Patient involvement in multidisciplinary team decision making in head and neck cancer :an ethnographic study

Abstract

Head and neck cancer (HNC) confers a poor prognosis and patients face complex treatment decisions. As with every cancer in the UK, recommendations for treatment are made through a multidisciplinary team (MDT). This thesis critically analyses the working of the MDT: data are presented from an ethnographic study across three head and neck cancer treatment centres. Data collection comprised non-participant observation of 35 MDT meetings and 37 MDT clinic appointments and semi-structured interviews with 19 patients pre- and post-treatment and nine staff members of the MDT. Data generated were analysed using a Constructionist Grounded Theory approach, drawing on symbolic interactionism and dramaturgical analysis. This thesis provides an in depth account of the backstage behaviour of the MDT members. Although an assessment of which treatment is considered ‘best’ drives their discussion, there is often disagreement or uncertainty surrounding this assessment. On delivering the recommendation to the patient, this backstage work often remains hidden, contributing to problems when offering treatment choice. Even when a choice of treatment is acknowledged, the MDT faces barriers in delivering and supporting this in the MDT clinic. For the patient, the majority of the work of decision making takes place away from the MDT clinic, a process which is not always supported by the MDT The difficulties of actively involving patients in the MDT decision process have never been explored, but the complexities of offering treatment choice in the MDT need to be recognised to support patients in this setting. The guiding principles, purpose and limitations of the MDT meeting and the resultant treatment recommendation need to be iii clear. A process of collaborative MDT decision making should allow effective communication of treatment risk and uncertainty, structured elicitation of patient preferences and support for patients to make decisions in line with their preferences and values.