Time estimates in prognostic discussions: A conversation analytic study of hospice multidisciplinary team meetings

BACKGROUND

Recommendations state that multidisciplinary team expertise should be utilised for more accurate survival predictions. How the multidisciplinary team discusses prognoses during meetings and how they reference time, is yet to be explored.

AIM

To explore how temporality is conveyed in relation to patients' prognoses during hospice multidisciplinary team meetings.

DESIGN

Video-recordings of 24 hospice multidisciplinary team meetings were transcribed and analysed using Conversation Analysis.

SETTING/PARTICIPANTS

A total of 65 staff participating in multidisciplinary team meetings in a UK hospice from May to December 2021.

RESULTS

Team members conveyed temporality in three different ways. (i) Staff stated that a patient was dying as part of the patient's current health status. These formulations did not include a time reference per se but described the patient's current situation (as dying) instead. (ii) Staff used specific time period references where another specific reference had been provided previously that somehow constrained the timeframe. In these cases, the prognosis would conflict with other proposed care plans. (iii) Staff members used unspecific time period references where the reference appeared vague and there was greater uncertainty about when the patient was expected to die.

CONCLUSIONS

Unspecific time period references are sufficient for achieving meaningful prognostic talk in multidisciplinary teams. In-depth discussion and accurate prediction of patient prognoses are not deemed a priority nor a necessity of these meetings. Providing precise predictions may be too difficult due to uncertainty and accountability. The lack of staff pursuing more specific time references implies shared knowledge between staff and a context-specific use of prognostic estimates.

Brief opportunistic interventions by general practitioners to promote smoking cessation: A conversation analytic study

Very brief opportunistic interventions for smoking cessation are effective, cost-saving for health systems, and universally recommended in guidelines. However, evidence suggests that clinicians are reluctant to intervene, citing interactional difficulties. Only one UK study has specifically examined smoking discussions, within naturally occurring primary care consultations. However smoking cessation treatment was not available at the time. We examined existing datasets amounting to 519 video-recordings of GP consultations in England for instances of talk about smoking. We used conversation analytic methods to assess patients' responses to doctors asking about smoking, giving advice on smoking, and offering cessation treatment. In 31 recordings it was apparent that the patient smoked, and, in 25/31 consultations, doctors initiated the topic of smoking. They did so by asking about smoking status, commonly during the history-taking phase of the consultation. In many instances, these questions led to active resistance from patients against being placed in a discreditable category, for example by minimising their smoking. This was more pronounced when GPs pursued efforts to quantify the amount smoked. Thereafter, where doctors returned to the topic of smoking, they did so typically by linking smoking to the patient's medical condition, which likewise led to resistance. Guidance recommends that GPs advise on how best to quit smoking where patients are interested in doing so, but this was only evident in a minority of consultations. Where GPs offered support for cessation, they did so using interactional practices that minimised the need for the patient to respond and thereby accept. Interactional difficulties were found to be common in consultations between GPs and people who smoke when GPs actions aligned with some VBA guidelines. Future research should examine when and how advice on how best to quit, and offers of support, should be delivered within primary care consultations.

Expanding the Scope of the Visit: Which Patient-Initiated Additional Concerns Receive Help?

This study examines patient-initiated additional concern presentations in general surgery visits to assess which factors contribute to them getting "helped." Concern presentations were analyzed for a variety of design features (e.g., social action (inquiry vs. informing), when patients initiate during a visit, how patients fit topic to previous talk or activity) and contextual factors (e.g., concern falls inside or outside surgeon's domain of expertise, chronic vs. acute concern-types, the history of the patient-physician relationship). This study uses a mixed-methods approach, combining case-level conversation analysis and aggregate-level statistical analysis. Data are video recordings of office visits from 2013-2015, with a longitudinal focus of following the same patients across time. In total, 62 patients spanning 175 visits were analyzed. 377 patient-initiated additional concerns were found, and 188 received help. Several factors were found to increase the likelihood of patients' concerns getting helped such as designing the concern as an inquiry, raising the concern early in the visit, and mentioning the concern more than once. These findings can help guide patients on how to better design additional concerns presentations to receive help and can benefit physicians by identifying more subtle practices patients are already using to broach concerns to help reduce unnoticed or unhelped concerns.

Managing uncertainty and references to time in prognostic conversations with family members at the end of life: A conversation analytic study

BACKGROUND

When patients are likely to die in the coming hours or days, families often want prognostic information. Prognostic uncertainty and a lack of end-of-life communication training make these conversations challenging.

AIM

The objective of this study is to understand how clinicians and the relatives/friends of patients at the very end of life manage uncertainty and reference time in prognostic conversations.

DESIGN

Conversation analysis of audio-recorded conversations between clinicians and the relatives/friends of hospice inpatients.

SETTING/PARTICIPANTS

Experienced palliative care clinicians and relatives/friends of imminently dying hospice inpatients. Twenty-three recorded conversations involved prognostic talk and were included in the analysis.

RESULTS

Requests for prognostic information were initiated by families in the majority of conversations. Clinicians responded using categorical time references such as 'days', allowing the provision of prognostic estimates without giving a precise time. Explicit terms such as 'dying' were rare during prognostic discussions. Instead, references to time were understood as relating to prognosis. Relatives displayed their awareness of prognostic uncertainty when requesting prognostic information, providing clinicians with 'permission' to be uncertain. In response, clinicians often stated their uncertainty explicitly, but presented evidence for their prognostic estimates, based on changes to the patient's function previously discussed with the family.

CONCLUSION

Prognostic uncertainty was managed collaboratively by clinicians and families. Clinicians were able to provide prognostic estimates while being honest about the related uncertainty, in part because relatives displayed their awareness of uncertainty within their requests. The conversation analytic method identified contributions of both clinicians and families, and identified strategies based on real interactions, which could inform communication training.

Stories of Change: Comparative Time-Framed Experience Telling in Health Promotion Group Discussions

In this article, we examine comparative time-framed experience telling: episodes of interaction in health promotion group discussions in which one of the participants tells their experience and, in response, another participant tells their own experiences from separate moments or periods of their life and compares them. In so doing, group members reinforce and encourage the previous speaker's positive stance or challenge the negative stance toward contextually relevant objects: behavior change and suggested solutions. This practice allows group members to demonstrate their independent access to experiences that are similar to those of the other, present evidence of similarities and differences between the experiences, and show their epistemic independence regarding their claims. By recontextualizing the experience of the other in this way, it becomes possible for the group members to interpret and even oppose it while maintaining a level of understanding of the differences between the experiences in question and respecting them.