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Tate A, Spencer KL. High-Stakes Treatment Negotiations Gone Awry: The Importance of Interactions for Understanding Treatment Advocacy and Patient Resistance. JOURNAL OF HEALTH AND SOCIAL BEHAVIOR 2024; 65:237-255. [PMID: 37905523 PMCID: PMC11058117 DOI: 10.1177/00221465231204354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Doctors (and sociologists) have a long history of struggling to understand why patients seek medical help yet resist treatment recommendations. Explanations for resistance have pointed to macrostructural changes, such as the rise of the engaged patient or decline of physician authority. Rather than assuming that concepts such as resistance, authority, or engagement are exogenous phenomena transmitted via conversational conduits, we examine how they are dynamically co-constituted interactionally. Using conversation analysis to analyze a videotaped interaction of an oncology patient resisting the treatment recommendation even though she might die without treatment, we show how sustained resistance manifests in and through her doctor's actions. This paradox, in which the doctor can both recommend life-prolonging care and condition resistance to it, has broad relevance beyond cancer treatment; it also can help us to understand other doctor-patient decisional conflicts, for instance, medication nonadherence, delaying emergent care, and vaccine refusal.
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2
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Pino M, Jenkins L. 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. HEALTH COMMUNICATION 2024; 39:778-792. [PMID: 36908097 DOI: 10.1080/10410236.2023.2185579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
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.
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Affiliation(s)
- Marco Pino
- School of Social Sciences and Humanities, Loughborough University
| | - Laura Jenkins
- School of Social Sciences and Humanities, Loughborough University
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3
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Koopman WJ, LaDonna KA, Kinsella EA, Venance SL, Watling CJ. Archetypes of incomplete stories in chronic illness medical encounters. PATIENT EDUCATION AND COUNSELING 2023; 117:107973. [PMID: 37734249 DOI: 10.1016/j.pec.2023.107973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 08/25/2023] [Accepted: 09/05/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE During encounters, patients and practitioners engage in conversations to address health concerns. Because these interactions are time-pressured events, it may be inevitable that any story exchanged during these encounters will be incomplete in some way, potentially jeopardizing how quality and safety of care is delivered. In this study, we explored how and why incomplete stories might arise in health interactions. METHODS Constructivist grounded theory methodology was used to explore how patients and practitioners approach their interactions during encounters. In this two-phase study, we interviewed patients (n = 21) then practitioners (n = 12). RESULTS We identified three distinct archetypes of incomplete storytelling - the hidden story, the interpreted story, and the tailored story. Measured information sharing, triadic encounters and pre-planned agendas influenced these storylines, respectively. CONCLUSION Both patient and practitioner participants focused on what each considered important, appropriate, and useful for productive encounters. While incomplete stories may be a reality, educating practitioners about how incomplete stories come about from both sides of the conversation creates new opportunities to optimize interactions at medical encounters for in-depth patient practitioner storytelling.
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Affiliation(s)
- Wilma J Koopman
- Health and Rehabilitation Sciences, Western University, London, Ontario, Canada; London Health Sciences Centre, London, Ontario N6A 3K7, Canada; Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario N6A 3K7, Canada; Centre for Education Research & Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario N6A 3K7, Canada.
| | - K A LaDonna
- Department of Innovation in Medical Education and Department of Medicine, University of Ottawa, Ottawa, Ontario K1G 5Z3, Canada
| | - E A Kinsella
- Health and Rehabilitation Sciences, Western University, London, Ontario, Canada; Institute of Health Sciences Education, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec H3A 1A3, Canada
| | - S L Venance
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario N6A 3K7, Canada
| | - C J Watling
- Centre for Education Research & Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario N6A 3K7, Canada
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4
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Abstract
This Viewpoint identifies examples of bad communication from cancer clinicians toward patients as well as better methods for clinicians to use when communicating with patients with cancer.
