Exploring Pathways to Optimise Care in malignant bowel obstruction (EPOC): A realist review of shared decision-making with people with advanced cancer and severe symptoms
Alison Bravington, Miriam Johnson, Sarah Greenley, Michael Patterson, Jason W. Boland, Fliss E. M. Murtagh, Michael Lind, Mark PearsonBackground:
Malignant bowel obstruction is a life-threatening condition associated with advanced cancer that causes severe pain, nausea and vomiting. Decision-making requires input from multiple specialities, outcomes are uncertain and clinical communication is challenging. Better understanding of the mechanics of shared decision-making would improve the management of this condition.
Aims:
To investigate behavioural and structural influences on decisional deliberation during the management of malignant bowel obstruction and develop strategies for improved communication.
Design:
A realist review following RAMESES guidelines; protocol registered in PROSPERO (CRD42022308251).
Data sources:
Iterative literature searches were conducted from December 2021 to January 2023, with an update search conducted in January 2024. All relevant data sources relating to shared decision-making in the management of malignant bowel obstruction were included.
Results:
Seventy-one papers were included. Realist synthesis led to the development of context-mechanism-outcome configurations in four conceptual areas to explain influences on practitioner, patient and caregiver engagement in shared decision-making: (1) implicit misunderstandings, (2) the nature of the decision, (3) interpersonal dynamics and (4) a fragmented ethos of care. Implicit social mechanisms can affect the transparency of shared decision-making and the value individual decision-makers assign to the process, and motivation to participate is likely to vary as circumstances change.
Conclusions:
Communication around patients with advanced cancer and malignant bowel obstruction is characterised by ambiguity, unrealistic expectations and a lack of interdisciplinary coordination. Crucial features of effective decisional deliberations include alignment of goals of care, unambiguous explanation of treatment limitations and iterative communication to facilitate the formation of realistic expectations.