In this study, we focus mainly on the palliative care provider’s interactional practices which work to deal with the patient’s pain concerns. By examining the provider’s interactional practices as they unfold within sequences of talk, we could have a better understanding of how the palliative care provider initiates, develops and completes a palliative care proposal.
Proposing hospice in an implicit way
Conversations about end-of-life decisions and the transition toward palliative care remain among the most challenging communication tasks for palliative care providers (Back et al., 2008, Fallowfield & Jenkins, 2004, Galushko et al., 2012),21,22,23 as initiating palliative care decisions often entails addressing a patient’s impending death. Consequently, the ability to initiate timely conversations about end-of-life decisions is considered a fundamental skill for palliative care providers (Bakitas et al., 2011).24 Extract 1 shows an instance where the palliative care provider proposes palliative care in an implicit way.
01 D: I think we need to talk about (0.5) what’s been going on for the last few days. The fact
02 that you didn’t respond to the spinal taps (.) I wouldn’t want to put you through any more
03 spinal taps. There’s going to be a time (.) when we’re not going to be able to deal with the
04 pressure (.) with the [steroids.
05 P: [Okay.
06 D:We will be able to help with pain and in making you comfortable.
07 I’m worried that your disease is progressing quickly.
08 We’ve talked about (.) you know (.) hospice before.
09 And I think this is the time where we need to discuss a bit more about it.
10 P:Well (.)Mary and I have talked many times and my thought again is I’m not afraid to die, but
11 I’m afraid of all the suffering that goes beforehand. So we just-we’re trying to find out,
12 you know, when that is going to come to pass just so we can-we can say goodbye to each
At the beginning of this extract, the palliative care provider tells the patient that her illness reaches a point where spinal taps is not useful for dealing with her ongoing symptom. In line 5, the patient responds with an agreement token, which indicates that the patient shows an agreement with what the palliative care provider has said. After receipt with the agreement token, the palliative care provider starts to talk about palliative care in lines 6–9, where he first says that they could be able to deal with pain and make the patient feel comfortable and then reports on the degree of her illness, where palliative care need to be considered. Notice that in line 6 an exclusive we was used instead of I at the beginning of an assertion in the treatment of pain, which permits the doctor to identify with other palliative care providers in his hospitals, thus adding authority to his position (which may reassure the patient as well). In line 7, the palliative care provider says that he is worried that the disease is progressing quickly, which implies that the disease may be out of control and the patient is approaching the end of life. Based on what the palliative care provider has said in lines 6 and7, it can be supposed the patient’s illness cannot be cured whereas something could be done to improve her quality of life. It paves the way for the recommendation of palliative care to deal with her illness. In line 8, the palliative care provider initiates the topic “hospice”, which indicates there are no clinical methods to cure the patient’s disease but could improve her quality of life. It is clear that the direct delivery of “hospice” could make the patient feel sad. Notice that the delivery of hospice is delayed by the use of “we have talked about” and “you know”. First, inclusive “we” works to evoke a sense of commonality and rapport between the palliative care provider and the patient. Then, by saying "you know” and leaving idea (hospice) less filled out, the palliative care provider can distance himself from potentially face-threatening utterance and invite the patient to participate in the ongoing talk. The palliative care provider begins to propose palliative care to the patient in line 9, where he says that it is time to start a palliative care in an implicit way. First, the provider’s claim is prefaced with epistemic marker “I think”, which can be seen as the provider’s cautiousness in making knowledge claims. Specifically, through downplaying his own source of knowledge, the provider tries to preserve the patient’s greater rights to decide whether palliative care should be put into practice. Second, talking about palliative care is quantified by an approximator “a bit more”, which can both leave adequate leeway to the patient and take the paint’s decision-making into consideration. In this sense, it indicates that the provider wants to involve the patient in the subsequent interaction, which is, hoping to get confirmation from the patient concerning the use of palliative care.
Soliciting the patient’s goals on pain management
Discussing goals of care requires a unique combination of good communication skills that should be separated conceptually from talking about prognosis or delivering bad news.25 Understanding the patient’s care goals in the context of a serious illness invites the patient to participate in designing a shared care plan.25 It is thus significant to understand how to solicit the patient’s care goals and how the patient responds to the provider’s inquiry. Let’s see extract 2 where the palliative care provider asks for the patient’s goals on pain management and the patient reports on her detailed goals on pain management.
