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

Treatment Classification by Intent in Oncology-The Need for Meaningful Definitions: Curative, Palliative and Potentially Life-Prolonging

BACKGROUND

Realistic cancer treatment goals should be used by health care professionals and communicated to patients, families, and the public. The current nomenclature on this subject is outdated and has not been changed since the advent of modern oncology in the middle of the 20th century.

METHODS

Based on the literature we propose a three-tier system composed of curative, palliative, and potentially life-prolonging (PLP) therapies, instead of the current two-tier system of only curative and palliative treatment.

RESULTS

The new system introduces the notion of prolonged survival. Furthermore, the negative connotation linked to palliative care is also eliminated in this setting.

CONCLUSION

The current terminology used to describe cancer treatment goals has not been updated since the mid-20th century and it is time for a more modern approach. We propose a three-tier system: (1) curative treatment, (2) palliative care, and (3) potentially life-prolonging therapy.

A Qualitative Exploration of Medication Experience and Factors Contributing to Adherence to Oral-Targeted Therapy Among Lung Cancer Survivors

OBJECTIVES

The introduction of oral-targeted therapy for cancer improves survival while adherence also presents as a challenge to patients. Current studies on oral anticancer agents are primarily limited to patients from developed countries with breast cancer and chronic myeloid leukemia receiving oral chemotherapy and hormonal therapy. This study explored experience of oral-targeted therapy adherence among Chinese patients with nonsmall cell lung cancer and its contributing factors by using a qualitative research.

DATA SOURCES

Semi-structured interviews with 16 patients and 7 family caregivers at a tertiary tumor hospital in China were conducted to understand their experience and perceptions of oral-targeted therapy. Thematic analysis was applied to generate the themes and to identify underlying factors associated with the adherence.

CONCLUSION

The lung cancer survivors struggled with ambivalence between survival and relief during taking targeted anticancer medication and showed diverse models of nonadherence, including intentionally or unintentionally intermittent medication and overadherence. Three main themes were identified: (1) cancer-related distresses, (2) inadequate social support, and (3) forgetfulness, together with seven subthemes, representing factors impeding patients' medication adherence. The themes demonstrate complicated and interrelated factors from personal, interpersonal, sociocultural, and structural forces contributing to patients' poor adherence.

IMPLICATIONS FOR NURSING PRACTICE

The findings suggest the imperativeness of reinforcing community- or home-based oral-targeted medication management in which nurses play a principal role to implement strategies of patient education, symptom management, reminder prompts, and monitoring to improve adherence.

The Online Representation of Palliative Care by Practice, Policy, and Advocacy Organizations: Definitional Variations and Discursive Tensions

Negative beliefs and a lack of clarity surrounding the meaning of palliative care have been widely reported as obstacles to its uptake. Information available to the public possibly contributes to this. A descriptive and discourse-theoretical analysis was conducted of information spread online by palliative care policy, advocacy, and practice organizations. Discrepancies were found in the way palliative care was defined in relation to curative, end-of-life, terminal, and supportive care. Beyond these definitional variations, meaning was generated through the representation of palliative care as a culture, connected to total care, compassion, and openness. Tensions arose around the concepts of autonomy, a natural death, and an emphasis on the quality of life away from death and dying. Overall, this study showed that the online information of palliative care is a potential source of confusion and might even contribute to its stigmatization. Insights are provided that may help improve clarity toward the public.

Palliative care in the context of immune and targeted therapies: A qualitative study of bereaved carers' experiences in metastatic melanoma

BACKGROUND

Immune and targeted therapies continue to transform treatment outcomes for those with metastatic melanoma. However, the role of palliative care within this treatment paradigm is not well understood.

AIM

To explore bereaved carers' experiences of immune and targeted therapy treatment options towards end of life for patients with metastatic melanoma.

DESIGN

An interpretive, qualitative study using a social constructivist framework was utilised. Interviews were recorded, transcribed and analysed using grounded theory methods.

SETTING/PARTICIPANTS

Participants (n = 20) were bereaved carers of patients who had received some form of immune and/or targeted therapy at one of three Australian metropolitan melanoma treatment centres.

RESULTS

Carers struggled to reconcile the positive discourse around the success of immune and targeted therapies in achieving long-term disease control, and the underlying uncertainty in predicting individual responses to therapy. Expectations that immune and targeted therapies necessarily provide longer-term survival were evident. Difficulty in prognostication due to clinical uncertainty and a desire to maintain hope resulted in lack of preparedness for treatment failure and end of life.

CONCLUSION

Immune and targeted therapies have resulted in increased prognostic challenges. There is a need to engage, educate and support patients and carers to prepare and plan amid these challenges. Educational initiatives must focus on improving communication between patients, carers and clinicians; the differences between palliative and end-of-life care; and increased competency of clinicians in having goals-of-care discussions. Clinicians must recognise and communicate the benefit of collaborative palliative care to meet patient and family needs holistically and comprehensively.

