Invoking death: How oncologists discuss a deadly outcome

High-Stakes Treatment Negotiations Gone Awry: The Importance of Interactions for Understanding Treatment Advocacy and Patient Resistance

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.

Video-based observation research: A systematic review of studies in outpatient health care settings

OBJECTIVE

To examine the use of video-based observation research in outpatient health care encounter research.

METHODS

We conducted a systematic search of MEDLINE, Scopus, Cochrane and other databases from database inception to October 2020 for reports of studies that used video recording to investigate ambulatory patient-clinician interactions. Two authors independently reviewed all studies for eligibility and extracted information related to study setting and purpose, participant recruitment and consent processes, data collection procedures, method of analysis, and participant sample characteristics.

RESULTS

175 articles were included. Most studies (65%) took place in a primary care or family practice setting. Study objectives were overwhelmingly focused on patient-clinician communication (81%). Reporting of key study elements was inconsistent across included studies.

CONCLUSION

Video recording has been used as a research method in outpatient health care in a limited number and scope of clinical contexts and research domains. In addition, reporting of study design, methodological characteristics, and ethical considerations needs improvement.

PRACTICE IMPLICATIONS

Video recording as a method has been relatively underutilized within many clinical and research contexts. This review will serve as a practical resource for health care researchers as they plan and execute future video-based studies.

"You'll need to settle your affairs": How the subject of death is approached by oncologists and advanced cancer patients in follow-up consultations

OBJECTIVES

This qualitative study aimed to investigate communication about death in consultations with patients undergoing chemotherapy with no curative intent. Specifically, we examined (i) how the topic of death was approached, who raised it, in what way, and which responses were elicited, (ii) how the topic unfolded during consultations, and (iii) whether interaction patterns or distinguishing ways of communicating can be identified.

METHODS

The data consisted of 134 audio-recorded follow-up consultations. A framework of sensitizing concepts was developed, and interaction patterns were looked for when death was discussed.

RESULTS

The subject of death and dying was most often initiated by patients, and they raised it in various ways. In most consultations, direct talk about death was initiated only once. We identified 4 interaction patterns. The most frequent consists of indirect references to death by patients, followed by a direct mention of the death of a loved one, and a statement of the oncologists aiming to skip the subject.

SIGNIFICANCE OF RESULTS

Patients and oncologists have multiple ways of raising, pursuing, addressing and evacuating the subject of death. Being attentive and recognizing these ways and associated interaction patterns can help oncologists to think and elaborate on this topic and to facilitate discussions.

Death and the treatment imperative: Decision-making in late-stage cancer

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.

"You become a slightly better doctor": Doctors adopting integrated medical expertise through interactions with E-patients

The accessibility of information via the internet has radically altered the doctor-patient relationship. By means of in-depth interviews with Israeli physicians from four different specialties, this study explored how physicians cope with internet-informed patients, referred to as e-patients, and examined how they make sense of their new professional roles. Findings show that three types of boundaries in the doctor-patient relationship have been blurred by the emergence of the e-patient: the boundaries between doctors' and patients' knowledge, between doctors' authority and patients' autonomy, and between positivistic knowledge and humanistic knowledge. Each of these is a boundary between liberal and non-liberal values. Only the combination of all these components produces, according to the participants, a good doctor. I call this new phenomenon integrated medical expertise and explain how it diverges from previous notions of 'good doctoring'.

The many faces of medical treatment imperatives: Biopower and the cultural authority of medicine in late-life treatment decisions in the United States

Despite changes in specific features of the US health-care system and policy environment in the past 50 years, professional dominance of medicine remains consistent. Extant social science research has considered how the cultural authority of medicine manifests and persists, sometimes emphasizing institutional structural influences and other times focusing on how individuals' agentic behaviour shapes their decisions and strategies regarding the consumption of health-care. We build on and extend these literatures using qualitative in-depth interview data to explore a typology of ways palliative care patients and their caregivers experience medical treatment imperatives across a range of social contexts. Rather than viewing or validating these lived experiences through a medical lens, we foreground the accounts of patients and caregivers as they describe their experiences of where, when, and how they perceive pressure to engage in medical treatment in late life. We adopt a Foucauldian lens to examine how this biopower is both an internal and external experience in our modern biomedicalized society. Our work reveals how treatment imperatives are generated within clinical medical encounters, but also coproduced through multiple and overlapping forces that compel individuals to pursue medical solutions to bodily problems.

Communicating with patients and families about illness progression and end of life: a review of studies using direct observation of clinical practice

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.

When do patients exercise their right to refuse treatment? A conversation analytic study of decision-making trajectories in UK neurology outpatient consultations

Using conversation analysis, this paper investigates when patients exercise their right to refuse treatment in neurology outpatient consultations recorded in the UK's National Health Service in 2012 (n = 224). NHS patients have a right to refuse treatment. However, there are good reasons to suppose that this may be difficult to exercise in practice. We know that clinicians tend to pursue acceptance if it's not forthcoming and those studies that have tracked decision-making trajectories through to their outcomes have shown that clinicians typically convert resistance to acceptance. By contrast, I show that, in 35/40 (87.5 %) cases in which patients sought to refuse treatments made available by a neurologist, they left without a prescription or referral. This paper seeks to explain this apparently anomalous finding. Starting with an example of what I expected to find - a 'duel' that ends with the neurologist persuading the patient to accept treatment - I show that this is, in fact, the exception. By contrast, most of the (attempted) refusals are collaborative, occurring after the neurologist has initiated decision-making in a way that designedly foregrounds the patients' views as the basis for deciding. I show also that, having done so, the neurologists typically continue to treat the decision as subject to the patient's preferences. Thus, the trajectories in my collection - despite including attempts to refuse treatment - do not typically become duels. Rather, patients are refusing treatment in a sequential context that facilitates making their own decision.

Presenting treatment options in breast cancer consultations: Advice and consent in Italian medical care

Variety, complexity and uncertainty in the therapy outcomes of cancer illness make the treatment recommendation (TR) in oncology a "monumentally difficult task". Previous studies have distinguished unilateral and bilateral formats of treatment recommendations, accordingly to whether, or to what extent, the patient's perspective is included in the consideration of therapeutic options. Others have also shown how the oncologists' presentation of therapeutic options varied accordingly to the severity of the diagnosis and the availability of alternatives. Yet, no study has systemically dentified and compared components of treatment recommendation in oncology on a common set of patients and clinicians. This paper analyzes how different options in breast cancer treatments - radiotherapy, hormone therapy and chemotherapy - are presented and discussed in a set of 12 first post-surgical breast cancer visits carried out by two oncologists of high experience and seniority in two Italian hospitals. Treatment recommendation sequences involving these three option types were analyzed using the methods of conversation analysis. They were also coded for the mention of side effects and treatment burden, and for whether consent to the recommendation was invited, or expressed by the patient. Results show that radiotherapy is presented as presupposed as an extension of surgery and is not further discussed, and hormone therapy is delivered as good news and as not implying any health or lifestyle burdens. Treatment burdens were raised in the much more extensive discussions of chemotherapy, which were also accompanied by a higher chance that the patient was asked for consent to therapy. Implications are drawn as regards the extent to which clinical practice meets theory in communication protocols available in oncology, and how to consider the doctor-patient partnership and the concept of shared decision-making in such an encounter.