Inviting the Patient to Talk About a Conversation They Had with Another Healthcare Practitioner: A Way of Promoting Discussion About Disease Progression and End of Life in Palliative Care Interactions

ABSTRACT

Discussing disease progression is a core task in palliative care. This is especially important when there are indications that a patient considers their death as less imminent than the clinical team does. This article examines a communicative action that palliative medicine doctors use to address such discrepancies in knowledge and understanding of the patient’s prognosis: inviting the patient to talk about the contents of a conversation they had with another healthcare practitioner. The study used conversation analysis to examine five consultations in which this action was identified. These were part of a larger data set of 37 consultations recorded in a large UK hospice and involving patients with palliative care needs, sometimes accompanied by family or friends, and palliative medicine doctors. Findings are that the action of inviting the patient to talk about a previous conversation creates an opportunity for patients to articulate what they know and understand about their disease progression – but without requiring them to do so. Discussing such sensitive matters is thus made a matter of ‘opting in’ (rather than ‘opting out’). Doctors thereby avoid being interactionally accountable for directly initiating a potentially distressing topic. The article shows how the task of discussing disease progression and end of life is intertwined with the delicate management of patients’ displayed states of awareness regarding their disease progression. The study thus has practical implications by documenting ways in which clinicians can help patients realign their expectations about such delicate matters.

Acknowledgment

We would like to thank the staff, patients, and their companions who consented to being recorded. We are grateful to Ruth Parry for her overarching work in establishing and leading the VERDIS project and building and supporting the team that made this paper possible. We are also indebted to Ruth for her invaluable input on the analyses leading up to this paper. We thank two anonymous reviewers for their detailed and helpful comments on an earlier version of this article. Our gratitude also goes to Elizabeth Jenkins, whose insightful clinical perspectives greatly improved the clarity of this paper.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes

1. This may also explain why the doctor did not do so right after the epistemic discrepancy emerged in Figure 2; the interactional environment in Figure 3, after Eashan has shown some orientation to concerns about disease progression, is more favorable.

Additional information

Funding

Part of this work was funded by The Health Foundation [Grant IDs: AIMS 1273316, AIMS 1273743/GIFTS 7210], an independent charity committed to bringing about better health and social care for people in the UK, and by the National Institute for Health Research Academy Career Development Fellowship to project lead Ruth Parry: ‘Enhancing staff-patient communication in palliative and end of life care’ (Grant ID CDF-2014-07-046). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.