Palliative Care Conversations by David Gramling Robert Gramling

Author:David Gramling,, Robert Gramling
Language: eng
Format: epub
Publisher: Walter de Gruyter,
Published: 2019-03-15T00:00:00+00:00

5.3That’s the frustrating part right there

Some Palliative Care conversations are openly antagonistic, due in part to patients’ justified frustrations about how infrastructural and informational deficits in communication between specialties negatively impact them. Clincians’ patient-centered modes of speaking sometimes exacerbate such frustrations, because they once again prompt patients to perform as the center of responsibility for information management and portrayal. This leads to complaint sequences (Couper-Kuhlen 2012b; Dersley and Wootton 2000; Drew and Holt 1998a; Drew and Walker 2009) and open antagonism (Dersley and Wootton 2000; Heritage 2002; Heritage 2010; see also Goodwin 2006). In this conversation we also encounter features of lay diagnosis (Beach 2001; see also Sarangi 2001) derived from the patient’s long-term involvement in hospital health care systems, customs, and language, compounded by his sense that the clinician is abdicating responsibility for information management. In this instance, we ask:

1) What pre-existing circumstances foment antagonism and discord in Palliative Care conversations?

2) What interactional features in Palliative Care conversations exacerbate pre-existing circumstances of antagonism?

3) What interactional features in Palliative Care conversations help to mitigate pre-existing circumstances of antagonism?

The patient in the following conversation self-identifies as a 45-year-old Black man and as financially insecure, reporting Associate’s-level education and Christian religious affiliation. He has been diagnosed with a stage-four colon cancer. He has “no idea” whether he will live for a year, while his clinician-rated survival prognosis at the time of the following consultation is three to six months. In fact, he lived 79 days beyond this consultation, i.e., within the expected clinical prognosis. The patient is unsure whether he prefers comfort over longevity in the treatment of his illness, and he rates his “global” quality-of-life over the previous two days at an eight out of ten. The clinician speaking is a Palliative Care physician.

1 MD: So I mean I just went through Dr. ____’s note when he first met you and-

2 and he had mentioned when he ↑talked to you that you were kind of a

3 straightforward ↑guy (0.5)°That you°(.) really liked people to be pretty-

4 (.) >pretty straight with you and not waste your ↑time?< (0.5) Is that

5 accu↑rate? (0.5)

6 Pt: ↓Yep. (0.5) ‘cause you can’t tell me how long you’re gonna be (0.2) or

7 what we’re gonna ↑talk about? (0.5) What ↑are we talking.

8 MD: >Because it completely depends on ↑what you have to say?< (0.5) ↑How

9 can I possibly know? (0.2)

10 Pt: <What will I have to say?> (1.8) All right.

The patient, having long become attuned to the discursive habitus of patient-centered clinical communication, appears uninterested in doing the symbolic labor of representing “his own perspective” for the clinician, especially after having been flattered with the attribution of straightforwardness. For her part, the physician is holding to the ‘patient-centered’ notion that hearing the state of things from his perspective is the sine qua non of a successful consultation. The patient then does, frustratedly, rehearse what it is that he understands about his current condition (below), but then promptly distances himself from that position. Being prompted to repeat back

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