01D: What should our goals be?
02P: My goals (.) I-I don’t-I want to be pain-free. I’ll be honest about that (.) I want to be
03 pain-free, I don’t like pain. I-I don’t-I can’t-I can tolerate emotional pain to a certain point,
04 but I cannot tolerate physical pain. I want to have some sort of pain-free living standard
05 where I can go on you know. And I want people to know that around me that are working
06 with me that this is (.) this is it from me. You know, this is where I am going, this where I’m, 07 and this is where-where I want to be. I don’t want to (.) people, I don’t want to fool people. 08 I know where I’m going. I’m- I’m in a-I’m in a dangerous situation. You know (.) I may not
09 wake up tomorrow. I may not wake up tomorrow. And my (0.5) and my husband knows that. 10 I know that. Well (.) all of the preparations are done. Everything is ready. And this is the
11 place for us to do it.This is where we get the support that we need.
In line 1, the palliative care provider asks the patient”what should our goals be”, soliciting an expectation of the therapeutic goals. By saying “our goals” instead of your goals, both the palliative care provider and the patient are involved in the design of pain management. On the one hand, it suggests that the provider and the patient are going hand in hand to deal with the patient’s pain. On the other hand, it offers an opportunity for shared decision-making, which will spark patient engagement in her own care. Here, the palliative care provider’s question is designed to communicate that the therapeutic goals being solicited are uncertain or unknown to him, which by their nature call for a response.15 In response to the physician’s new-concern question, the patient: (1) begins her answer with “my goals”, then cuts herself off after”my goals-”and finally presents her goal, “I… I don’t… I want to be pain-free” where self-repair occurs.26 (2) offers a detailed description of his goals with emotional disclosures (i.e., I don’t like pain, in line 3; I cannot tolerate physical pain, in line 4) and (3) elaborates on her perception and attitude towards her own illness, (i.e., I’m in a dangerous situation, in line 8; everything is ready, in line 10). In sum, the patient displays her orientation to the doctor’s “What are our goals”as a solicitation of an expectation of pain management in palliative care.
Soliciting the patient’s presenting pain concerns
After visits are opened, physicians typically solicit patients’ presenting concerns with questions such as How are you feelings today?..27,28 These questions have an important role to play in maintaining the effective communication between physicians and patients because different question designs/formats (i.e., different wordings) can significantly influence and constrain patients’ answers. Extract 2 shows an instance of how the palliative care provider uses questions to solicit the patient’s presenting pain concerns.
01 D: Being in bed as you are right now, sitting quite still, do you have any pain at all right now?
02 P: No, no.
03 D: Oh, no pain right now?
04 P: No.
05 D: So what you are saying is that when your sit in bed as you are, you are comfortable?
06 P: Yes.
07 D: If you get up and try to walk, then your legs are painful?
08 P: Yeah, painful yeah.
At the beginning of this extract, the palliative care provider’s question, “do you have any pain at all right now?” solicits an update or evaluation of the patient’s current situation. Turn-terminal, temporal modification, " right now”, invites the patient to evaluate the current state of his condition relative to its previous state (presumably during the prior visit). Here, the doctor’s question prefers a negative response because of the use of the negative polarity term”any…at all”.29 In what follows, the patient’s response in a brief and immediate way is aligned to that preference. Notice that the patient’s response “no” was repeated twice, which is a report of improvement on her health status and thus demonstrates a positive evaluation of her ongoing physical-heath condition. Subsequently, the palliative care provider’s question in line 1 was expressed in an alternative way in line 3, that is, in a negative declarative question, “no pain right now?” The question “no pain right now” is polarized in a negative direction favoring a “no” response. Again, the patient’s response is both aligned to the polarity preference expressed in the question, and produced in preferred format, that is, the response is designed briefly and produced without significant delay. In line 5, the palliative care provider initiates a new question, which is prefaced with a “so” positioning it as building on the patient’s talk. Here，the provider attempts to formulate what the patient has said in the preceding turns and confirm the current state of her body. After getting the patient’s confirmatory response, the palliative care provider in line 7 raises a new question, which draws out an implication of what they have talked about in the preceding turns. Notice that in this extract, three close-ended questions are designed to solicit an evaluation of an ongoing physical-health condition. Closed-ended questions communicate that although the palliative care provider has some idea about the nature of patient’s concerns, he does not have primary authority（including knowledge）concerning the sate of the patient’s pain concerns.30 In other words, the patient has primary access to, and knowledge of, her pain concerns.
