Emotionally reflexive labour in end-of-life communication

Being kind in unkind spaces: a qualitative examination of how medical educators and first year medical students perceive empathy training

Introduction

It has become de rigueur for healthcare systems to tout their ability to provide compassionate medical care that addresses the emotional as well as physical needs of patients. Not surprisingly, then, there is considerable pressure on medical schools to train their students to be empathic. Existing literature on empathy training in medicine tends to focus on how to build emotional intelligence in individual trainees, largely ignoring the sociocultural factors that contribute to or thwart empathy development in medical school. Additionally, research tends to examine student perspectives, with little attention given to medical educators and their viewpoints.

Methods

In this paper, we adopt an "emotion practice" framework and utilize an inductive descriptive study design to qualitatively consider how first year medical students (N = 23) and their instructors (N = 9) perceive empathy training at a site we call Midtown Medical School.

Results and discussion

We find that both groups have an understanding of empathic capital but differ in their beliefs about the utility and legitimacy of this capital. Both educators and students also recognize the limitations of standardized empathy curriculum but do not agree on the implications of such rote learning. Finally, students and instructors alike find the hidden curriculum of medical school to be antithetical to empathy development, concurring that it is difficult to cultivate empathy in spaces where biomedical coursework is prioritized over social-emotional learning. In short, both groups find it difficult to be kind in an unkind place.

How physiotherapists attend to the human aspects of care when working with people with low back pain: a thematic analysis

Pain is a multidimensional experience. Physiotherapy has attempted to enhance earlier biomedical approaches to patient care through approaches like the 'biopsychosocial' model. Nevertheless, physiotherapy continues to focus on biomedical and/or behavioural aspects of care. We critically investigated how physiotherapists attend to human (psychosocial, emotional, existential, and moral) aspects of low back pain care. We co-analysed ethnographic data with researchers, patients, and physiotherapists using concepts of conforming, tinkering and abandoning 'scripts'. Data included observations of 28 physiotherapy interactions between 26 patients and 10 physiotherapists and 7 researcher-clinician dialogues. Analysis suggests when conforming to scripts, clinicians have difficulty recognising and responding to emotions; time pressure limited clinicians focus, and a biological focus often distracted from psychosocial aspects of people's back pain experiences. In contrast, tinkering with or abandoning scripts allowed space to broaden the focus. Drawing from theorists such as Butler (1999) and Gibson et al. (2020) our analysis contributes to health sociology, arguing that 'tinkering' with or 'abandoning' scripts can foster more humanistic, flexible and reflexive approaches to care. Although health sociologists have explored tinkering, abandoning is new; within physiotherapy, it encapsulates being able to respond with agility to non-physical elements of care without constraint from traditional ways of thinking and doing.

Uncertainty in low back pain care - insights from an ethnographic study

PURPOSE

To explore how uncertainty plays out in low back pain (LBP) care and investigate how clinicians manage accompanying emotions/tensions.

MATERIALS AND METHODS

We conducted ethnographic observations of clinical encounters in a private physiotherapy practice and a public multidisciplinary pain clinic. Our qualitative reflexive thematic analysis involved abductive thematic principles informed by Fox and Katz (medical uncertainty) and Ahmed (emotions).

RESULTS

We identified three themes. (1) Sources of uncertainty: both patients and clinicians expressed uncertainty during clinical encounters (e.g., causes of LBP, mismatch between imaging findings and presentation). Such uncertainty was often accompanied by emotions - anger, tiredness, frustration. (2) Neglecting complexity: clinicians often attempted to decrease uncertainty and associated emotions by providing narrow answers to questions about LBP. At times, clinicians' denial of uncertainty also appeared to deny patients the right to make informed decisions about treatments. (3) Attending to uncertainty?: clinicians attended to uncertainty through logical reasoning, reassurance, acknowledgement, personalising care, shifting power, adjusting language and disclosing risks.

CONCLUSIONS

Uncertainty pervades LBP care and is often accompanied by emotions, emphasising the need for a healthcare culture that recognises the emotional dimensions of patient-clinician interactions and prepares clinicians and patients to be more accepting of, and clearly communicate about, uncertainty.IMPLICATIONS FOR REHABILITATIONUncertainty pervades LBP care and is often accompanied by emotions.Neglecting complexity in LBP care may compromise person-centred care.Acknowledging uncertainty can enhance communication, balance patient-clinician relationships and address human aspects of care.

Lived experiences of end-of-life communication among nursing home staff: An interpretive phenomenological study

AIMS

To explore and understand lived experiences of end-of-life communication among nursing home staff.

