In the first clip the doctor asks the patient about his thoughts and feelings in relation to his symptoms. Eashan’s responses include “Sometimes I think: ‘Oh this is it now.’ This we could describe a ‘cue’ that the doctor can then pick up on in a movement towards talking about end of life and advance care planning. In the second clip, the doctor asks a question that could open up these opportunities, asking Eashan if he has thought through what might be coming next. But at this point, the conversation does not work towards talk about dying and advance planning. In the third clip, the doctor returns to asking about the future, and to the ‘end of life relevant’ matter raised in the first clip – that Eashan sometimes wonders if ‘this is it’. The conversation now moves to a good deal of talk about dying, about not wanting to die and wanting to fight. The doctor raises ‘worst case scenario’ planning, and the talk moves gradually towards talk about preferred place of death.
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This case can be used to prompt discussion about how practitioners sometimes have to balance attention to hope and optimism and to a patient’s current focus on these, with input that will provide the patient with opportunities to consider or recognise that they may die soon, and that allows them opportunities to consider and influence their care at the very end. Several times Eashan suggests he does not want to engage with the topic, but several times, he does in fact go on to engage with the topic (and, as the case synopsis describes, at the end of the consultation, the patient remarks to the doctor how helpful it has been to talk things over with him). This is a helpful case for (1) thinking about how people can be ‘in two minds’ about whether or not they wish to engage in talk about dying and end of life care, and (2) that what patients and relatives end up talking about is very much influenced by the healthcare professional’s questions and also their responses to what patients and relatives say. Some consideration of how what people say relates to their inner thinking can be found in the first chapters of two books listed below1, 2•
You may notice that the doctor tends not to make proposals about what the patient may be thinking and feeling in relation to dying. Instead he asks questions that strongly encourage the patient himself to report on his feelings and thoughts. Notice that the questions he asks do not presume knowledge of what the patient is feeling and thinking3. In this case,whilst the doctor in some ways takes the lead in getting dying and end of life care planning onto the conversational surface, he does so in a way that results in Eashan actually making the most direct references to it: from “Sometimes I think: ‘Oh this is it now.” through to clip three in which he notes that “probably my time’s up” and then later: “I would like to die peacefully somewhere like this place, yeah.” Doctors in the set of recordings upon which Real Talk is based by and large make the running in terms of getting the topic of dying and end of life care onto the conversational surface. But they often do so in ways that mean it is the patient who makes the crucial moves in doing so. (As an analogy, envisage a cycle race in which the doctor is the pace maker, but peels off at just the right moment for the patient to take the lead). A number of communication practices used by practitioners can allow a patient to make the crucial moves4. One is asking questions about the patient’s
thoughts and feelings. Another is to encourage discussion of what the patient has already been thinking about in relation to their dying. We see this in clip two when the doctor
says: “I don’t know what you think might be coming next. Have you had a chance to think that through?” At first, this meets with little success in that the patient moves to talk about practical arrangements that are coming next. But in clip three the doctor’s: “Do you ever wonder what’ll happen if they don’t have treatment that works?” meets with some success in moving the topic forward. Encouraging patients to talk about what they have already been thinking about helps create a sense that dying and advance care planning are not matters that are solely on the health professional’s agenda, but rather are things already on the patient’s agenda.
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Like other examples, for instance in the Lynn Real Talk case, we see the doctor asking a feeling/thinking question (in clip one) that results in the patient saying something that implies dying, (‘this is it’), and the doctor later returning to what the patient has said in order to move talk towards dying and end of life plans.•
In the third clip, we hear Eashan telling the doctor that, if he is honest, he just wants to live. Throughout the consultation, Eashan very clearly expresses his efforts and desire to live longer. It seems clear that the doctor is concerned that in fact Eashan might die soon (the doctor is particularly keenly pursuing talk about dying, and Eashan has reported being in bed 24/7). Eashan’s ‘I just want to live’ presents a communicative dilemma for the doctor, which he deals with through displaying empathy ‘That’s understandable’ and through conveying advance care planning in a softened form which conveys it as just in case rather than vital because the end is near – he refers to ‘worst case scenario planning’ (this issimilar to the ‘rainy day planning’ phrase we hear in the Sam case). Joe Ford and colleagues have written about how practitioners in palliative care display empathy in certain difficult situations4. They note: “our paper on empathy shows that it doesn’t simply work to help
with rapport-building or helping the patient ‘feel good.’ Instead, it can be integrated into healthcare tasks, softening and adding a human dimension to what could otherwise be a detached, rationalistic process. While this integration is of particular benefit in palliative care (where patients’ emotions are likely to be especially strong and practitioners’ tasks particularly difficult), it could also be important in any context where experience and expertise somehow come into conflict.”
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As a final point, healthcare professionals need to decide in any individual situation whether and how hard to encourage talk about end of life. Some communication practices make it particularly easy for a patient to opt not to move towards this topic, others push harder towards it5, 6. In the case, the d•
octor opted to repeatedly encourage end of life talk with a patient who had beendeteriorating rapidly, it seems the doctor here decided it was in the patient’s best interests to encourage end of life talk fairly strongly.
REFERENCES AND FURTHER READING
1. Benwell, B. and E. Stokoe (2006). Discourse and identity, Oxford University Press 2. Sidnell, J. (2010). Conversation Analysis. Chichester, Wiley-Blackwell
3. Heritage, J. (2009). Questioning in medicine. ‘Why do you ask?’: The Function of Questions in Institutional Discourse. A. Freed & S. Ehrlich, Oxford University Press 42-68.
4. Pino, M., R. Parry, V. Land, C. Faull, L. Feathers, J. Seymour (2016). Engaging terminally ill patients in end of life talk: How experienced palliative medicine doctors navigate the dilemma of promoting discussions about dying. PLoSOne 11(5). http://bit.ly/ PinoParryBroachingDying
5. Ford J, Hepburn A, Parry R. (2019). What do displays of empathy do in palliative care consultations?. Discourse Studies http://bit.ly/FordHepburnParryEmpathy2019
6. Parry, R., V. Land and J. Seymour (2014). “How to communicate with patients about future illness progression and end of life: a systematic review.” BMJ supportive & palliative care: bmjspcare-2014-000649: http://bit.ly/ParrySystReviewCommAboutFuture