| الوصف: |
Febrile neutropenia is the commonest life-threatening complication of treatment for children with cancer. Though the majority of children have no significant complications associated with its occurrence, current management includes intravenous antibiotics and in-patient care. Reduced therapy regimes for children at low risk of complications may have benefits for families and the National Health Service. This thesis aimed to answer two main questions: In children and young people with low risk febrile neutropenia, are reduced therapy regimes safe, effective and acceptable to key stakeholders? What factors are involved in decision-making about acceptability of early discharge regimes? Given the complexity of the research problem, the work utilised a mixed methods approach, selecting appropriate methodologies for each aspect of the problem and then combining results to provide a nuanced consideration of this multifaceted topic. Three sequential phases were performed, each informing and developing the next, whilst simultaneously allowing deeper interpretation of findings in earlier phases. Phase one, a quantitative systematic review, provided safety and treatment failure rates relating to reduced therapy regimes, whilst phase two, a qualitative synthesis, presented an interpretive account of experiences of early discharge. Phase three involved a focus group study exploring experiences and perceptions of key stakeholders involved in febrile neutropenia care in the United Kingdom. Following mixing of phases in both design and interpretation stages, the thesis found that reductions in therapy are associated with increased readmission rates, but not increased risk of serious adverse events. It exposed the previously underestimated harms of febrile neutropenia admissions and the paternalistic nature of decision making. Increasing shared decision making through discussing risks, developing mutual trust and negotiating control is necessary to achieve individualised treatment and improve experiences for stakeholders. The thesis outlines aspirations for future care of these children and young people and proposes various actions to achieve these goals. |