DESIGN

Interpretive phenomenological study.

METHODS

In-person, semi-structured, in-depth interviews were conducted from May to August 2021 with 21 nursing home staff members involved in end-of-life communication (four managers, four chief nurses, three chief medical officers, three nurses, three psychologists, two occupational therapists, one chief nurse aide and one nurse aide). Data were analysed by van Manen's hermeneutic approach, which uses the lifeworld existentials of spatiality, corporeality, temporality and relationality to guide reflection on the human experience. Data were reported according to the Consolidated Criteria for Reporting Qualitative Research.

RESULTS

Thirteen categories were identified and framed within the four existentials. Regarding spatiality, end-of-life communication took place in a physical, mental, socio-cultural and professional competence space. With regard to corporeality, interviewees reported difficulties in managing their own feelings and those of family caregivers. For temporality, interviewees reported delays in end-of-life communication due to staffing issues and an increase in urgent and temporary relief admissions to nursing homes. To compensate, they tried to assure that all interactions that did take place were of high quality. Finally, with regard to relationality, interviewees lived end-of-life communication through their relationships with family caregivers and colleagues. The supportive role of colleagues was expressed as teamwork, which helped promote reflexivity about how to tailor communication, manage challenging emotions and situations, set aside time for communication, and prepare family caregivers for death.

CONCLUSION

End-of-life communication was an all-encompassing experience for nursing home staff. The supportive role of colleagues was stressed across all existentials, suggesting that teamwork is essential in delivering effective communication at the end-of-life.

PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public contribution to this study, which addresses the experiences of nursing home staff only.

Characterizing the Language Used to Discuss Death in Family Meetings for Critically Ill Infants

Importance

Communication during conversations about death is critical; however, little is known about the language clinicians and families use to discuss death.

Objective

To characterize (1) the way death is discussed in family meetings between parents of critically ill infants and the clinical team and (2) how discussion of death differs between clinicians and family members.

Design, Setting, and Participants

This longitudinal qualitative study took place at a single academic hospital in the southeast US. Patients were enrolled from September 2018 to September 2020, and infants were followed up longitudinally throughout their hospitalization. Participants included families of infants with neurologic conditions who were hospitalized in the intensive care unit and had a planned family meeting to discuss neurologic prognosis or starting, not starting, or discontinuing life-sustaining treatment. Family meetings were recorded, transcribed, and deidentified before being screened for discussion of death.

Main Outcomes and Measures

The main outcome was the language used to reference death during family meetings between parents and clinicians. Conventional content analysis was used to analyze data.

Results

A total of 68 family meetings involving 36 parents of 24 infants were screened; 33 family meetings (49%) involving 20 parents (56%) and 13 infants (54%) included discussion of death. Most parents involved in discussion of death identified as the infant's mother (13 [65%]) and as Black (12 [60%]). Death was referenced 406 times throughout the family meetings (275 times by clinicians and 131 times by family members); the words die, death, dying, or stillborn were used 5% of the time by clinicians (13 of 275 references) and 15% of the time by family members (19 of 131 references). Four types of euphemisms used in place of die, death, dying, or stillborn were identified: (1) survival framing (eg, not live), (2) colloquialisms (eg, pass away), (3) medical jargon, including obscure technical terms (eg, code event) or talking around death with physiologic terms (eg, irrecoverable heart rate drop), and (4) pronouns without an antecedent (eg, it). The most common type of euphemism used by clinicians was medical jargon (118 of 275 references [43%]). The most common type of euphemism used by family members was colloquialism (44 of 131 references [34%]).

Conclusions and Relevance

In this qualitative study, the words die, death, dying, or stillborn were rarely used to refer to death in family meetings with clinicians. Families most often used colloquialisms to reference death, and clinicians most often used medical jargon. Future work should evaluate the effects of euphemisms on mutual understanding, shared decision-making, and clinician-family relationships.

Prescribing as affective clinical practice: Transformations in sexual health consultations through HIV pre-exposure prophylaxis

New medicines can transform routines and priorities in clinical practice, but how do clinicians think and feel about these changes, and how does it affect their work? In Australia, the HIV prevention regimen pre-exposure prophylaxis (PrEP) has been rapidly rolled out, transforming the sexual cultures and practices of users, but less attention has been given to the ways PrEP has reconfigured clinical practice. This paper draws on 28 qualitative semi-structured interviews conducted between 2019 and 2020 with PrEP-providing doctors and nurses in Australia to consider how they have affectively engaged with PrEP and put it into practice. Through a reflexive thematic analysis, we explore how clinicians adapted to PrEP, how the field of HIV prevention has been transformed, and how these developments have changed how clinicians approach patients. While the introduction of PrEP was initially received with uncertainty and shock, clinicians described PrEP as enjoyable to prescribe, and better aligned with the moral duties of sexual health consultations than existing HIV prevention strategies like condoms. Through approaching clinical work as an 'affective practice', we argue for attending not only to how new interventions change expectations and practices, but also how these changes are felt and valued by clinicians.

