There is just one clip, it comes towards the end of the consultation – the foregoing talk has focused mostly on Lucy’s acute abdominal symptoms and their management. As the clip begins, the doctor asks Lucy if there is anything she wants to ask her. This provides an ‘opportunity space’ in which Lucy asks a question about how much time she has left. In most of the episodes of talk about life expectancy in our recordings, the patient raises life expectancy, ‘how long’, after the doctor gives the patient opportunities to raise things1.
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In the way Lucy asks her question, she makes some reference to knowing that it is difficult to be precise or certain about this. In the collection of recordings from which this case comes, patients often indicate this understanding1. It seems important for both doctors andpatients to establish an understanding that precision is not possible.
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At the start of the clip, notice the doctor asks Lucy two distinct questions, one about things she might be able to do for her, a second about things Lucy might like to ask. This works well in that although Lucy responds no to the first question, she takes the second question as an opportunity to ask about something that is a concern to her.•
Each ‘How long have I got’ case in the Real Talk materials is different in terms of the context in which the patient asks the question. Here, Lucy implies her question comes in a circumstance where she feels read to die – having mentioned the Grim Reaper, she says “I do feel a bit like he’s too long”. In other cases, patients convey they want more time and/or want to know so as to plan what they do in the time remaining to them. However, whatever the context in which the question is asked, there seem to be common features in how the doctors we recorded respond. We see these here. First, if the patient has not already volunteered it, they try to ascertain what the patient already knows and understands – in this case, the doctor does this by asking Lucy what she has already been told. This means that when the doctor gets to the point of giving some estimated time frame, they can do so in a context where they have already ascertained something of the patient’s understanding and emotional perspective. This allows them to fit what they say to the individual patient’s understandings and needs. Turning to giving difficult and bad news more broadly, when doing so a practitioners can seek the patient’s perspective first before actually delivering the news. Getting the patient’s perspective first means the practitioner can fit what they say appropriately to the patient’s understanding and emotional state, and convey the news both sensitively and effectively bringing the patient towards a realisation of their situation2,3.•
The patient is clearly distressed during much of the recording and we can see within this clip the doctor responding to this emotional context in several ways – noticeably her posture and positioning, and the softness of her voice. During the clip she also (1) asks Lucy about her feelings, and (2) conveys she has some understanding of how Lucy may be feeling – she responds empathically. When we respond empathically, we convey that we in some degree apprehend or comprehend the other person’s emotional state or condition – what they are feeling, or would be expected to feel4. We see the doctorthe moment, I guess it can’t come too soon”, and then by referring more broadly to the fact that ‘some people’ find it hard to ‘get their heads around’ end of life estimates. Lucy’s response to each of these bits of talk by the doctor suggest that she has said the right thing for Lucy and her circumstances. (Further reading on empathy from a conversation analysis or interactional perspective: Ruusuvuori 2005, Hepburn & Potter 2007, Ruusuvuori 2007, Heritage 2011).
REFERENCES AND FURTHER READING
1. Pino, M. Parry, R. (2018) How and when do patients request life-expectancy estimates? Evidence from hospice medical consultations and insights for practice. Patient
Education and Counseling doi: 10.1016/j.pec.2018.03.026 Download: http://bit.ly/ PinoParryHowPatsAskReLifeExpectancy
2. Maynard, D. W. (1997). “How to tell patients bad news: the strategy of “forecasting”.”
Cleveland Clinic Journal of Medicine 64, 4: 181-182. http://bit.ly/MaynardHowToTellBadNews 3. Parry, R., V Land, J Seymour (2014) How to communicate with patients about future illness
progression and end of life: a systematic review. BMJ Supportive and Palliative Care: http:// bit.ly/ParrySystReviewCommAboutFuture
4. Heritage, J. (2011). Territories of knowledge, territories of experience: empathic moments in interaction. The Morality of Knowledge in Conversation. T. Stivers, L. Mondada and J. Steensig. Cambridge, Cambridge University Press. http://bit.ly/HeritageEmpathicMoments 5. Hepburn, A. and J. Potter (2007). “Crying receipts: Time, empathy, and institutional
practice.” Research on Language and Social Interaction 40(1): 89-116. http://bit.ly/ HepburnCryingEmpathy
6. Ruusuvuori, J. (2005). ““Empathy” and “sympathy” in action: Attending to patients’ troubles in Finnish homeopathic and general practice consultations.” Social Psychology Quarterly 68(3): 204-222. http://bit.ly/RuusuvuoriEmpathyandSympathy
7. Ruusuvuori, J. (2007). “Managing affect: integration of empathy and problem- solving in health care encounters.” Discourse Studies 9(5): 597-622. http://bit.ly/ RuusuvuoriEmpathyandProbSolving