Pain talk in palliative care: A qualitative analysis

Aim Using the method of Conversation Analysis (CA), this study aims to demonstrate how the palliative care provider uses different types of interactional practices to address patient’s pain concerns. Background The delivery of palliative care services could be facilitated through effective communication. The method of conversation analysis is effective in improving communication skills. Conversation analysis, used in other healthcare settings, also is a useful way to explore the interactional details between palliative care providers and terminally ill patients. Method The data showed in this study are obtained from 2 videotapes of provider-patient interaction in palliative care settings. The videos and the initial transcript of them are collected from the Alexander St website http://ctiv.alexanderstreet.com, an educational resource presenting a large collection of psycho-therapeutic videos. The data is analyzed using the method of conversation analysis. provider responds problematic experiences. analytical how

terminally ill patient in terms of pain concerns. The findings in this study could inform how the palliative care provider initiates, delivers and develops a pain talk with the terminally ill patient effectively.

Introduction
Palliative care consists of a holistic and interdisciplinary approach to care that seeks to improve the quality of life of patients and their families when confronted with a life-threatening illness. 1,2 Healthcare providers in hospice and palliative care work to relieve the physical, psychological, social, cultural and spiritual concerns and suffering of persons with life-limiting illness, and they assist patients to maintain an acceptable quality of life. 3 The delivery of hospice and palliative care services could be facilitated through effective communication. 4 One of the key elements of physician-patient communication in any type of medical consultation (e.g., palliative care, acute care, primary care) is the solicitation of information from patients about their immediate concerns (Boyd & Heritage, 2006; Heritage, 2010; Robinson, 2006;Stivers & Heritage, 2001). 5,6,7,8 Pain is a major problem and primary concern of patients in palliative care. 3 Based on the method of conversation analysis, a number of studies have been conducted to examine doctor-patient interaction in palliative care setting. 9,10 Asking for information from patients about their concerns could contribute to a good understanding of their emotional, physical and psychological state in palliative care. 1 The type and amount of the patient's concerns the palliative care provider could obtain has a strong influence on the quality of care received by the patient. 11 If a palliative care provider obtains only minimal information about a patient's concerns, it is likely that the palliative care provider will not make an effective patient care plan. 12 Although Conversation Analysis (CA) is a very useful method for examining the patient's concerns in palliative care, few studies has examined the ways in which the palliative care provider addresses the patient's pain concerns in palliative care. In this study, using the method of CA, we aim to examine the conversational practices used by the palliative care provider to deliver pain talk. This study provides a detailed description and interpretation of the conversational practices used to construct the palliative care provider participation in delivering pain talk.

Patient and Public Involvement
The transcribed data showed in this study was obtained from one videotape of doctor-patient interaction in palliative care setting. The recorded data and its initial transcript were collected from the Alexander St website http://ctiv.alexanderstreet.com, an educational resource presenting a large collection of psycho-therapeutic videos. The data were re-transcribed using Jefferson's system. 13 In this study, the data consists of two palliative care sessions lasting about 50 minutes. A palliative care provider and two terminal cancer patients are involved. Study into two palliative care sessions can, by no means, tell the whole picture of medical interaction in palliative care setting but might motivate palliative care providers' reflection on their communicative skills and shed some light on how to communicate with terminal patients in palliative care setting.

Data analysis
Conversation analysis is the study of'talk-in-interaction'. The general aim of CA studies is to show how conversation is sequentially organised, turn-by-turn and action-by-action, and how this sequence organisation in interaction enables interlocutors to manage intersubjectivity and communicate with each other smoothly. 14,15,16 The central claim of CA is that the current turn is not only shaped by the preceding turn, but also influence what the next speaker is going to say in the subsequent turn.
Conversation analysts qualitatively examine recordings of naturally occurring interactions to unravel the reoccurring interactional practices through which social actions (such as complaining or advising) are constructed in moment-by-moment processes. 17 CA offers a rigorous method (applicable to large data sets) to the study of interaction in health settings. 18 In CA studies in medical settings, a key focus is how the doctor's turn arises from the patient's previous turn and how the doctor's turn controls the patient's subsequent turns (or viceversa). As is pointed out by Peräkylä et al. (2008), CA provides a new way for observing and understanding medical interaction. 19 CA unfolds the sequential organization in the medical consultation in detail and explicates the practices and patterns through which the consultation is performed. 20

Results
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 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, 6 13 other.
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  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)  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. 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. Extract 5 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. 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.
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.

Conclusion
Using the method of conversation analysis, this study identify five types of interactional resources which are used to deal with the patient's pain concerns in palliative care setting. Conversation analytical studies on pain talk in palliative care provides a turn-by-turn description of how the palliative care provider communicates with the patient in terms of pain concerns. In addition, by examining sequential features of pain talk in palliative care setting, we may get a better understanding of the interactional details in process of achieving palliative care. This study not only enriches studies of palliative care but also helps to improve palliative care providers' communication skills. This is a preliminary study of pain concerns in palliative care, and thorough investigations would be carried out in future studies.