Emotion as reflexive practice: A new discourse for feedback practice and research

INTRODUCTION

Like medicine and health care, feedback is a practice imbued with emotions: saturated with feelings relevant to one's identity and status within a given context. Often this emotional dimension of feedback is cast as an impediment to be ignored or managed. Such a perspective can be detrimental to feedback practices as emotions are fundamentally entwined with learning. In this critical review, we ask: What are the discourses of emotion in the feedback literature and what 'work' do they do?

METHODS

We conducted a critical literature review of emotion and feedback in the three top journals of the field: Academic Medicine, Medical Education and Advances in Health Sciences Education. Analysis was informed by a Foucauldian critical discourse approach and involved identifying discourses of emotion and interpreting how they shape feedback practices.

FINDINGS

Of 32 papers, four overlapping discourses of emotion were identified. Emotion as physiological casts emotion as internal, biological, ever-present, immutable and often problematic. Emotion as skill positions emotion as internal, mainly cognitive and amenable to regulation. A discourse of emotion as reflexive practice infers a social and interpersonal understanding of emotions, whereas emotion as socio-cultural discourse extends the reflexive practice discourse seeing emotion as circulating within learning environments as a political force.

DISCUSSION

Drawing on scholarship within the sociology of emotions, we suggest the merits of studying emotion as inevitable (not pathological), as potentially paralysing and motivating and as situated within (and often reinforcing) a hierarchical social health care landscape. For future feedback research, we suggest shifting towards recognising the discourse-theory-practice connection with emotion in health professional education drawing from reflexive and socio-cultural discourses of emotion.

Hopeful dying? The meanings and practice of hope in palliative care family meetings

Hope can carry considerable allure for people facing imminent mortality and for those who care for them. Yet, how hope is variously and relationally (re)produced within end-of-life care settings, remains under-researched. In this study, we aimed to better understand hope as it circulates within palliative care, drawing on video recorded family meetings and pre- and post-meeting qualitative interviews, within two hospitals in Queensland, Australia. Our findings highlight family meetings as an important site for articulations of hope and hopefulness. The results illustrate how hope is recalibrated within the transition to and through palliative care, the tensions between hope and futility, and the work of hope in discussions of goals and expectations. Through our analysis we argue that hopefulness within family meetings, and in palliative care more broadly, is collectively produced and opens up discourses of hope to the lived experience of terminality. Attending to the nuances of hope, including moving beyond the determinative (hope for more life/hope for a quick death), can elucidate the possibilities and problems of the collective negotiation of hope at the end of life, including how hope can be drawn on to express support and solidarity.

Healthcare professionals' perspectives of patient and family preferences of patient place of death: a qualitative study

BACKGROUND

Home death is one of the key performance indicators of the quality of palliative care service delivery. Such a measure has direct implications on everyone involved at the end of life of a dying patient, including a patient's carers and healthcare professionals. There are no studies that focus on the views of the team of integrated inpatient and community palliative care service staff on the issue of preference of place of death of their patients. This study addresses that gap.

METHODS

Thirty-eight participants from five disciplines in two South Australian (SA) public hospitals working within a multidisciplinary inpatient and community integrated specialist palliative care service, participated in audio-recorded focus groups and one-on-one interviews. Data were transcribed and thematically analysed.

RESULTS

Two major and five minor themes were identified. The first theme focused on the role of healthcare professionals in decisions regarding place of death, and consisted of two minor themes, that healthcare professionals act to: a) mediate conversations between patient and carer; and b) adjust expectations and facilitate informed choice. The second theme, healthcare professionals' perspectives on the preference of place of death, comprised three minor themes, identifying: a) the characteristics of the preferred place of death; b) home as a romanticised place of death; and c) the implications of idealising home death.

CONCLUSION

Healthcare professionals support and actively influence the decision-making of patients and family regarding preference of place of death whilst acting to protect the relationship between the patient and their family/carer. Further, according to healthcare professionals, home is neither always the most preferred nor the ideal place for death. Therefore, branding home death as the ideal and hospital death as a failure sets up families/carers to feel guilty if a home death is not achieved and undermines the need for and appropriateness of death in institutionalised settings.