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Affiliation(s)
- Donald R Sullivan
- Division of Pulmonary, Allergy, and Critical Care Medicine, Oregon Health and Science University, Portland
- Knight Cancer Institute, Oregon Health and Science University, Portland
| | - William E Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Abby R Rosenberg
- Division of Pediatric Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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5
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Porter AS, Woods C, Stall M, Velrajan S, Baker JN, Mack JW, Kaye EC. Oncologist approaches to communicating uncertain disease status in pediatric cancer: a qualitative study. BMC Cancer 2022; 22:1109. [PMCID: PMC9620648 DOI: 10.1186/s12885-022-10190-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 09/28/2022] [Accepted: 10/17/2022] [Indexed: 11/10/2022] Open
Abstract
Background Most patients with cancer and their caregivers desire honest, clear prognostic communication, yet oncologists often disclose prognosis inconsistently. Prognostic communication becomes even more challenging when disease progression is unclear or equivocal. Presently, oncologist approaches for discussing uncertain disease findings are poorly understood. Methods In this prospective, longitudinal study, we audio-recorded serial disease reevaluation conversations between children with high-risk cancer, their families, and their primary oncologists over 24 months and conducted content analysis at recorded timepoints when oncologists categorized disease progression as equivocal. Results Of the 265 medical discussions recorded across the illness course for 33 patient-parent dyads, a total of 40 recorded discussions took place at equivocal timepoints, comprising > 500 min of medical dialogue. Prognosis talk encompassed < 3% of dialogue and was absent in nearly half of equivocal discussions (17/40, 42.5%). Curability statements were identified in only two conversations. Inductive content analysis of dialogue revealed four distinct patterns for communicating equivocal disease status: (1) up-front reassurance, (2) softening the message, (3) describing possible disease progression without interpretation, (4) expressing uncertainty without discussing the bigger picture. Conclusion Oncologists rarely discuss prognosis with children with high-risk cancer and their families at timepoints when disease progression is not definitive. Formal guidance is needed to better support oncologists in navigating uncertainty while sharing honest, person- and family-centered information about prognosis. Supplementary information The online version contains supplementary material available at 10.1186/s12885-022-10190-6.
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Affiliation(s)
- Amy S. Porter
- grid.240871.80000 0001 0224 711XSt. Jude Children’s Research Hospital, Memphis, TN USA
| | - Cameka Woods
- grid.240871.80000 0001 0224 711XSt. Jude Children’s Research Hospital, Memphis, TN USA
| | - Melanie Stall
- grid.267313.20000 0000 9482 7121The University of Texas Southwestern Medical Center, Dallas, TX USA
| | | | - Justin N. Baker
- grid.240871.80000 0001 0224 711XSt. Jude Children’s Research Hospital, Memphis, TN USA
| | - Jennifer W. Mack
- grid.65499.370000 0001 2106 9910Dana-Farber Cancer Institute, Boston, MA USA ,grid.2515.30000 0004 0378 8438Boston Children’s Hospital, Boston, MA USA
| | - Erica C. Kaye
- grid.240871.80000 0001 0224 711XSt. Jude Children’s Research Hospital, Memphis, TN USA ,grid.240871.80000 0001 0224 711XDivision of Quality of Life and Palliative Care, Department of Oncology, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Mail Stop 1121, 38105 Memphis, TN USA
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6
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Tate A. Death and the treatment imperative: Decision-making in late-stage cancer. Soc Sci Med 2022; 306:115129. [PMID: 35717824 PMCID: PMC10772987 DOI: 10.1016/j.socscimed.2022.115129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 06/03/2022] [Accepted: 06/10/2022] [Indexed: 11/22/2022]
Abstract
Care at the end-of-life in the United States has expanded in the past decade in large part due to structural changes such as increased access to hospice care, the integration of palliative care, policy mandates, and financial incentives. Despite these shifts, research shows that appropriate end-of-life care continues to be underutilized. This paper uses conversation analytic (CA) and ethnographic methods to examine doctor-patient interactions among a sample of 14 Stage IV cancer patients and the way decisions unfold about next steps in treatment during a moment that larger policy changes began to take place following passage of the Affordable Care Act. This work reveals that, despite structures designed to better facilitate end-of-life care transitions for patients in late life, doctors continue to demonstrate interactional hesitancy in discussing the possibility of a patient's end-of-life in treatment discussions and an orientation to the treatment imperative. Examining doctor-patient interaction as one key trouble source in end-of-life care implementation shows in situ evidence that the treatment imperative supersedes the structural shifts supporting less medical intervention in late life.
