Feasibility of implementing a decision aid for advanced cancer patients in a comprehensive cancer centers' outpatient setting: Valuable lessons learned

Background: Decision aids (DAs) have been proposed as tools to empower patients in decision-making. However, implementing DA for decisions in advanced cancer is challenging. This study focuses on perspectives of oncologists and other healthcare providers on the hindering and facilitating factors for implementing a customizable DA. This DA is designed to support discussions about whether patients with advanced, incurable cancers should pursue or forgo further anticancer treatment.

Methods: This qualitative study utilized content analysis following Sandelowski's approach on two different datasets derived from research projects on decision-making in advanced cancer. To inform the development of a DA and understand challenges related to its implementation, we conducted semi-structured interviews with 24 oncologists (Dataset 1) and three focus groups with various healthcare professionals (n = 19) and in addition post-implementation semi-structured interviews with oncologists who used the DA in conversations with their cancer patients (n = 5) (Dataset 2). Furthermore, the insights from process evaluation of developing and implementing the DA in an outpatients' settings was incorporated, enriching the analytical framework.

Results: Two overall themes emerged: (1) Tension between standardizing the use of a DA and responding to individual patient needs. To address this conflict, a two-part DA was developed, combining structured elements with flexibility. (2) Prerequisites for the use of the DA in outpatients' settings: Senior physicians' support, education in palliative care options and in the use of the DA, and organizational conditions.

Conclusion: Oncologists identified both structural and content-related aspects for a successful implementation of a DA for patients with advanced cancer. While the content-related aspects were factored into the development of the DA, structural (organizational) issues need to be especially focused on during implementation.