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Managing uncertainty and references to time in prognostic conversations with family members at the end of life: A conversation analytic study

BACKGROUND: When patients are likely to die in the coming hours or days, families often want prognostic information. Prognostic uncertainty and a lack of end-of-life communication training make these conversations challenging. AIM: The objective of this study is to understand how clinicians and the...

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Autores principales: Anderson, Rebecca J, Stone, Patrick C, Low, Joseph T S, Bloch, Steven
Formato: Online Artículo Texto
Lenguaje:English
Publicado: SAGE Publications 2020
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7336362/
https://www.ncbi.nlm.nih.gov/pubmed/32233831
http://dx.doi.org/10.1177/0269216320910934
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author Anderson, Rebecca J
Stone, Patrick C
Low, Joseph T S
Bloch, Steven
author_facet Anderson, Rebecca J
Stone, Patrick C
Low, Joseph T S
Bloch, Steven
author_sort Anderson, Rebecca J
collection PubMed
description BACKGROUND: When patients are likely to die in the coming hours or days, families often want prognostic information. Prognostic uncertainty and a lack of end-of-life communication training make these conversations challenging. AIM: The objective of this study is to understand how clinicians and the relatives/friends of patients at the very end of life manage uncertainty and reference time in prognostic conversations. DESIGN: Conversation analysis of audio-recorded conversations between clinicians and the relatives/friends of hospice inpatients. SETTING/PARTICIPANTS: Experienced palliative care clinicians and relatives/friends of imminently dying hospice inpatients. Twenty-three recorded conversations involved prognostic talk and were included in the analysis. RESULTS: Requests for prognostic information were initiated by families in the majority of conversations. Clinicians responded using categorical time references such as ‘days’, allowing the provision of prognostic estimates without giving a precise time. Explicit terms such as ‘dying’ were rare during prognostic discussions. Instead, references to time were understood as relating to prognosis. Relatives displayed their awareness of prognostic uncertainty when requesting prognostic information, providing clinicians with ‘permission’ to be uncertain. In response, clinicians often stated their uncertainty explicitly, but presented evidence for their prognostic estimates, based on changes to the patient’s function previously discussed with the family. CONCLUSION: Prognostic uncertainty was managed collaboratively by clinicians and families. Clinicians were able to provide prognostic estimates while being honest about the related uncertainty, in part because relatives displayed their awareness of uncertainty within their requests. The conversation analytic method identified contributions of both clinicians and families, and identified strategies based on real interactions, which could inform communication training.
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spelling pubmed-73363622020-08-03 Managing uncertainty and references to time in prognostic conversations with family members at the end of life: A conversation analytic study Anderson, Rebecca J Stone, Patrick C Low, Joseph T S Bloch, Steven Palliat Med Original Articles BACKGROUND: When patients are likely to die in the coming hours or days, families often want prognostic information. Prognostic uncertainty and a lack of end-of-life communication training make these conversations challenging. AIM: The objective of this study is to understand how clinicians and the relatives/friends of patients at the very end of life manage uncertainty and reference time in prognostic conversations. DESIGN: Conversation analysis of audio-recorded conversations between clinicians and the relatives/friends of hospice inpatients. SETTING/PARTICIPANTS: Experienced palliative care clinicians and relatives/friends of imminently dying hospice inpatients. Twenty-three recorded conversations involved prognostic talk and were included in the analysis. RESULTS: Requests for prognostic information were initiated by families in the majority of conversations. Clinicians responded using categorical time references such as ‘days’, allowing the provision of prognostic estimates without giving a precise time. Explicit terms such as ‘dying’ were rare during prognostic discussions. Instead, references to time were understood as relating to prognosis. Relatives displayed their awareness of prognostic uncertainty when requesting prognostic information, providing clinicians with ‘permission’ to be uncertain. In response, clinicians often stated their uncertainty explicitly, but presented evidence for their prognostic estimates, based on changes to the patient’s function previously discussed with the family. CONCLUSION: Prognostic uncertainty was managed collaboratively by clinicians and families. Clinicians were able to provide prognostic estimates while being honest about the related uncertainty, in part because relatives displayed their awareness of uncertainty within their requests. The conversation analytic method identified contributions of both clinicians and families, and identified strategies based on real interactions, which could inform communication training. SAGE Publications 2020-04-01 2020-07 /pmc/articles/PMC7336362/ /pubmed/32233831 http://dx.doi.org/10.1177/0269216320910934 Text en © The Author(s) 2020 https://creativecommons.org/licenses/by-nc/4.0/ This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access page (https://us.sagepub.com/en-us/nam/open-access-at-sage).
spellingShingle Original Articles
Anderson, Rebecca J
Stone, Patrick C
Low, Joseph T S
Bloch, Steven
Managing uncertainty and references to time in prognostic conversations with family members at the end of life: A conversation analytic study
title Managing uncertainty and references to time in prognostic conversations with family members at the end of life: A conversation analytic study
title_full Managing uncertainty and references to time in prognostic conversations with family members at the end of life: A conversation analytic study
title_fullStr Managing uncertainty and references to time in prognostic conversations with family members at the end of life: A conversation analytic study
title_full_unstemmed Managing uncertainty and references to time in prognostic conversations with family members at the end of life: A conversation analytic study
title_short Managing uncertainty and references to time in prognostic conversations with family members at the end of life: A conversation analytic study
title_sort managing uncertainty and references to time in prognostic conversations with family members at the end of life: a conversation analytic study
topic Original Articles
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7336362/
https://www.ncbi.nlm.nih.gov/pubmed/32233831
http://dx.doi.org/10.1177/0269216320910934
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