Date of Award

2023

Degree Name

Doctor of Philosophy (College of Medicine)

Schools and Centres

Medicine

First Supervisor

Professor David Kissane

Second Supervisor

Professor George Mendz

Abstract

For many, a cancer diagnosis signals death's inevitability and elicits much existential concern. In the quest for life prolongation, many are offered or seek life-sustaining treatments, fail to appreciate a declining trajectory and lack the opportunity to seek information or plan meaningfully for their future.

Advance care planning (ACP) provides an avenue for patients and their caregivers to plan for future care. ACP is defined ‘as a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals and preferences regarding future medical care’ and is a key quality indicator in cancer care. An increased emphasis is now placed on exploring values and beliefs to ensure alignment with the choices made relating to treatment decisions and end-of-life desirables.

The uptake of ACP in cancer remains poor due to patient, caregiver, practitioner, and operational factors. For the clinician, the challenge remains as to how best to maintain hope, despite provoking and honest conversations. Increasingly, novel interventions are being developed to promote uptake in ACP. This includes the vignette technique (VT), whereby patients and/or caregivers are exposed to future scenarios in written or video material.

My studies were the first to explore the use of video vignettes to explore values conversations between patient-caregiver dyads. These studies described older participants as more likely to identify with ACP and values conversations, the importance of ACP in improving patient-caregiver concordance in communication and that cancer patients concurrently postured vulnerability and resilience, despite conflicting emotions and experiences.

I highlight that ACP requires contextualisation of individual situations and values and should focus on achieving meaningful outcomes beyond completing documents. Future research will focus on improving and measuring concordance in communication as an outcome for ACP and techniques to enhance ACP engagement in younger cancer patients.

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