How adverse events and permanent medication stoppages affect changes in patients' beliefs about oral antineoplastic agents

BACKGROUND

Patients with advanced cancer often experience adverse events related to oral antineoplastic agents (OAAs) and permanent OAA medication stoppages, yet it is unknown how these factors impact medication beliefs. Such beliefs about OAA therapy may lend insight into decisions about continued cancer treatment near the end of life.

PURPOSE

To explore relationships that adverse events and permanent OAA stoppages have on medication beliefs during the first 12 weeks following new OAA initiation.

DESIGN

A secondary data analysis from a National Cancer Institute-funded randomized controlled trial testing an intervention to promote symptom management and OAA adherence.

SETTING/SUBJECTS

Patients ≥ 21 years of age initiating a new course of OAA medication were recruited from six United States Comprehensive Cancer Centers. This analysis was based on a subset of patients with advanced disease (N = 60).

MEASUREMENTS

Beliefs about Medicine Questionnaire, Common Terminology Criteria for Adverse Events, and medical records of permanent OAA stoppages.

RESULTS

Significant decline in beliefs regarding the necessity of OAA medications existed between patients experiencing three or more adverse events and those experiencing a permanent OAA stoppage.

CONCLUSIONS

Beliefs about the necessity of OAA medication change when physicians stop OAA medication or the patient experiences three or more adverse events. Concern regarding OAA medication did not change in response to medication stoppage or adverse events for this sample. Perhaps, patients with advanced cancers may be more accepting of adverse events that occur along the treatment trajectory and are not concerned about OAA medication once it is stopped. Findings suggest the importance of physicians' discussions of adverse events and decisions to permanently stop OAA medication as a means of transitioning to a new phase of cancer care that may include palliative or hospice considerations, given that beliefs about medication necessity are changing during these threats to cancer treatment.

The medicalisation of the dying self: The search for life extension in advanced cancer

Although many studies have previously examined medicalisation, we add a new dimension to the concept as we explore how contemporary oncological medicine shapes the dying self as predominantly medical. Through an analysis of multiple case studies collected within a comprehensive cancer centre in Ontario, Canada, we examine how people with late-stage cancer and their healthcare providers enacted the process of medicalisation through engaging in the search for oncological treatments, such as experimental drug trials, despite the incurability of their disease. The seven cases included 20 interviews with patients, family, physicians and nurses, the analysis of 30 documents and 5 hr of field observation. A poststructural perspective informed our study. We propose that searching for life extension enacts medicalisation by shaping the dying person afflicted with terminal cancer into new medical subjectivities that are knowledgeable, active, entrepreneurial and curative. Participants initially took up medical thinking from the formal oncology system, but then began to apply and internalise medical rationalities to alter their personhood, thereby generating new curative possibilities for themselves. For people seeking life extension, the embodied and day-to-day experiences of suffering and being close to death became expressed and moderated in fundamentally medicalised terms.

Conceptualisation of medication beliefs among patients with advanced cancer receiving oral oncolytic agents using a theory derivation approach

OBJECTIVE

This paper describes a derived model that provides a conceptual framework for understanding medication beliefs among patients with advanced cancer receiving oral oncolytic agents.

METHODS

Theory derivation was used to (a) examine the phenomenon of medication beliefs in cross-disciplinary research; (b) select a parent theory for derivation; (c) identify parent theory concepts and/or structure to use in derivation; and (d) redefine parent theory concepts and structure to create a derived model.

RESULTS

Medication beliefs are shaped by previous experiences, including cognitive and emotional factors, past health and illness encounters, and medication-taking behaviours. Medication beliefs are defined within a larger mental model of illness representation for which medication was prescribed. Individuals independently hold both positive and negative medication beliefs at the same time. This distinction is critical to understanding how dichotomous components of medication beliefs change over time as they are influenced by varying treatment-related factors.

CONCLUSION

This paper contributes to conceptual knowledge regarding the phenomenon of medication beliefs and their impact on health behaviour. Findings can support oncology interventions to improve patient outcomes including medication adherence.

Recognizing Risk and Vulnerability in Research Ethics: Imagining the "What Ifs?"

Research ethics committees (RECs) may misunderstand the vulnerability of participants, given their distance from the field. What RECs identify as the vulnerabilities that were not adequately recognized in protocols and how they attempt to protect the perceived vulnerability of participants and mitigate risks were examined using the response letters sent to researchers by three university-based RECs. Using a critical qualitative method informed by feminist ethics, we identified an overarching theme of recognizing and responding to cascading vulnerabilities and four subthemes: identifying vulnerable groups, recognizing potentially risky research, imagining the "what ifs," and mitigating perceived risks. An ethics approach that is up-close, as opposed to distant, is needed to foster closer relationships among participants, researchers, and RECs and to understand participant vulnerability and strength better.