Doing understanding during triadic decision-making with people living with dementia

This paper examines how patients with dementia reveal their level of understanding during the complex process of making decisions around their medical care. Using Conversation Analysis, we examined 172 decision-making sequences across 64 memory clinic consultations and found that understanding is best viewed as an interactionally constructed continuum that patients can move along with the help of their interlocutors. We identified specific behaviours, both spoken and embodied, that patients, their companions, and the healthcare practitioners display, which index the patient's location on the continuum of understanding. This has consequences for the patient's level of involvement in decision-making, and who ultimately contributes to the decision. Patients who display clear understanding are frequently treated as the primary decision-maker, while situations in which patients are treated as showing a lack of understanding typically result in the companion becoming the primary decision-maker. Only when the patient is revealed to sit between these two poles does the decision-making become more of a shared endeavour. We highlight the need for patient understanding to be assessed continuously within the decision-making sequence due to the potential for patients to move along the continuum of understanding as the talk progresses.