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

Abstract

The presence of companions adds complexity to healthcare interactions. Few studies have characterized 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 characterize 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.

How companions speak on patients’ behalf without undermining their autonomy: Findings from a conversation analytic study of palliative care consultations

“… 1 1 We do not mean to suggest that the companions in our data never take positions that are at odds or even conflict with those that the patients endorse. This happens in our data within other sequences of action than the ones we have examined in this report, and we have documented this elsewhere (Pino et al, 2021). …”

Being in Place: A Multimodal Analysis of the Contribution of the Patient's Companion to “First Time” Oncological Visits

“…Communicating about cancer poses a huge burden upon patients, due to the high complexity of the information that they have to process (Davis et al, 2002 ; Han et al, 2011 ), the intense and potentially frightening emotions that may arise, primarily in the first stages of apprehending the illness (Nail, 2001 ; Singer, 2018 ), the variety and relevance of cognitive and decision making processes that have to engage, including the consideration of treatment options, the assessment of benefits and risks, the practical issues related to the beginning of the treatment (Epstein and Street, 2007 ; Fatigante et al, 2020 ). In this context, the presence of the patients' companions to the visit can have a strong impact on various aspects of doctor-patient communication, including doctors' and patients' chances to understand each other and/or attune to each other (Pino et al, 2020 ), and to engage in decision—making (Hubbard et al, 2010 ; Laidsaar-Powell et al, 2013 ; Laryionava et al, 2018 ).…”

“…The in-depth, sequential analysis conducted by the authors show that, more than binding and simply replacing the patient's opportunity to respond to certain doctor's question, companions' contributions are managed as to sequentially open the relevant conversational slot for the patient to produce a request by herself, i.e., about life—expectancy estimate. Conversation Analysis is also applied by another study by Pino et al ( 2020 ) to analyze healthcare providers' responses to companions' turns in the context of palliative care. Authors show that healthcare providers precisely monitor the sequence of patient- companion's turns in order to avoid to be heard as siding with one or another, and to express a position on an independent, expert basis.…”

Discourse, Conversation and Argumentation: Theoretical Perspectives and Innovative Empirical Studies - Volume I

“…Communicating about cancer poses a huge burden upon patients, due to the high complexity of the information that they have to process (Davis et al, 2002;Han et al, 2011), the intense and potentially frightening emotions that may arise, primarily in the first stages of apprehending the illness (Nail, 2001;Singer, 2018), the variety and relevance of cognitive and decision making processes that have to engage, including the consideration of treatment options, the assessment of benefits and risks, the practical issues related to the beginning of the treatment (Epstein and Street, 2007;Fatigante et al, 2020). In this context, the presence of the patients' companions to the visit can have a strong impact on various aspects of doctorpatient communication, including doctors' and patients' chances to understand each other and/or attune to each other (Pino et al, 2020), and to engage in decision-making (Hubbard et al, 2010;Laidsaar-Powell et al, 2013;Laryionava et al, 2018).…”

“…The in-depth, sequential analysis conducted by the authors show that, more than binding and simply replacing the patient's opportunity to respond to certain doctor's question, companions' contributions are managed as to sequentially open the relevant conversational slot for the patient to produce a request by herself, i.e., about life-expectancy estimate. Conversation Analysis is also applied by another study by Pino et al (2020) to analyze healthcare providers' responses to companions' turns in the context of palliative care. Authors show that healthcare providers precisely monitor the sequence of patient-companion's turns in order to avoid to be heard as siding with one or another, and to express a position on an independent, expert basis.…”