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7
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Xu T, Qin Y, Ou X, Zhao X, Wang P, Wang M, Yue P. End-of-life communication experiences within families of people with advanced Cancer in China: A qualitative study. Int J Nurs Stud 2022; 132:104261. [DOI: 10.1016/j.ijnurstu.2022.104261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 04/13/2022] [Accepted: 04/17/2022] [Indexed: 12/24/2022]
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8
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Ekberg S, Parry R, Land V, Ekberg K, Pino M, Antaki C, Jenkins L, Whittaker B. Communicating with patients and families about illness progression and end of life: a review of studies using direct observation of clinical practice. BMC Palliat Care 2021; 20:186. [PMID: 34876096 PMCID: PMC8651503 DOI: 10.1186/s12904-021-00876-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 10/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is growing recognition that a diverse range of healthcare professionals need competence in palliative approaches to care. Effective communication is a core component of such practice. This article informs evidence-based communication about illness progression and end of life through a rapid review of studies that directly observe how experienced clinicians manage such discussions. METHODS The current rapid review updates findings of a 2014 systematic review, focussing more specifically on evidence related to illness progression and end-of-life conversations. Literature searches were conducted in nine bibliographic databases. Studies using conversation analysis or discourse analysis to examine recordings of actual conversations about illness progression or end of life were eligible for inclusion in the review. An aggregative approach was used to synthesise the findings of included studies. RESULTS Following screening, 26 sources were deemed to meet eligibility criteria. Synthesis of study findings identified the structure and functioning of ten communication practices used in discussions about illness progression and end-of-life. CONCLUSION The ten practices identified underpin five evidence-based recommendations for communicating with patients or family members about illness progression and end of life.
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Affiliation(s)
- Stuart Ekberg
- School of Psychology & Counselling, Queensland University of Technology, Victoria Park Road, Kelvin Grove, Queensland, 4059, Australia.,Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Ruth Parry
- School of Social Sciences and Humanities, Loughborough University, Brockington Building, Epinal Way, Margaret Keay Road, Loughborough, LE11 3TU, UK.
