Influences on multidisciplinary team decision-making

Abstract

The objective is to explore how clinical decisions are made in a cancer multidisciplinary team meeting (MDM). The study design is qualitative based on participant observation, in depth interviews, and questionnaires. The research setting was weekly cancer MDM which provides a forum for clinical debate for practitioners in the field of women's health, working within one Cancer Network in England. The participants were 53 practitioners attending a weekly MDM over a 4-month period. Analysis of nonparticipant observation data and practitioner interview narratives identified key influences on the work of the MDM, and in particular decision-making. The research identified three major influences on the conduct of the MDM. First, MDM discussions are dominated by those with surgical, medical, or diagnostic expertise with limited contributions from those with a nursing, palliative, or psychosocial background. Second, decision-making is shaped by an overriding need to comply with policy initiatives concerning the organization of diagnosis and treatment. The third influence is whether the patient is known or unknown to some degree by members of the MDM. Where there is preexisting knowledge of the patient, the discussion and decision is inclusive of a wider range of disciplines. Team working in these circumstances is an acknowledged source of satisfaction and motivation. Where the patient is not known, discussion concerns only the physical details necessary to make a diagnosis and contributions from the wider team (including those with knowledge of psychosocial care) are rare. Practitioners' sphere of expertise, Department of Health policy, and familiarity of the team with the patient are key factors in shaping decision-making in MDMs.

Is it worth reorganising cancer services on the basis of multidisciplinary teams (MDTs)? A systematic review of the objectives and organisation of MDTs and their impact on patient outcomes

“…Essentially, there were three types of formats in clinical practice. Firstly, there were meetings, which lasted anywhere from 30 min to 2 h and included either all or a selection of diagnosed and/or referred patients; patients were selected by the specialist in charge based on the case's level of complexity or the wide range of therapeutic possibilities, prearranged team criteria, or triage by the clinical coordinator [27,30,[32][33][34]46,48,50]. A second MDT format was the multidisciplinary clinic, where patients were not only seen but also simultaneously examined [16,38,40,53,54] or remotely coordinated by all board members [42].…”

“…Nonetheless, an analysis of the studies allowed the differentiation between 'inward' responsibilities (MDT organisation and efficient direction) and Harrison [45] Lanceley [46] Soukop [47] Choy [48] Chirgwin [49] Scher [ Wilcoxon [52] Magnani [53] Hudak [54] Wiederholt [55] Maslin-Prothero [56] Kuroki [57] Sweeney [58] Brennan [60] Jefford [61] Hong [62] Jones [63] Bellardita [64] Mandate adapted from Wright et al [12] 'outward' responsibilities (clinical management of the care plan). Whereas inward responsibilities consisted of scheduling agendas for meetings, drawing up the list of patients to be discussed, ensuring that all necessary tests were obtained and available in advance of the discussion, and recording the MDT decisions and rationales agreed [34,38,42,45,46], outward tasks entailed communicating decisions to patients/families, GPs, providers and referring physicians, as well as coordinating outpatient visits and referrals from satellite centres, and facilitating the link to research either directly or by improving liaison with the clinical trial coordinator [24,32,34,38,42,43,53,54]. Other studies documented the role of clinical nurses in guiding the patient through the care pathway or assuming the task of coordinating the follow-up [29,40,42,43,45,47,…”

The welfare model: A paradigm shift in medical decision-making

“…It is the preservation of the patient's welfare that is central to the MDT and their actions are defined by prevailing clinical, professional and legal standards [21][22][23][24]. Therefore, while it may be in keeping with the principle of autonomy to discharge the patient, the MDT must determine if there is adequate care available at home and whether the patient's safety can be guaranteed.…”

“…The WM is not an attempt to replace family-led decision-making with physician-led medical paternalism, but seeks instead to ensure that patient welfare, as determined holistically by a multidisciplinary team (MDT), is not compromised [8,14]. The WM dispenses with the notion of physicians as sole arbitrators and employs an MDT to holistically determine the best interests of patients [21][22][23][24]. An MDT is defined as a "group of people from different healthcare disciplines, meeting together at a given time to discuss the management of patients, as well as elaborate upon the various biopsychosocial, spiritual and cultural determinants that may be relevant to the provision of care and support to patients and their families".…”

“…Each member of the team approaches the patient from their own clinical perspective, acknowledging them as autonomous individuals while simultaneously recognizing the influence of social, cultural, familial and economic factors. The team members work together in a seamless fashion, maintaining transparency and accountability and adhering to the current professional, clinical and legal guidelines with the central goal being, ensuring a holistic and balanced picture of the patient and their needs [21][22][23][24].…”