Initiating decision-making conversations in palliative care: an ethnographic discourse analysis

Area of Science:

• Palliative Care Medicine
• Health Services Research
• Medical Communication

Background:

• End-of-life care discussions are challenging for healthcare providers.
• Delayed conversations hinder terminally-ill patients' decision-making participation.
• Limited research observes physician-patient end-of-life care interactions.

Purpose of the Study:

• To explore how patients and family physicians initiate end-of-life decision-making conversations.
• To investigate the influence of organizational context on these discussions within a palliative care service.

Main Methods:

• Qualitative study combining discourse analysis and ethnographic methods.
• One-year field research involving participant observation and audio-recorded consultations.
• Analysis of 101 consultations across 18 patients, 6 family physicians, and 2 nurses.

Main Results:

• Care organization and referral timing significantly impact patient participation in decision-making.
• Physicians initiated symptom management discussions directly by addressing patient complaints.
• Discussions about impending death were initiated indirectly (probing patient understanding) or directly (justifying the topic).

Conclusions:

• The initiation of end-of-life decision-making conversations is shaped by care organization and referral processes.
• Symptom management is an expected professional role, while end-of-life preparation decisions remain patient-controlled.
• Physician discourse plays a rhetorical role in introducing palliative care decisions.