| | - Victoria Land
- School of Social Sciences and Humanities, Loughborough University, Brockington Building, Epinal Way, Margaret Keay Road, Loughborough, LE11 3TU, UK
| | - Katie Ekberg
- School of Early Childhood & Inclusive Education, Queensland University of Technology, Victoria Park Road, Kelvin Grove, Queensland, 4059, Australia.,School of Health & Rehabilitation Sciences, University of Queensland, St Lucia, Queensland, 4072, Australia
| | - Marco Pino
- School of Social Sciences and Humanities, Loughborough University, Brockington Building, Epinal Way, Margaret Keay Road, Loughborough, LE11 3TU, UK
| | - Charles Antaki
- School of Social Sciences and Humanities, Loughborough University, Brockington Building, Epinal Way, Margaret Keay Road, Loughborough, LE11 3TU, UK
| | - Laura Jenkins
- School of Social Sciences and Humanities, Loughborough University, Brockington Building, Epinal Way, Margaret Keay Road, Loughborough, LE11 3TU, UK
| | - Becky Whittaker
- School of Social Sciences and Humanities, Loughborough University, Brockington Building, Epinal Way, Margaret Keay Road, Loughborough, LE11 3TU, UK
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9
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Westendorp J, Evers AWM, Stouthard JML, Budding J, van der Wall E, Plum NMF, Velting M, Francke AL, van Dulmen S, Olde Hartman TC, Van Vliet LM. Mind your words: Oncologists' communication that potentially harms patients with advanced cancer: A survey on patient perspectives. Cancer 2021; 128:1133-1140. [PMID: 34762305 PMCID: PMC9298810 DOI: 10.1002/cncr.34018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 09/20/2021] [Accepted: 09/27/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Many complaints in medicine and in advanced illnesses are about communication. Little is known about which specific communications harm. This study explored the perspectives of patients with advanced cancer about potentially harmful communication behaviors by oncologists and helpful alternatives. METHODS An online survey design was used that was based on literature scoping and patient/clinician/researcher input. Patients with advanced cancer (n = 74) reflected on the potential harmfulness of 19 communication situations. They were asked whether they perceived the situation as one in which communication could be harmful (yes/no). If they answered "yes," they were asked whether they perceived the examples as harmful (yes/no) or helpful (yes/no) and to provide open comments. Results were analyzed quantitatively and qualitatively (content analysis). RESULTS Communication regarding information provision, prognosis discussion, decision-making, and empathy could be unnecessarily potentially harmful, and this occurred in various ways, such as making vague promises instead of concrete ones (92%), being too directive in decision-making (qualitative), and not listening to the patient (88%). Not all patients considered other situations potentially harmful (eg, introducing the option of refraining from anticancer therapy [49%] and giving too much [prognostic] information [60%]). Exploring each individual patients' needs/preferences seemed to be a precondition for helpful communication. CONCLUSIONS This article provides patient perspectives on oncologists' unnecessarily potentially harmful communication behaviors and offers practical tools to improve communication in advanced cancer care. Both preventable pitfalls and delicate challenges requiring an individualized approach, where exploration might help, are described. Although providing difficult and unwelcome news is a core task for clinicians, this study might help them to do so while preventing potentially unnecessary harm.
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Affiliation(s)
- Janine Westendorp
- Health, Medical, and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, the Netherlands
| | - Andrea W M Evers
- Health, Medical, and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, the Netherlands
| | | | | | - Elsken van der Wall
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Nicole M F Plum
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Mirjam Velting
- Dutch Breast Cancer Association (BVN), Utrecht, the Netherlands
| | - Anneke L Francke
- Netherlands Institute for Health Services Research, Utrecht, the Netherlands.,Amsterdam Public Health Institute, Vrije Universiteit, Amsterdam, the Netherlands
| | - Sandra van Dulmen
- Netherlands Institute for Health Services Research, Utrecht, the Netherlands.,Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Tim C Olde Hartman
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Liesbeth M Van Vliet
- Health, Medical, and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, the Netherlands
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10
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Anderson RJ, Stone PC, Low JTS, Bloch S. Transitioning out of prognostic talk in discussions with families of hospice patients at the end of life: A conversation analytic study. PATIENT EDUCATION AND COUNSELING 2021; 104:1075-1085. [PMID: 33199091 DOI: 10.1016/j.pec.2020.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To examine transitions out of prognostic talk in interactions between clinicians and the relatives and friends of imminently dying hospice patients. METHODS Conversation analysis of 20 conversations between specialist palliative care clinicians and the families of imminently dying patients in a hospice. RESULTS Following the provision and acknowledgement of a prognostic estimate, clinicians were able to transition gradually towards making assurances about actions that could be taken to ensure patient comfort. When families raised concerns or questions, this transition sequence was extended. Clinicians addressed these questions or concerns and then pivoted to action-oriented talk, most often relating to patient comfort. CONCLUSION In conversations at the end of life, families and clinicians used practices to transition from the uncertainty of prognosis to more certain, controllable topics including comfort care. PRACTICE IMPLICATIONS In a context in which there is a great deal of uncertainty, transitioning towards talk on comfort care can emphasise action and the continued care of the patient and their family.
