods of waiting from referral to clinical investigations and the implementation of a treatment plan. Difficulties in obtaining an accurate diagnosis for their child elicited anxiety for parents. Emotions were described in terms of a rollercoaster with highs and lows and times of despair, anger, relief, and hope. Experiences of personal support varied and had lasting impacts on relationships. However, the support from other parents with a child with retinoblastoma was perceived to be instrumental in facilitating coping.

CONCLUSIONS

The findings show parental experiences were characterised by numerous difficulties and suggest a need for greater awareness of childhood eye cancer. This research highlights the importance of psychological and social support for parents of a child with retinoblastoma.

The Effects of Session Standardization and Template Optimization on Improving Access to High-Demand Pediatric Subspecialty Care

A major focus of US health care systems is ensuring timely patient access to subspecialty care. This article describes the experiences of a large children's hospital after implementation of clinic session standardization and template optimization. Outpatient specialty clinic sessions were standardized to 4-hour periods, and all unfilled complex appointment slots were made available for any appointment type within 72 hours of the clinic date. Three high-demand outpatient clinical services achieved increased aggregate potential and completed outpatient appointments over a 2-year period. These improvements were mostly due to an increase in providers and were not always coupled to shorter patient lag times.

Foregrounding the built environment in the experience of cancer care: A qualitative study of autobiographical cancer narratives

BACKGROUND

For cancer patients, exposure to cancer care facilities entails confrontation in multiple ways. The value ascribed to these places grows over time and can be expected to affect the experience of care.

OBJECTIVE

The purpose of this study was to foreground the role of the built environment in this experience.

METHODS

This qualitative study is based on seven autobiographical narratives written by cancer patients being treated in Belgium or in neighbouring countries.

RESULTS

The thematic analysis of these accounts raises awareness of architecture's role in the experience of cancer patients. Their radius of action is typified by the contrasting adventurous undertakings and shrinking lifeworlds. The built environment furthermore provides leads to metaphors for patients to reformulate their experiences of illness and care.

CONCLUSIONS

Deterritorialised landscapes of cancer care include multiple, geographically dispersed places of care, rather than a single prominent care facility. Simultaneously, exposure to buildings where formal cancer care takes place is intense and meaningful. Metaphors are linked to the built environment and can be seen, through their use in the narratives, to support coping. Further research could look into the potential of metaphors to enhance understanding between stakeholders collaborating around design for cancer care.

Individuals With the Rare Disease Pemphigus: A Quest for Diagnostic

This qualitative study conducted in France of "individuals living with a pemphigus" (ILPs; N = 54) highlights the taxing diagnostic trajectory of those suffering from these rare autoimmune diseases. Beyond enduring a diagnostic period that may prove long, during their numerous medical appointments, these individuals internalize the expectations of the medical professionals who are treating them. In some cases, numerous inconclusive medical tests and, at times, a doctor's condescension may push the patient toward a process of renunciation. This article relates the ILPs' critiques of the medical work conducted during the trying diagnostic period.

Reba and Her Insurgent Prose: Sex Work, HIV/AIDS, and Subaltern Narratives

Narratives of cultural stakeholders in marginalized sex worker spaces often do not find the traction to influence mainstream health discourse. Furthermore, such narratives are framed against the grain of the dominant cultural narrative; they are resistive texts, and they depict enactments of resistance to the normal order. This article, based on 12 weeks of field study in a sex worker community in India, foregrounds how sex workers communicatively frame and enact resistance, and hence formulate insurgent texts, along a continuum-from overt violence to covert negotiation on issues such as condom and alcohol use. Making note of these insurgent texts is crucial to understanding how meanings of health are locally made in a sex worker community as it is often that members of such marginalized communities take recourse to covert and ritualistic forms of resistance to work, to survive, and to stay free of HIV infection.

The promise of virtual navigation in cancer care: Insights from patients and health care providers

Virtual navigation (VN) in health care is a proactive process by which patients obtain information and support via Internet resources to manage their illness demands. The objective of this analysis was to explore converging and diverging perspectives of key stakeholders: patients with cancer and Health Care Providers (HCPs), about a cancer-related VN tool called the Oncology Interactive Navigator (OIN™). A qualitative secondary analysis was performed combining data sets from two prior studies exploring perspectives of VN among patients (study 1, n=20) and HCPs (study 2, n=13). An inductive approach was used to explore converging and diverging views across groups. Findings explore how patients' and HCPs' views converge and diverge and the processes necessary to ensure optimal uptake of VN innovations in cancer care.

