Practitioners’ dilemmas and strategies in decision-making conversations where patients and companions take divergent positions on a healthcare measure: an observational study using conversation analysis
journal contributionposted on 21.08.2020, 13:37 by Marco PinoMarco Pino, Ann Doehring, Ruth ParryRuth Parry
The presence of companions adds complexity to healthcare interactions. Few studies have characterised challenges arising when interactions involve healthcare professionals (HCPs), patients, and companions, or how those challenges are managed. Using conversation analysis, we examined recorded episodes where patients and companions adopt divergent positions on healthcare measures (e.g., walking aids, homecare, medications). We found nine such episodes within a dataset of 37 palliative care consultations with 37 patients, their companions, and ten healthcare practitioners (HCPs)—doctors, physiotherapists, and occupational therapists. Palliative care is one of several healthcare domains where companions substantially contribute to care, consultations, and decision making. We propose that, when patients and companions adopt divergent positions, HCPs face a ‘dilemma of affiliation’ wherein taking a position on the healthcare measure (e.g., recommending it) entails siding with one party, against the other. By examining what happens in the face of patient-companion divergence, we characterise HCPs’ strategies and substantiate our proposal that these reflect an underlying dilemma. We show that: HCPs do not immediately take a position on the healthcare measure after patient-companion divergence emerges; and when HCPs take a position later in the consultation, they do so without ostensibly siding with the party who previously supported the healthcare measure. Further, once an HCP takes a position, the party who supports the measure can treat the HCP as an ally. We offer insights and propose implications for: palliative care; the interactional complexities of healthcare decision-making; and consultations in which companions participate.
Preparatory stages of this work were supported by the University of Nottingham, including via a Research Development Fund grant from the University of Nottingham’s Centre for Advanced Studies; later stages of work were funded by The Health Foundation [Grant IDs: AIMS 1273316, AIMS 1273743 / GIFTS 7210], an independent charity committed to bringing about better health and social care for people in the UK, and by the National Institute for Health Research Academy Career Development Fellowship to Parry: “Enhancing staff-patient communication in palliative and end of life care” (Grant ID CDF-2014-07-046).
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