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Affiliation(s)
- Rebecca J Anderson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, London, UK.
| | - Patrick C Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, London, UK
| | - Joseph T S Low
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, London, UK
| | - Steven Bloch
- Department of Language and Cognition, Division of Psychology and Language Sciences, UCL, London, UK
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11
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Abstract
PURPOSE OF REVIEW Our goal was to provide healthcare professionals (HCPs) with evidence-based data about what can be done to handle prognostic discussions with empathy. RECENT FINDINGS First, disclosing prognosis involves a good reason to do so and making sure that the patient will be able to process the discussion. Second, communication tips are given for the three dimensions of empathy: "establishing rapport with the patient," which should not be overlooked; the emotional dimension, which involves an accurate understanding of the patient and communication skills; and the "active/positive" dimension which is about giving hope, explaining things clearly and helping patients take control with shared decision-making and a planned future. Although communication tips are helpful, empathy training should be based more on the development of HCPs' emotional skills, in order to help them regulate their emotions and thus be more comfortable with those of patients and families. Furthermore, research into empathy toward minorities and relatives is needed.
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Affiliation(s)
- Sophie Lelorain
- Univ. Lille, CNRS, UMR 9193 - SCALab - Sciences Cognitives et Sciences Affectives, F-59000, Lille, France.
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12
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Hauge AM. One last round of chemo? Insights from conversations between oncologists and lung cancer patients about prognosis and treatment decisions. Soc Sci Med 2020; 266:113413. [PMID: 33096509 DOI: 10.1016/j.socscimed.2020.113413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 09/18/2020] [Accepted: 09/30/2020] [Indexed: 11/29/2022]
Abstract
One more chemo or one too many? The increasing use of expensive cancer treatments close to the patient's death is often explained by oncologists' failure to communicate to patients how close to dying they are, implying that patients are often both ill-prepared and over-treated when they die. This article aims at interrogating the politically charged task of prognosticating. Drawing on an ethnographic study of conversations between oncologists and patients with metastatic lung cancer in a Danish oncology clinic, I show that oncologists utilize, rather than avoid, prognostication in their negotiations with patients about treatment withdrawal. The study informs the emerging sociology of prognosis in three ways: First, prognostication is not only about foreseeing and foretelling, but also about shaping the patient's process of dying. Second, oncologists prognosticate differently depending on the level of certainty about the patient's trajectory. To unfold these differences, the article provides a terminology that distinguishes between four 'modes of prognostication', namely hinting, informing, calibrating and organizing. Third, prognosticating can unfold over time through multiple consultations, emphasizing the relevance of adopting methodologies enabling the study of prognosticating over time.
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Affiliation(s)
- Amalie M Hauge
- VIVE - the Danish Center for Social Science Research, Herluf Trollesgade 11, 1052, København K, Denmark.