The "Conflicted Dying": The Active Search for Life Extension in Advanced Cancer Through Biomedical Treatment

Using a poststructural perspective, we examine the subjectivities that are produced when advanced cancer patients seek life extension through biomedical treatments. Seven case studies were developed that included 20 interviews with patients, family, nurses, and physicians recruited from a tertiary hospital in Canada, 30 documents, and 5 hours of participant observation. We identify seven types of subjectivity: (a) the Desperate Subject, (b) the Cancer Expert Subject, (c) the Proactive Subject, (d) the Productive Subject, (e) the Mistrusting Subject, (f) the Model Patient Subject, and (g) the Suffering Subject. We characterize the "conflicted dying," a contemporary figure who holds multiple perspectives about seeking curative treatment despite the acknowledgment of death. Using active strategies to gain access to treatment, this figure resists traditional arrangements of power/knowledge established by health care providers. We suggest that the search for life extension is a process of shaping the self to fit certain aesthetical traits associated with surviving cancer.

Time while waiting: patients' experiences of scheduled surgery

Research on patients' experiences of wait time for scheduled surgery has centered predominantly on the relative tolerability of perceived wait time and impacts on quality of life. We explored patients' experiences of time while waiting for three types of surgery with varied wait times--hip or knee replacement, shoulder surgery, and cardiac surgery. Thirty-two patients were recruited by their surgeons. We asked participants about their perceptions of time while waiting in two separate interviews. Using interpretative phenomenological analysis (IPA), we discovered connections between participant suffering, meaningfulness of time, and agency over the waiting period and the lived duration of time experience. Our findings reveal that chronological duration is not necessarily the most relevant consideration in determining the quality of waiting experience. Those findings helped us create a conceptual framework for lived wait time. We suggest that clinicians and policy makers consider the complexity of wait time experience to enhance preoperative patient care.

How does an online patient-nurse communication service meet the information needs of men with recently diagnosed testicular cancer?

Online communication has become a potential means of communication between patients and health care providers, but so far few studies are published about online communication as part of nursing care. The aim of this study was to explore how an online patient-nurse communication (OPNC) service meets the information needs of men with newly diagnosed testicular cancer. We applied a qualitative approach by examining the content of online messages sent by patients to nurses in a specialist cancer unit. In addition, individual interviews were conducted with patients who had used the OPNC service. Four themes became distinct through a synthesis of the material from the interviews and the messages: “a means for managing illness-related concerns at home,” “a means for ensuring information flow,” “a means for strategic information seeking,” and “not yet available when needed most.” Individualized information provided by nurses with access to their medical record was shown to be important to these patients. The findings of this study indicate that not only may access to an OPNC service help patients fulfill their otherwise unmet information needs, but also it may prevent delays and discontinuity in care due to informational gaps and lead to improved patient safety.

Living with arthritis: using self-management of valued activities to promote health

In this article, we explore how adults with arthritis use self-care strategies in their valued leisure activities, and variations in use based on their access to environmental resources. We conducted six focus groups (N = 34) with adults aged 55 and older with a diagnosis of arthritis. Adults living in residential communities were recruited, with 31% of the sample residing in subsidized housing. Focus group transcripts were analyzed using content analysis based on themes of selective optimization with compensation. We found some differences in strategy use between the resource-rich and resource-poor participants. Adults highlighted the value of their leisure activities and the importance of leisure in maintaining their health and well-being. Our findings point to the need to incorporate leisure education into interventions and programs targeting adults with arthritis.

The emotional journey of women experiencing a breast abnormality

Using grounded theory, a multidisciplinary study team compared the narratives of 30 women who had recently experienced a breast cancer scare. Even though 10 women received a benign diagnosis, all women reported a difficult time prediagnosis, characterized by an array of emotions and contemplation of the meaning of life. Diagnosis separated the two groups with emotional relief dominant for the benign group and intensification of emotions for the cancer group. For those diagnosed with cancer, three factors contributed to arriving at a point of acceptance about the diagnosis and treatment: (a) sustained coping mechanisms; (b) a belief system that shifted the meaning of the cancer experience; and (c) the ability to manage non-cancer-related stressful events. Implications include the need for tailored biopsychosocial treatments that focus on reducing stress, enhancing support systems, reframing beliefs about the illness, and providing the opportunity for the women to talk about their experiences.