So far down the track”: the phenomenological exploration of a supportive model of care for patients being considered for colorectal liver resection
Sherwood, Linda Ann
This study explores the experiences of patients being considered for colorectal liver resection combined with the views of health professionals involved in this pathway with the sole intention of developing a supportive model of care for future patients.The treatment of colorectal liver metastases (CRLM) has continued to evolve with promising pace (Stintzig 2018, Adam & Kitano 2019). For many patients, multimodal treatment including surgery and systemic anti-cancer therapy have created a paradigm shift in how a diagnosis of secondary colorectal liver disease is viewed. With this in mind, there is a necessity to develop patient services to be responsive to the needs of those living longer with secondary cancer (Kmietowicz 2015), particularly as issues of survivorship begin to emerge (Haggstrom & Cheung 2019). More than 50% of patients with colorectal cancer will develop CRLM at some point in their disease trajectory (Chow & Chok 2019), making the prospect of radical treatments certainly attractive. Yet, only 20-30% people with CRLM will be eligible for surgery (Manfredi et al 2006, Valderrama-Treviño et al 2017) and as such, issues of uncertainty can punctuate the pathway to potential surgery and beyond. Observationally, working as a nurse specialist within the multidisciplinary colorectal cancer team, it is evident that the pathway to liver resection can be especially demanding for patients, as patients hold in tension the knowledge that their cancer has metastasised with the hope for containment or even cure. However, there is little evidence from the literature to support such observations or how the needs of these patients can best be met. In order to address unanswered questions regarding support, this study is primarily a phenomenological inquiry, staged around the examination of an existing pathway in Phase 1 of the study. In response to this phase, an interim period allowed for the development of a new support structure, led by the specialist nursing team, incorporating a systematic telephone model, development of a patient literature series and development of a patient buddy service. Phase 2 of the study allowed for evaluation of this service development. Both phases include qualitative data from interviews with patients who had been considered for CRLM as well as focus group data from health professionals involved with the pathway. The study is influenced by hermeneutic phenomenology as developed by the twentieth century philosopher, Hans-Georg Gadamer (1960, 1996), in order to guide both method and meaning throughout the progress of the work detailed in the thesis. It draws on the tenets of Gadamer’s ‘fusion of horizons’ (1960) as a fitting vantage point incorporating different viewpoints and my own having insider-outsider knowledge as the researcher. It also latterly brings in the relevance of Frank’s illness narrative (1995). Three overarching themes were identified from Phase 1 which were embedded in the pathway and specific aspects were used to develop the support model;-a path of expectation; an enduring horizon-the companion of uncertainty; a unified horizon-a journey of personal understanding; an individual horizonMoreover, complete analysis from both sets of data uncovered a central strand in these unique and differing patient experiences which translated these experiences into stories of hope. Hope was the mechanism used throughout the pathway and expectation, uncertainty and understanding were components of that hope. This calls into question how we, as health professionals, view hope in metastatic surgery of a radical nature and how we can foster it amidst uncertainty.