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13
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Zimmermann CJ, Jhagroo RA, Wakeen M, Schueller K, Zelenski A, Tucholka JL, Fox DA, Baggett ND, Buffington A, Campbell TC, Johnson SK, Schwarze ML. Opportunities to Improve Shared Decision Making in Dialysis Decisions for Older Adults with Life-Limiting Kidney Disease: A Pilot Study. J Palliat Med 2020; 23:627-634. [PMID: 31930929 DOI: 10.1089/jpm.2019.0340] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: Lack of awareness about the life-limiting nature of renal failure is a significant barrier to palliative care for older adults with end-stage renal disease. Objective: To train nephrologists to use the best case/worst case (BC/WC) communication tool to improve shared decision making about dialysis initiation for older patients with limited life expectancy. Design: This is a pre-/postinterventional pilot study. Setting/Subjects: There were 16 nephrologists and 30 patients of age 70 years and older with estimated glomerular filtration rate (eGFR) <20 mL/min per 1.73 m2 in outpatient nephrology clinics, in Madison, WI. Measurements: Performance of tool elements, content of communication about dialysis, shared decision making, acceptability of the intervention, decisions to pursue dialysis, and palliative care referrals were measured. Results: Fifteen of 16 nephrologists achieved competence performing the BC/WC tool with standardized patients, executing at least 14 of 19 items. Nine nephrologists met with 30 patients who consented to audio record their clinic visit. Before training, clinic visits focused on laboratory results and preparation for dialysis. After training, nephrologists noted that declining kidney function was "bad news," presented dialysis and "no dialysis" as treatment options, and elicited patient preferences. Observer-measured shared decision-making (OPTION 5) scores improved from a median of 20/100 (interquartile range [IQR] 15-35) before training to 58/100 (IQR 55-65). Patients whose nephrologist used the BC/WC tool were less likely to make a decision to initiate dialysis and were more likely to be referred to palliative care. Conclusions: Nephrologists can learn to use the BC/WC tool with older patients to improve shared decision making about dialysis, which may increase access to palliative care.
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Affiliation(s)
- Christopher J Zimmermann
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Roy A Jhagroo
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Maureen Wakeen
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Kathryn Schueller
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Amy Zelenski
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Jennifer L Tucholka
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Daniel A Fox
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Nathan D Baggett
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Anne Buffington
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Toby C Campbell
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Sara K Johnson
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Margaret L Schwarze
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Medical History and Bioethics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
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14
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Abernethy ER, Campbell GP, Pentz RD. Why many oncologists fail to share accurate prognoses: They care deeply for their patients. Cancer 2019; 126:1163-1165. [PMID: 31774548 DOI: 10.1002/cncr.32635] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 10/31/2019] [Accepted: 11/04/2019] [Indexed: 11/10/2022]
Affiliation(s)
| | | | - Rebecca D Pentz
- Department of Hematology and Oncology, Emory University School of Medicine, Atlanta, Georgia
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15
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Tate A. Invoking death: How oncologists discuss a deadly outcome. Soc Sci Med 2019; 246:112672. [PMID: 31954997 DOI: 10.1016/j.socscimed.2019.112672] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 10/30/2019] [Accepted: 11/07/2019] [Indexed: 11/19/2022]
Abstract
Existing sociological research documents patient and physician reticence to discuss death in the context of a patient's end of life. This study offers a new approach to analyzing how death gets discussed in medical interaction. Using a corpus of 90 video-recorded oncology visits and conversation analytic (CA) methods, this analysis reveals that when existing parameters are expanded to look at mentions of death outside of the end-of-life context, physicians do discuss death with their patients. Specifically, the most frequent way physicians invoke death is in a persuasive context during treatment recommendation discussions. When patients demonstrate active or passive resistance to a recommendation, physicians invoke the possibility of the patient's death to push back against this resistance and lobby for treatment. Occasionally, physicians invoke death in instances where resistance is anticipated but never actualized. Similarly, death invocations function for treatment advocacy. Ultimately, this study concludes that physicians in these data invoke death to leverage their professional authority for particular treatment outcomes.
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Affiliation(s)
- Alexandra Tate
- Department of Medicine, The University of Chicago, 5841 S. Maryland Ave, MC1005, M200, Chicago, IL 60637, United States.
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16
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Pino M, Parry R. Talking about death and dying: Findings and insights from five conversation analytic studies. PATIENT EDUCATION AND COUNSELING 2019; 102:185-187. [PMID: 30765048 DOI: 10.1016/j.pec.2019.01.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Marco Pino
- School of Social Sciences, Loughborough University, Margaret Keay Rd, LE11 3TU, UK.
| | - Ruth Parry
- School of Social Sciences, Loughborough University, Margaret Keay Rd, LE11 3TU, UK
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