Displaying affiliation with the patient’s pain concerns
In palliative care, the patient creates empathic opportunities by displaying their affectual stance towards his/her pain symptom. In response, the palliative care provider deals with the patient’s pain concerns through affiliative displays. Extract 4 is a case in point.
01 P： If I can walk without pain, that will be something fine =
02 D: = Ye:ah
03 P: I have had pain there for-for-for 5 months now.
04 D: Hmm (.) Hmm. Well (.) that’s what we’re aiming for (.) get rid of the pain (.) and get you
06 P: Yeah.
At the beginning of this extract, it can be seen that the paint is afflicted by pain ( “If I can walk without pain”, line 1）and she expects to get rid of pain (“that will be something fine”, line 1).The palliative care provider responds to this with an acknowledgement token “yeah”. The provider does not continue his turn, and a 1.0 silence ensues, after which the patient says that she suffers pains for 5 months, which suggests the patient has been eager to get the pain away, and thus can be heard to pursue a stronger response from the physician. Proposals of affiliation were usually made after the patient had put some effort into pursuing affiliation from the professional.31 The provider responds with a twice-repeated acknowledgement token ‘hmm’, then with a particle “well”. Turn-initial well functions as an alert that the talk to follow will privilege the speaker’s perspectives, experiences or feelings.32 After the particle “well”, the palliative care provider deals with the patient’s pain concerns through affiliative displays (“we’re aiming for (.) get rid of the pain (.) and get you walking.”, lines 4 and 5), which affiliates with the patient’s ongoing concerns.
Alleviating the patient’s pain concerns
Palliative care providers should actively listen to their patients’ pain concerns and deal with them patiently. The palliative care provider will usually tell the patient that they could manage his/her pain well.33 For patients, they would find it reassuring to know that their pains can be managed well. Extract 5 is case in point.
01 D:When you wake up like that, it’s because you are worried or because of pain, or you just
02 wake up?
03 P:It-It-It could be pain but no, and I don’t worry. Well (.) of course, when here, you (0.5) you
04 don’t know how it’s going to end and there is always a bit of anxiety against the same for
05 everybody, but it was the same at home, I wouldn’t sleep at night (.) it was my nightmare too.
06D: What do you mean you don’t know how it’s going to end?
07P: Am I going to suffer? How is it going to (.) Am I going to get into a coma? It’s all question
08 that you, we don’t know, but there is always, you know (.) you-you ask yourself.
09D: What do you think will happen? What do you imagine might happen?
10 P: Well, to me cancer, it means it’s not curable and you suffer a lot.
11 D: You suffer a lot like from pain.
12 P: Yeah, Yeah (.) Maybe I’m wrong today (.) maybe they’ve got [medication
13 D: [Yeah.
14 P: but to me, that’s the way it is.
15 D: What if I told you that we do have the means and we do have the medication to control pain
16 in almost all cases, like almost a hundred percent.
27 P: Yeah.
At the beginning of this extract, the palliative care provider inquires the patient about why she wakes up while other patients sleep. In response, the patient in lines 3–5 reports that she cannot sleep at night because of both anxiety and pain. In lines 12 and 14, the patient says that she wake up mainly because of pain while other patients who sleep may have gotten medication. In what follows, the palliative care provider in lines 15 and 16 switches to talking about non-problematic, positive issues in managing the patient’s pain, which is a common way to exit from troubles-telling sequences in ordinary conversation (Jefferson, 1984). Notice that the palliative care provider uses extreme case formulation like”in almost all cases, a hundred percent” to display an orientation to the fact that the patient’s pain could be definitely controlled. In this sense, the provider’s presentation of comforting utterances tend to formulate the patient’s pain both as common and as basically relivable and manageable.