Transcript Decision-making in a health care crisis: Men under 60

Decision-making in a
health care crisis:
Men under 60 diagnosed
with prostate cancer
Tawna Skousen
Supervisory Committee Members:
Lynne Durrant, PhD Chair (HPE)
Barbara J. Richards, PhD (HPE)
Susan L. Morrow, PhD (Educ Psychology)
Teresa M. Pavia, PhD (Marketing)
Saundra S. Buys, MD (Oncology)
Outline

Background & Introduction
 Literature Review
 Research Questions
How I did it

Methods
What I found out

Results
What I thought about what I found out

Discussion
Background & Introduction
Prostate cancer is an “old man’s” disease
Annual age-specific incidence rates, 1973-2000
10000
80+
1000
60-69
100
50-59
10
40-49
Diagnosis Y ear
1999
1997
1995
1993
1991
1989
1987
1985
1983
1981
1979
1977
1975
1
1973
Rate per 100,000
70-79
Literature Review
• The Big “C”
– Prostate cancer
Literature Review
• The Big “D”
– Decision making
• When Big “C” meets Big “D”
– Decision making &
prostate cancer
Research questions
Research question #1
• What are the decisions being made
by men diagnosed with prostate
cancer under age 60?
Research question #2
• What are the data elements associated with
these decisions? How do they reach a treatment
decision? (Are there particular steps?)
– Subsumed under this question: To what extent are
health care decisions based on past experiences of
decision-making? To what extent are they
dependent on doctor recommendation or support
systems and other feedback? To what extent are
these treatment decisions based on fear of death –
or fear of impotence or incontinence? Are their
decisional processes the same as when making any
other major decision?
Methods
Qualitative focus
• Designed to explore human aspects and
life’s circumstances
• Seeks to understand what the
situation/phenomenon/experience
means
Grounded theory
• Is used to generate a middle-range
theory that explains basic social
processes
• Rationale: a theory formed during data
collection will be more applicable than one
developed before a study begins
• Symbolic interactionism
• meaning, language, thought
Grounded theory, cont.
Data Collection
First Interview
Second Interview
Third Interview
Close to Saturated
Categories
Data Analysis
Preliminary Categories
Refined Categories
More Refined Categories
Saturation
Participants
• Recruitment
• Sampling
Data collection
• Interviews
• Demographic
questionnaire
• Field
observation
• Archival
materials
• Memos
Data analysis
• Concept formation & development
• Coding: open, axial, selective
• Core category
• Concept modification & integration
Results
-Phone: said biopsy
was “positive” for
cancer – “so, come in
soon, okay?”
-Phone: nurse said
“you have a little bit of
cancer”
-“Sheer panic”. Wanted
cancer out ASAP.
-Not overwhelmed or
shocked
-Even-tempered,
handles stuff well
-Job, family
responsibilities
-”Biggest
support is
family”
Personality
Developmental stage
Support system
Medical
communication
Emotional
impact
Initial
management
Domain I: Health Care
Orientation
• Family experience
• Health care experience
• Health care beliefs
Domain II: Crisis of Diagnosis
• Medical communication
• Emotional impact
• Initial management
– Support
[wife] “From the beginning, the cancer had become ‘ours,’ not
just his. I became involved in his treatment decisions and
went with him to his doctor’s visits, asking many questions.
Later, I would find myself saying things like, ‘We’re going to
have surgery.’”
Domain III: Investigating
Prospects
• Information acquisition
“I wasn’t hearing anything I wanted
to hear.”
“I wanted good honesty, not bad
honesty.”
“…proceeded to get drunk and started
searching the Internet - which was
probably a huge mistake, but in some
ways, it is good that I educated myself.
Um.. I mean a lot of it just flat scared me
to death and made me depressed beyond
words.”
• Issues explored
The emotions I was feeling were shock,
depression; the worst pain of all was
having my son, my little 7 year old son,
see me whither away and not be the
strong thing that he had come to know.
And that was making me feel the worst.
Um.. I want to be, I want him to be proud
of me.”
Domain IV: Determining Choice
• Synthesizing data
– Expert opinions
Domain V: Reflections
•
•
•
•
•
Treatment experience
Precipitating event
Education and knowledge wished for
Lifestyle change
Meanings of and reasons for cancer
Core Category
• Main theme, pulling all other categories
together
• Reflects actions/decisions of
participants
Expectation
Health
Care
Orientation
Investigating
Prospects
Time crunch
Treatment experience
Reflections
Crisis of
Diagnosis
Determining
Choice
Health Care
Orientation
Crisis of
Diagnosis
Investigating
Prospects
Determining
Choice
Time crunch
Reflections
Discussion
Symbolic Interactionism
Meaning
– Fear, dread, belief of imminent death if cancer not
removed
– Unpleasant, unwelcome disease that could be treated
and eliminated
Language
– “Get it out!” “Cut it out!”
• Surgery (excise cancer)
– “Get rid of it.” “Deal with it.”
• Pursued other options (eliminate cancer)
Symbolic Interactionism
Thought (mental conversation)
– Hope versus harsh reality
• HOPE: doctor assurances, others’ positive
experiences, religion, philosophy, spiritual beliefs
• HARSH REALITY: others’ negative experiences,
recurrence
short
long
Decision-making
My domains (categories)
Health Care Orientation
Health Care Beliefs
Crisis of Diagnosis
Investigating Prospects
Determining Choice
Treatment Experience
Reflections
Expectation
Decision theory stages
Environmental, Internal Factors
Biases, Heuristics
Diagnostic, Identification of the
Problem
Actions, Obtaining Necessary
Information, Production of Possible
Solutions or Alternatives
Evaluation of Solutions, Selection
of Alternative or Strategy
Implementation of Selection
Evaluation of Selection,
Probabilities for Recurrence,
Regret Theory
Utilities, Rewards, Satisficing
Limitations
Sample size
Demographics
– Education, ethnicity, SES – insurance
Implications
Provides a research-based framework to
explain decisions made in the context of a
health crisis.
Provides insight to educators, health care
providers, and researchers about influences
involved in making treatment decisions
Facilitates decision making (understanding
of components and personal values)