Cancer and dementia: an exploratory study of the experience of cancer treatment in people with dementia

Objective Patients with comorbid cancer and dementia have poorer outcomes than those without dementia. We observe oncology teams managing patients with dementia and memory loss and explore these patients' needs and experiences of outpatient cancer services. Methods A single site investigation of case study design to examine practices in four clinics using multi‐methods of data collection: retrospective note review, observation, interviews, and recorded consultations. A framework analytic approach identifies themes within and across cases. Results Thirty‐three clinical encounters with patients with memory loss were observed. Ten consultations were audio‐recorded and 16 individuals interviewed (n = 6 patients‐carer dyads, n = 1 lone patient, and n = 5 staff). Medical records were reviewed for 338 cases. Cancer referrals did not document memory health, so clinicians rely on patient/carer disclosure to identify patients with memory problems. In practice, the problem often remains hidden. Treating teams who do become aware of memory difficulties are unsure how to support patients, but marked memory loss can limit treatment options and preclude radical intent. Carers are key facilitators of successful cancer consultations and management. Their support needs are largely unrecognized. Conclusions Training that educates cancer teams on how to identify and support individuals with memory problems before and during treatment and recognize the carer role may facilitate complex cancer care and help reduce inequalities of outcomes

Begreppet verkligt värde : En studie med utgångspunkt i sambandet mellan redovisning och beskattning.

I Sverige har vi ett starkt samband mellan redovisning och beskattning. Under de senaste åren har redovisningen förändrats på grund av en ökad internationalisering. Detta har bland annat inneburit att användandet av verkligt värde har ökat vilket även har fått konsekvenser för beskattningen på grund av det nämnda sambandet. Begreppet verkligt värde har till och med införts i skattelagstiftningen, i 18 kap. 18 § IL som säger att om det verkliga värdet är lägre än det skattemässiga får ytterligare avdrag göras utöver det vanliga värdeminskningsavdraget. Dock finns ingen närmare förklaring av vad som menas med begreppet verkligt värde eller hur det ska tolkas. Huvudregeln i inkomstslaget näringsverksamhet är att resultatet ska beräknas enligt god redovisningssed om inga specifika skatterättsliga regler finns enligt 14 kap. 2 § IL. Detta skulle kunna innebära att god redovisningssed kan användas för att utreda hur begreppet verkligt värde ska tolkas i 18 kap. 18 § IL. I sådana fall visar studien att endast ett fåtal av de tillgångar som omfattas av paragrafen faktiskt skulle kunna skrivas ned och regeln skulle endast kunna användas att ett begränsat antal företag. Dessutom skulle det lägre värdet behöva vara bestående om det är god redovisningssed som ska gälla. Dock är det svårt att dra den slutsatsen på grund av ett rättsfall som jag anser ökar förvirringen kring den aktuella paragrafen. Detta innebär att det är svårt att utröna exakt vad som ska gälla och en klar och tydlig redogörelse för begreppet verkligt värde kan inte presenteras. Därför blir min slutsats att det behövs tydligare riktlinjer i skattelagstiftningen angående hur begreppet verkligt värde ska tolkas i 18 kap. 18 § IL

Crisis management for people with dementia at home: Mixed‐methods case study research to identify critical factors for successful home treatment

Best practice in dementia care is support in the home. Yet, crisis is common and can often result in hospital admission with adverse consequences. The objective of this mixed‐methods case study research was to identify the critical factors for resolving crisis for a person with dementia living at home. The research was an in‐depth investigation of what happens during crisis for people with dementia and how it is managed by a Home Treatment Crisis Team to resolution and outcome at 6 weeks and 6 months. The methods were; observation of crisis management for 15 patients with dementia (max three observations per patient, total 41), interviews with patients with dementia (n = 5), carers (n = 13) and professionals (n = 14, range one to six interviews per person, total 29), focus group (nine professionals), and extraction of demographics and medical history from medical records. Analysis focused on the identification of factors important for crisis resolution and avoidance of hospital admission. Critical factors for the Home Treatment Crisis Team to enable successful crisis resolution were: immediate action to reduce risk of harm, expertise in dementia care and carer education, communication skills to establish trust and promote benefits of home treatment, shared decision‐making, medication management, addressing the needs of carers independently of the person with dementia and, local availability of respite and other community services. The Home Treatment Crisis Team integrated the seven factors to deploy a biopsychosocial systems approach with embedded respect for personhood. This approach enabled crisis resolution for a person with dementia by creating a system of services, treatments, resources and relationships, ‘Safe Dementia Space’, in the community with avoidance of hospital admission in more than 80% of referrals. The identified critical factors for crisis resolution are important considerations in the design and delivery of home treatment services for people with dementia.Research for Patient and Public Benefit, Healthcare Research Wales. RfPPB-16-118

Understanding approaches to continence care for people with dementia in acute hospital settings: an ethnographic study

Background: The acute hospital setting has become a key site of care for people living with dementia. People living with dementia are one of the largest populations in our hospitals, with the Department of Health and Social Care recognising that 25–50% of all acute hospital admissions are people who are also living with dementia. However, people living with dementia are a highly vulnerable group in the hospital setting and following an acute admission their functional abilities can deteriorate quickly and significantly. Detailed research is required to explore what constitutes ‘good care’. Objectives: This study’s focus was a common but poorly understood aspect of everyday care for people living with dementia during an acute admission, that is continence care. We asked the following questions: what caring practices are observable when interacting with this patient group? How do ward teams respond to and manage continence needs? What informs these approaches? What are staff doing and why? Design: This ethnography was informed by the symbolic interactionist research tradition, focusing on understanding how action and meaning are constructed within a setting. In-depth evidence-based analysis of everyday care enabled us to examine how ward staff responded to the continence care needs of people living with dementia and to follow the consequences of their actions. We carried out a mixed-methods systematic narrative review to refine our approach to fieldwork and analysis. Setting: This ethnography was carried out for 180 days, across 12 months, in six wards in three hospitals across England and Wales that were purposefully selected to represent a range of hospital types, geographies and socioeconomic catchments. Participants: In addition to general observations, 108 individuals participated directly in this study, contributing to 562 ethnographic interviews. Ten detailed case studies were also undertaken with people living with dementia. Results: This study identified ‘pad cultures’ as an embedded practice on these acute wards. The routine use of continence pads among people living with dementia (regardless of continence and independence) was widespread. The use of continence pads was viewed as a precautionary strategy, the rationale being to provide safeguards, ensure containment and prevent ‘accidents’ or incontinence episodes, with an expectation that patients living with dementia not only will wear pads, but will use them. Conclusions: These ‘pad cultures’ enabled the number of unscheduled interruptions to the institutionally mandated timetabled work of these wards to be reduced, but had significant impacts on people living Q2 with dementia and, in turn, wider impacts on the individuals and their identities. Ward staff described feeling abandoned with the responsibility of caring for large numbers of people living with dementia, believing that it was impossible to work in other ways to support their patient’s continence. Limitations: Limitations identified included the potential for the Hawthorne effect to influence data collection. Future work: In collaboration with a specialist dementia care and continence teams, the findings are informing the development of education and training at an interactional and organisational level. Study registration: This study is registered as PROSPERO CRD42018119495